Karur MC-Final Draft With Questionnaire

Draft Report of the “Analysis of District Mental Health and Primary Care
Personnel's Involvement in Suicide Prevention and Mental Health

Promotional Activities: A community based qualitative study”
Institution: Karur Govt. Medical College.

CONTENTS
CHAPTER PAGE NO.
INTRODUCTION 1
LITERATURE REVIEW 3
NEED OF THE STUDY 17
METHODOLOGY 18
RESULTS 24
DISCUSSION 70
LIMITATION AND IMPLICATIONS 79
CONCLUSION 80
REFERENCES 81
LIST OF ABBREVATIONS
ATP - Advanced Tour Program
ASHA - Accredited Social Health Activist
AYUSH - Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy
AB-HWC - Ayushman Bharat Health and Wellness centres
CEO - Chief Educational Officers
CHC - Community Health Centre
CMCHIS - Chief Minister’s Comprehensive Health Insurance Scheme
DALY - Disability Adjusted Life Years
DMHP - District Mental Health Program
DPM - Diploma in Psychiatric medicine
ECT - Electroconvulsive therapy
ECRC - Emergency Care and Recovery Centres
FGD - Focussed Group Discussion
GBDS - Global Burden of Disease Study
GH - Government Hospital
GNM - Diploma in General Nursing & Midwifery
ICDS - Integrated Child Development Services
M.Sc. - Master of Science
MBBS - Bachelor of Medicine and Bachelor of Surgery
MD - Doctor of Medicine
MO - Medical Officer
MTM - Makkalai Thedi Maruthuvam
M. Phil. - Master of Philosophy
MSW - Master of Social Work.
NCD - Non communicable disease

NGO - Non-Governmental Organization
NMHP - National Mental Health Program
NMHS - National Mental Health Survey
NSPS - National Suicide Prevention Strategy
OPD - Outpatient department
PHC - Primary Health Centre
PPT - Power Point Presentation
VHN - Village Health Nurse
WHO - World Health Organisation
YLD - Years Lived with Disability

List of Tables
No. Title
1 Demographic details of the DMHP staffs
2 List of subthemes and code under the theme “Training”
3 List of subthemes and codes under the theme “Services offered”
4 List of subthemes and codes under the theme “Promotion of mental health”
5 List of subthemes and codes under the theme “Challenge”
6 List of subthemes and codes under the theme “Strategies Utilized”
7 List of subthemes and codes under the theme “Need of DMHP Staff &
Community”
8 List of Health Care Institutions visited to recruit participants for secondary

objective
9 Sociodemographic profile of patients
10 Details related to diagnosis and pharmacological management
Details related non-pharmacological services provided

11
Mean score on various aspects related to communication of DMHP staff with the
12 patients and their family members
Time in years required to reach 3 mental health human resource per one lakh
13 population
Analysis of District Mental Health and Primary Care Personnel's
Involvement in Suicide Prevention and Mental Health Promotional
Activities: A community based qualitative study
Introduction
In epidemiologic transition theory Abdel R Omran states that economic development of a

country is linked to a shift from communicable disease to non-communicable ones. This shift
has taken place all over the world in last century and now non communicable diseases are a
huge contributor to premature mortality, especially in developing countries like India (1)
Rise of Non-Communicable disease
As per 2017 Global Burden of Disease Study, percentage contribution of non-communicable

diseases like ischemic heart disease, stroke, chronic obstructive lung disease and depression
to total DALY (DALY) have increased significantly when compared to 1990’s. Depressive
disorders is the third leading contributor to all age Years lived with disability (YLD). For the
age group of 10-24 years, self-harm and depression are the third and fourth leading cause for
DALY. It is also worth mentioning that interpersonal violence and anxiety disorders are the
fifth and sixth leading causes for DALY in this age group. For the age group of 25-49 years,
depression and self-harm are the sixth and eleventh leading cause for DALY (2). In our
country, the contribution of mental disorders to total DALY has almost doubled from 2.5% in
1990 to 4.7% in 2017. With a contribution of 33.8 %, depressive disorders alone contributing
a massive 33.8% to the total DALY due to mental disorders in India (3).
Relationship between Mental disorders and Suicide
People with mental disorders are found to have eight-fold higher risk for suicide when
compared to those without any mental health issues. Patients with disorders such as
Borderline personality disorder, Depression, Anorexia nervosa, Bipolar disorder, Opioid
abuse and Schizophrenia are noted to have even higher risk for suicide (4)
Definition of Suicide and Global Suicidal Rate
Suicide is defined as a fatal self-injurious act with some evidence of intent to die (5). On
September 9, 2019 World Health Organisation (WHO) Director, General Dr. Tedros
1
Adhanom Ghebreyesus said, “Despite progress, one person still dies every 40 seconds of
suicide”. In 2019 alone, around 7, 00,000 people died by suicide and the global age standard
suicidal rate for that year was 9.0 per 100000 population. There were 20 times greater
number of suicidal attempts than this number which goes unnoticed. The rate was also 2.3
times higher in males (12.6 per 100000) than females (5.4 per 100000). Middle and lower-
income countries were reported to have around 77% of the global suicidal counts and around
58% of those suicides occur before the age of 50. In many of the youngsters of age group
between 15- 29, suicide becomes the fourth leading cause of death (6).
Suicidal Rate in India and Tamilnadu
During 2021, total number of deaths due to suicide in our country was reported to be around
1,64,000 with Tamilnadu being the second highest contributor to the national tally. When
compared to 2020, there was a 7.2% increase in the total number of suicides in our country
and the suicidal rate also increased by 6.2% to 12.0 per 100000 from 11.3 per 100000
population in 2021. 2.6 times more suicide is reported in male population when compared to
female population. Total number of suicides reported from Tamilnadu during the year 2021
was 18,925 and the suicidal rate of 24.7 per 100000 population for the state of Tamil Nadu
was 2 times higher than the national rate. Around 66% of the suicides is reported from the
age groups of 18 to 45 years (7).
Causes for Suicide
Family Problems (33.2%), Illness (18.6%), Drug Abuse/ Alcoholic Addiction’ (6.4%),
Marriage Related Issues (4.8%), Love Affairs (4.6%), Bankruptcy or Indebtedness (3.9%),
Unemployment (2.2%) were some of the common causes for suicide in India (7). Through
complex and multi directional interaction between them, all these causes directly or indirectly
predispose a person to develop mental illness and vice versa (8).
Impact of Suicidal Death on Family
Suicidal deaths have been noted to leave a long-lasting impact on the family function. Studies
have shown that suicide survivors experienced more guilt, shame, social withdrawal and are
more prone to develop complex bereavement disorder. Suicide can affect the cohesion within
the family members and adaptation of the family post suicide as the support they receive
2
from extended social circle is affected secondary to the issues of shame, stigma and blame
(9–11)
.
Importance of Mental Health
WHO defines, mental health as “state of mental well-being that enables people to cope with
the stresses of life, realize their abilities, learn well and work well, and contribute to their
community” (12). A mere absence of a mental disorder is not sufficient to say that a person is
in good mental health. Likely prevention and treatment of mental health disorders alone does
not translate in to good mental health state. We also need promotional strategies that can help
an individual to enhance his/her functioning, so that he/she can contribute more towards the
wellbeing of the society/nature as a whole.
Global Mental Health Action Plan
WHO labelled, ‘Suicide as a major global health concern and developed the global mental
health action plan in 2013 with suicide prevention being an integral part of the plan’. The
goal was to reduce the suicidal rate in member countries to 10% by 2020 (13). Subsequently
in 2015, the United Nations, General Assembly passed the agenda 2030, comprising 17
interlinked global goals called Sustainable developmental Goals, so that all people can live in
peace and prosperity. Specifically target 3.4 of Sustainable developmental Goal was to bring
1/3rd reduction in premature mortality due to non-communicable disease by 2030 through
prevention and treatment and to promote mental health. Suicide mortality rate would be used
as an indicator to measure the progress made towards promoting good mental health (14).
PROMOTION OF POSITIVE MENTAL HEALTH IN INDIA
Bhore Committee report
The need to promote positive mental health in India has been recognised even before
independence. In order to do that, 1946 Report of the Health Survey and Development
Committee headed by Sir Joseph William Bhore recommended, the country should adopt a
mental health programme incorporating four major recommendations such as creation of
mental health organisations at national and State level, improving the facilities in already
existing mental health care facilities and to create more such institutions, creating facilities
for training of medical and ancillary mental health professionals and establishment of mental
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health department in the All India Institute of Mental Health, so that both curative and
preventive services in the field of mental health care can be provided (15). By the time
Mudaliar committee published the report in 1962, All India Institute of Mental Health was
established in Bangalore and Mental Hospital, Ranchi was taken over by the central
government. All India Institute of Mental Health also started diploma courses in
psychological medicine, mental psychology and psychiatric nursing. All over India, Child
Guidance Clinic and Dept. of Psychiatry were started in 8 medical colleges.
Mudaliyar committee report
Mudaliyar committee recommended that in order to improve the curative services,

independent mental health clinics to be started, each district hospital should have a
psychiatric clinic, minimum of 5 to 10 beds in each district should be ear marked for
psychiatric cases, mental hospitals with a bed strength of 750 should be developed on
regional basis. Preventive psychiatric services can be provided in all levels of school
education by employing trained school teaches as School Counsellors, who would be able to
handle emotional disturbances in children, child guidance and psychiatric clinics should be
started in all teaching hospital, major and district hospitals and pre-marital and marital
counselling can be provided in social field. The report also highlighted the need to train all
professionals engaged in family welfare and child welfare such as school teachers, nurses,
paediatricians, social administrators on mental health care and also the need for research
work about the causes for mental disorders and in to the factors that can promote positive
mental health and prevent suicides (16). Subsequent Srivastava Committee in 1972, also
highlighted the need to train the proposed Community health worker category on identifying
and management of mental health emergencies (17).
Challenges for mental health services in developing countries
Rising burden of mental illness and the hardship that it causes on the life of patient, their
family and community and the lack of resources to treat them, particularly in developing
countries, were first recognised internationally as an emerging health issue in 1974 WHO
Expert Meeting on Organisation of mental health services in developing countries. As per
the committee report, stigma and illiteracy about mental health disorders in general
population and community leaders, preoccupation of the government health machinery in
combating infectious disease and improving reproductive and child health care, lack of
4
trained mental health professionals and psychotropic drugs, poorly equipped and
overcrowded mental health care facilities providing institutionalized care for mental illness,
outdated law and administrative procedures on handling people with mental illness, lack of
adequate funding for improving mental health care were identified to be major problems in
developing nations which have to be addressed in order to improve mental health care in
those countries. A total of 17 recommendations (with recommendation 6 speaking about the
need for national mental health policy tailor made to individual countries) has been put
forward by the committee in order to address the raising mental health concern in developing
nations. Member nations of WHO were requested to try pilot projects in Community mental
health care to test the practicability of providing basic mental health care through already
well-established health care projects (18).
Efforts to develop mental health care plan and pilot projects in India
In 1975, WHO initiated a multinational project involving countries of Brazil, Colombia,

Egypt, India, Philippines, Senegal and Sudan on strategies for extending mental health care as
none of the individual countries possessed adequate resources to implement a pilot project on
the community mental health care and other recommendations proposed by 1974 WHO
expert committee meeting at Geneva. In India, Raipur Rani Block of Haryana was chosen for
this study with Department of Psychiatry, Post Graduate Institute of Medical Health and
Research Institute as the nodal agency for implementation of this project in India (19–22).
Also, the community mental health unit of National Institute of Mental Health and Neuro
Sciences (NIMHANS) in 1975 started the Sakalwara community mental health project
(23–25)
. These two pilot projects demonstrated that with proper training, basic mental health
services can be provided through PHC level medical professionals and formed the frame
work for the national mental health programme.
Birth of National Mental Health Programme
In the 1979 WHO Mental Health Advisory Group at Manila, all the member nations of the
WHO were urged to develop a national mental health programme tailor made to address the
metal health challenges in their country. After two national level workshops, the draft
proposal on National Mental Health programme was accepted by the Central council of
Health and family welfare in august 1982 and thus India became one of the developing
countries to have a National Mental Health Programme (NMHP) in the early 1980’s.
5
Objectives of NMHP
Treatment of mentally ill, their rehabilitation and prevention and promotion of positive
mental health are the 3 main components of NMHP and its main objectives are as follows:
(i) To ensure availability and accessibility of minimum mental health care for all, in
the foreseeable future, particularly to the most vulnerable and under privileged
sections of population.
(ii) To encourage application of mental health knowledge in general health care and in
social development.
(iii) To promote community participation in the mental health services development
and to stimulate efforts towards self-help in the community.
The specific approaches suggested for implementation of the NMHP are
1. Diffusion of mental health skills to the periphery of the health service system.
2. Appropriate appointment of tasks in mental health care.
3. Equitable and balanced territorial distribution of resources.
4. Integration of basic mental health care into general health services and
5. Linkage with community development
Treatment Component of NMHP
Under the treatment component multipurpose workers and health supervisors at village and
sub-centre level, under the supervision of medical officers, should be trained in management
of psychiatric emergencies, administration and supervision of maintenance treatment for
chronic psychiatric disorders, diagnosis and management of grand –mal epilepsy, liaison with
local school teacher and parents regarding mental retardation and behaviour problems in
children and provide counselling for problems related to alcohol and drug abuse. Medical
Officers at Primary Health Centre (PHC) should be trained to supervise these multipurpose
workers at sub-centre and village level. They should also be able to do elementary diagnosis
and treatment of functional psychosis, able to treat uncomplicated cases of psychiatric
disorders associated with physical diseases, able to manage uncomplicated psychosocial
problems and do epidemiological surveillance of mental morbidity. District hospitals should
6
have 30 to 50 beds marked for psychiatric patients and there should be at least 1 psychiatrist
attached to every district hospital to look over the clinical care of patients and provide
training to non-specialist health workers. Teaching hospitals with psychiatric units and
mental hospitals should act as referral centres for special cases as well as centres of teaching.
They should have specialised facilities to provide occupational therapy, psychotherapy,
counselling and behaviour therapy.
Rehabilitation and Prevention component
Rehabilitation component comprised providing maintenance treatment of patients with

seizure disorder and mental illness at the community level itself and focused on development
of rehabilitation centres at both district level and referral centre level. Prevention component
was community based and focused on the prevention of addiction disorders, suicide and child
delinquency.
Issues with NMHP
NMHP was designed based on the already existing health service infrastructure already
available in our country so that integration of mental health services with the existing health
services will be possible in near future. It was designed so to efficiently handle the scant
trained human resources in mental health so that the mental health needs of our vast country
with its huge population can be addressed. There were multiple critics about the efficiency of
the program in published literature. It was developed on the experienced gained from studies
conducted by well-established research institutes and the population scale was also smaller
with number up to a lakh only. More importance was given to curative component rather than
prevention and promotion component. No adequate importance was given for the role of
family members and the community in the treatment process. Short term goals were given
priority over long term planning. Also, there was no mention about source of funding for the
programme (26). There were many questions to be answered about how we are going to take
this programme to the common public.
Bellary Project
In response, NIMHANS along with the District Commissioner of Bellary and the Govt. of
Karnataka undertook a pilot project in the District of Bellary with a population of about 20
lakhs. All PHC level medical officers and health workers were trained on mental health care
7
in the district headquarters. 6 essential psychotropic and anti-epileptic drugs (injection
fluphenazine deaconate, chlorpromazine, trihexyphenidyl, amitryptyline, phenobarbitone and
diphenyl hydantoin) were made available in all primary health centers and sub centers. If
needed, they will refer the patient to mental health clinic comprising of psychiatrist, clinical
psychologist, a psychiatric social worker and a statistical clerk operating at the District Head
Quarters Hospital. This team also provided inpatient care for the needy ones. There were
systematic steps to ensure proper maintenance of case records, monthly reporting and
monitoring. The data collected from 1985 to 1990, demonstrated that basic mental care can
be provided in a whole district by proper training of primary health care personnel and with a
District level mental Health team to assist them in needy cases (27–29).
Birth of District Mental Health Programme
District Mental Health Programme (DMHP) was incorporated into the national mental health
programme to decentralise it and was launched in 1996-1997 as a central government
sponsored scheme covering 4 districts (each one from the states of Tamilnadu, Assam,
Rajasthan and Arunachal Pradesh) with the objective of
 Providing sustainable mental health services to the community and to integrate these
services primary health care services
 Early detection and treatment of patients of mental illness and epilepsy within the
community itself
 Ensure that patients and their relatives do not have to travel long distances to seek
treatment and reduce the burden on existing mental health facilities
 Reduce the stigma attached to mental illness through change in public attitudes and
 Treat and rehabilitate mentally ill patients discharged from the mental hospitals within
the community.
By the end of the 9th five-year plan 27 districts spread across 20 states and 2 union territories
had DMHP (17). There was a felt need from the Expenditure Finance Committee that that
there should be proper evaluation of functioning of DMHP project in districts implemented in
9th five-year plan, if DMHP was to be expanded to 100 districts in the 10th five-year plan.
Achievements and failures of DMHP
8
Initial evidences for fulfilment of objectives under DMHP can be found in the report of
evaluation of DMHP by NIMHANS in 2003. After evaluating 27 districts, the evaluation
team reported that mental health services have been decentralised from mental hospital and
medical college hospitals to district level and early identification and treatment of patients
with in the community itself has been enhanced. District mental health clinics have been
established in majority of the districts where there was no provision for mental health care in
the past. In patient care was made available at district level. Patient registers were maintained
at District level. The patients who got treated there and their relative’s reported reduction of
the symptoms of the disorder and improved functioning of the patients after treatment. Over
all they reported general satisfaction with the services available. Available reports indicated
that there was increased need of demand for the services and the scope of the services offered
were expanding. Patients travelling distance has reduced. Essential psychotropic medicines
are available at district levels and there is variation in the availability of medicines at PHC
level. Majority of the districts have carried out training programme on mental health for PHC
level health workers and some centres even provided training to school teachers to identify
mental issues in students. In districts where the programme is functioning effectively,
considerable reduction in stigma related to mental illness have been observable in the local
community secondary to the educational and awareness activities carried out by the DMHP
team in association with health department, government agencies and voluntary
organisations. In such districts, effective use of public speech, role plays, street plays,
newspapers, movie theatres and cable channels for awareness creation activities were
observed.
Drawbacks of DMHP as per the 2003 report
The report observed that the motivation and involvement of the DMHP Staff, level of
support from the state government and also the absence of effective central coordination and
monitoring system and uniform reporting system were some of the reasons responsible for
the varied effectiveness and efficiency of the programme observed in those districts. The
report noted that training of PHC level health care workers in mental health care was weak
and there was no active participation from private psychiatrist and general practitioners.
Recommendations as per the 2003 report.
9
The report also highlighted the need to develop operational manual for DMHP, need to
review and improve the training and support provided to PHC level medical officers with
respect to identification and treatment of disorders, need to expand the scope of service to
offer under DMHP and the need to incorporate more prevention and promotion of mental
health activities and the need for regular monitoring and time bound targets to measure the
progress. The report also recommended that budget should be allocated as per the
geographical size of the districts and salary of DMHP staff should be increased with
additional allowances for peripheral filed activities (30).
The re-strategized NMHP was launched in the year 2003 as a part of 10 th five-year plan. By
the end of the plan, DMHP was extended to 110 districts. Psychiatry departments of 76
government medical colleges were upgraded with the intention to increase exposure for
undergraduate students during their course and increase training during internship period. 23
State run mental hospitals and general hospitals were modernised in such a way to overcome
their past custodial role and more importance was given to information, education and
communication component, research and training in community psychiatry and Monitoring &
Evaluation activities.
ICMR evaluation of DMHP In 2008
Similar evaluation of DMHP was done by Indian Council for Market Research (ICMR) in
2008 at the end of the 10 th five-year plan. 20 DMHP beneficiary districts (4 each from five
zones of the country – East, West, North, South and Central) and 5 non-DMHP districts
(control) were selected for the evaluation. DMHP beneficiary districts were chosen
proportionately from the 9th and 10th 5-year plan period.
Findings of the 2008 ICMR study
Number of DMHP districts that have fully utilized the allocated funds were low.
Administrative delay, difficulty in recruiting and retaining qualified mental health
professional were main reason for underutilization of funds. Lack of organizational skills in
the DMHP team, low community participation in the programme and lack of coordination
with the district health system has resulted in significant underutilization of funds respect to
training and IEC activities. District hospitals has been the first point of care for 61% of the
beneficiaries. The percentage of patients accessing community health centers and primary
health centers treatment of mental health disorders were low. 90% of the patients felt that
10
diagnosis was explained to them and also around 60% reported they were informed about the
medicine side effects. Around 75% of the patients reported that they were treated with respect
and dignity. Around 73% of the patients reported they have full trust and confidence on the
treating team and around 25% reported that they had trust and confidence to some extent on
the treatment team. Around 18% of the beneficiaries reported that they were referred to
district centers for treatment. 80% of the beneficiaries across all districts reported that
receiving some psychotropic drugs from the health centers. However only 25% of the
districts reported that there is regular inflow of drugs. This highlighted the lack of a dedicated
drug procurement and dispersal system at district and state level. Around 55 % of the health
care professional reported that they have received training under the program and more than
half of them were satisfied with the training program. Rest of the trained health care
professionals reported that the training modules should be simple, involve case studies and
there should be more refresher training programmes. Knowledge about mental illness,
symptoms and treatment availability were higher among beneficiaries and community
members in DMHP district as compared to non DMHP districts.
2008 ICMR recommendations
The committee acknowledged that the DMHP program has provided basic mental health care
services to public at district and sub district level and recommended to expand the program to
other districts of the country. The committee also recommended that the services at sub-
centre, PHC and Community Health Centre (CHC) level should be strengthened, so that they
become more accessible to the patients. For the same the DMHP team should be trained
adequately in programme management and organizational skills, networking and involvement
of all stakeholders like district health system. DMHP teams should organise more training
programme for grass root level workers about diagnosis, management and how to involve the
family members and community in the treatment process. There should be more IEC
activities and mental health promotion components by involving local media in awareness
creation and stigma reduction and doing more programmes on suicide prevention, workplace
stress management and starting counselling services in schools and colleges. DMHP team
should ensure the availability of both pharmacological and psychosocial mode of treatment
for the patients and evolve proper mechanism for follow up of drop out cases by involving
psychiatric social worker and community nurses. There should be adequate involvement of
11
community level organisation or leaders in organising awareness programme to maximize its
impact.
Central and state government should ensure regular flow of allocated funds and initiation of
the programme once the funds are allocated, ensure the appointments of DMHP staffs and
their continuity at job by providing adequate salary and ensure the continuity of the
programme beyond the plan period by shifting the financial burden to state government and
and integration of mental health program in to other health program has to be done. The
committee recommended to increase the number of seats in post graduate course like
M.Phil. in Clinical Psychology, PSW, etc. so that more qualified manpower will be available
for the programme. Respective state government should streamline the drug procurement
system to ensure availability of psychotropic drugs in all health centres and provide adequate
secretariat level support to state mental health authorities to discharge their role and functions
so that they can supervise and monitor the DMHP team. There should also be continuous
monitoring and reporting of DMHP by state health society and external evaluation of the
DMHP program for needed mid-course correction (31).
DMHP in the 11th five-year plan
During the 11th five year more importance was given to address the human resource shortage
which hindered the mental health service delivery. In order to develop new work force and
provide training to mental health professionals, 11 new Centres of Excellence in the field of
mental health were established by upgrading existing mental health institutions and also
mental health departments of around 30 government medical colleges were upgraded so that
intake of post graduate students in mental health courses can be increased. New components
like school mental health programme, college counselling programmes, life skills training
with focus on work place stress management and suicide prevention and out research services
were added. It was also decided to further strengthen the IEC and monitoring and evaluation
component by allocating more founds for research activities. The role of NGO’s in promoting
mental health was highlighted and in order to ensure optimal utilization of existing other
health care service resources and easy implementation of the program, it was decided to
mainstream NMHP through NRHM and NUHM (17,32)
2011 NIMHANS Evaluation of DMHP
12
As per NIMHANS 2011 report, “Report of Evaluation of District Mental Health Programs in
states of Tamil Nadu, Karnataka, Andhra Pradesh and Maharashtra” documented that large
number of patients and their families have benefited from the services available under
DMHP. Following positive developments were also observed.
1) In most of the evaluated districts OPD based mental health services are provided by
the DMHP team by visiting taluk hospitals at least once in a week.
2) Procurement and distribution of drugs haven been done through state run agencies in
all 4 states and
3) State governments have started taking over the responsibility of providing fund for the
programme in certain districts, once the central government fund flow has stopped.
4) DMHP teams have networks with NGO and also started providing disability cards to
the needed person by active liaison with revenue department and social welfare
department.
Drawbacks of DMHP as per the 2011 report
Though there have been no issues in funding, delayed and irregular dispersal of funds
to district level and administrative procedural delay while utilizing the funds at district level
have been a major reason responsible for underutilization of the funds, which hindered the
proper implementation of DMHP. Non availability of implementation guidelines, no
uniformity in nodal agency, IEC activity, resources and approaches and lack of training and
sensitization for state nodal officers, programme officers and psychiatrist are some of the
major problems for implementation of the program. There is no periodic review of DMHP
performance and there is no central or state monitoring committee to review the performance
of DMHP staff. It has to be documented that though most of the DMHP implementing
districts reported that large number of patients utilized their services, there is no way to
ascertain the actual number of patients benefitted since there are no database available with
respect to treatment and follow up regularity/irregularity/drop out/migration and also
regarding no change/ exacerbation/complete remission of symptoms. Another major criticism
being the project is still being specialist driven in most of the states. It has also been noted
that there is a lack of clarity on the role played by psychologist and psychiatric social workers
in most of the states. It was clear that integration of mental health service and primary health
care has not taken place. Only Minimal number of PHC level medical officers and other
health care professionals are trained. Though these training programmes improved the
13
knowledge of primary level health care workers, they still need assistance from the district
level mental health team in diagnosing and treating common mental health issues since the
training sessions were of short duration and no follow up training were conducted.
Recommendations from the 2011 Report
The report suggested that the outreach model of delivery should be stopped immediately. The
primary care personnel and PHC should be the health care professional and outlet of care
respectively for most of the mental health problems. Implementation of DMHP should be
under department of public health to ensure proper coordination with PHCs. Training of PHC
level staffs to be increased and should be done by program officers/district psychiatrist as it
improves the connectivity between them and also there should be a data base of patients
registered with each PHC so that each patient can be tracked easily and treatment adherence
can be ensured in the PHC level itself. All district hospitals should have inpatient treatment
facilities. Drug procurement should be restricted to essential psychotropic only and freedom
to purchase drugs at individual health centre level needs to be curtailed down to avoid
procuring expensive drugs to make the program cost effective. There should be adequate
training program for DMHP staffs and there should be uniformity on IEC materials and
activities. Psychiatrist should actively engage with non-governmental organisations/agencies
in the community to rehabilitate the treated patients using the available resources within the
community. The role of psychologist and psychiatric social worker has to be defined so that
they are engaged in role appropriate tasks. Their salary should be increased and consideration
to be given for permanent job when the DMHP program was taken over by state government.
There should also be regular review meeting of DMHP performance so that reforms can be
implemented. State nodal officers should be provided with necessary resources so that above
mentioned recommendations can be implemented (33).
DMHP in 12th Five-year Plan
The budget allocated for the 12th five-year plan was Rs.1265 cores with the vision of
extending the programme to all the districts of India. Budget provisions were made to
upgrade 39 psychiatry departments of government medical colleges and reconstruction of 20
mental hospitals. More importance was given to early diagnosis, treatment and disability
reduction of psychiatric issues special population like paediatric and geriatric age group,
victims of abuse, poverty, destitution, abandonment, natural and man-made disaster and also
14
to improve the preventive mental health care services available to them. More importance
was laid to increase the access for preventive services to these special population, in
particular, addressing the risk of suicide and attempted suicide. One of the intended goals was
to ensure that patients with mental illness and their relatives were made aware of the
provisions available under the rights of persons with disabilities act and they receive care and
treatment as per the provisions available under the act. Central and state mental health
authorities should be reinforced to implement these goals. As of 2020, 692 districts in our
country are added to have DMHP (17,34,35).
Findings of the 2015-2016 National Mental Health Survey of India
Treatment gap for various mental illness
As per 2015-2016 National Mental Health Survey of India (NMHS), overall treatment gap for
any mental health problem is around of 83%. Treatment gap for common mental disorders
like major depressive disorders and anxiety disorders were noted to be higher than the
treatment gap for severe mental disorders like bipolar affective disorder and non-affective
psychotic disorders. Treatment gap 90% of was observed substance abuse disorders. It was
observed to be treatment gap for any suicidal risk behaviour was above 80% (36).
Reasons for the treatment Gap
Low perceived need due to limited awareness, socio-cultural beliefs, values and stigma were
identified to be the key demand side barriers and insufficient, inequitably distributed, and
inefficiently used resources are the supply side barrier responsible for this gap. Poor quality
of care associated with mental health services and high out-of-pocket costs are some of the
other reasons responsible for high treatment gap. NMHS also documented that the Primary
health care personnel were noted to be reluctant to treat common mental illness secondary to
the deficiencies in training provided to them and hence their confidence in treating such
disorders is also low (36).
Published literature about DMHP in Tamil Nadu
Achievements
2011“Report of evaluation of district mental health programs in Tamil nadu, Karnataka,

Andhra pradesh and Maharashtra”by National Institute of Mental Health & Neurosciences,
15
gave more information regarding the functioning of DMHP in Tamilnadu. Mental health
clinics are conducted in district hospitals and taluk hospitals weekly once. It was documented
that a large number of persons received care from these clinics for varied mental health
problems. Patient visit details were documented in a register and they were also provided a
small booklet containing information about the diagnosis and treatment. All patients were
issued free drugs and referred back to taluk hospitals or PHC for further follow up by medical
officers (not uniformly seen). Admission facilities and treatment for severe psychiatric
conditions were available in most of the district hospitals. Mental health camps were
conducted in all districts along with other government departments to provide disability
identification cards. Many DMHP teams are noted to have active linkage with NGO’s which
were used for promotional activities (33).
Criticism about the functioning of DMHP in Tamil Nadu
Though there are positive developments, certain findings with respect to the implementation
of DMHP in Tamil Nadu are heart-breaking. It has been documented that current scenario of
the DMHP in Tamil Nadu is specialist driven. Only two DMHP psychiatrist were trained in
the operational aspects of DMHP. None of the DMHP members were aware of the
operational guidelines about the implementation of DMHP in the district. District and taluk
hospitals has been the delivery point of care in all districts. DMHP team travel from District
Hospitals to taluk hospitals every week to provide care. These visits are associated with
logistic difficulties as there was no adequate fund to support the travel. There’s no clarity on
the role played by psychologist and psychiatric social workers. They are not utilized to their
full potential. Many posts remained vacant due to because of poor salary, lack of job
description and poor job satisfaction. The role of medical officers and para medical staff at
PHC level in providing mental health care is very low as there was no adequate training on
metal health care provided to them. Lack of coordination between the different health
directorates has also been a barrier for proper implantation of the program (33).
It has been concluded that “However, from a situation of no care to some care in Tamil Nadu
is a positive development due to DMHP. But in terms of efficiency, reaching the unreached,
providing care closer to where patients live and integration of mental health with general
health services was not achieved at all. The mental health care being available once a week in
taluk and district headquarters hospitals will not be able to cater to the needs of the people
living in rural areas and the purpose of DMHP meant is therefore defeated” (33).
16
In the 2015-2016 NMHS though the state of Tamil Nadu has scored well in areas like having
a mental health action plan and coordinated mechanism to implement the same and ensuring
availability of psychotropic drugs. The state has also scored low in certain activities like
training program on mental health, IEC activities, and intra and inter sectoral collaboration
and monitoring. (36)
Fig 1. Mental Health Score Card of Tamil Nadu from NMHS (36)
Reason for the Study
With more than two decades of existence and huge amounts of money being spent on the
DMHP program there is still a lot of scope for reducing suicides in Tamil Nadu. The 2008
Indian Council of Market Research (ICMR) study has also evaluated the overall performance
of the DMHP in 20 districts including Madurai. It has focused on the availability and
utilization of services including drugs, referral, supportive and collaborative services,
awareness of DMHP services among communities, to analyse the expertise level of health
staff, utilization of funds, etc (31). The 2011 National Institute of Mental Health
Neurosciences (NIMHANS) study has evaluated the DMHP in terms of overall problems
encountered in implementation and availability of drugs, training of staff, and documentation
of mental health problems and status of persons using the mental health services in 23
districts of Tamil Nadu, Karnataka, united Andhra Pradesh and Maharashtra (33).
17
However, these two studies were not exclusively focused on the specific strategies used by
DMHP staff to prevent suicide and promotion of mental health in the community. It would
be good to understand the knowledge and perspectives of DMHP stakeholders on the
strategies and mechanisms used to prevent the suicides and promote mental health in the
community. This will help to understand the best practices used by the DMHP team towards
preventing suicides and promoting mental health. Also, it helps us to understand the
challenges experienced by the DMHP staffs which should be addressed on priority.
Research Questions
1. What is the level of knowledge and perspectives among DMHP team on prevention of
suicide and promotion of mental health?
2. How are they integrating suicide prevention strategies in their routine work?
3. What are all the mental health promotional strategies they are adopting in their work?
4. What are some of the best practices on prevention of suicide and promotion of mental
health?
5. What are the challenges they experience in their work towards the prevention of
6. What are their perceived met and unmet needs while working for the prevention of
Multiple recommendations have been recommended in the 2011 NIMHANS specifically with
respect to delivery of mental health services through PHC level medical professionals and
engagement of psychologists and psychiatric social workers in role-specific tasks. Following
topics are added as secondary objective to know whether the recommended midcourse
correction has taken place and has benefited the beneficiaries.
1. To understand about the profile of patients receiving care under DMHP and about the
availability and accessibility of mental health services to public at various level of
health care institutions and medical personnel engaged in providing the services.
2. To understand about the availability of non-pharmacological services to patients
receiving mental health services under DMHP.
18
3. To understand about the level of satisfaction of the beneficiaries receiving care under
DMHP that may help us to further improve the services offered.
Approach and Methodology
Operational Definitions
District Mental Health Program: It is an integral part of National Mental Health Programme
of India aimed at decentralizing the mental health services and providing mental healthcare in
the community through primary and secondary health care systems.
District Mental Health Team: It consists of mental health professionals including psychiatrist,
clinical psychologist, psychiatric social worker, mental health nurse, and case registry
assistant.
Suicide Prevention: It consists of district mental health programmes’ efforts or strategies to

reduce the risk of suicide at individual, group, or community level.
Mental Health Promotion: It consists of district mental health programmes’ efforts or

strategies to promote mental wellbeing at individual, group, or community level.
Best Practices: They are any unique strategies of DMHP to reduce suicidal risk and promote
mental wellbeing at individual, group or community level.
Challenges: These are any hurdles or difficulties experienced by the DMHP personnel while
discharging their services to prevent suicide and promotion of mental health.
Met Needs: These are any support/assistance/training availed/accessed by the DMHP

personnel while discharging their services to prevent suicide and promotion of mental health.
Unmet Needs: These are any support/assistance/training not available to the DMHP personnel
while discharging their services to prevent suicide and promotion of mental health.
Research Design:
The current study is an explorative qualitative research design. Qualitative exploratory

research design is a type of research approach that is used to investigate and explore a topic
of interest in-depth. It is usually adopted when there is a lack of literature available on a
particular research topic. It involves collecting data through various methods such as
19
interviews, observations, focus groups, and document analysis. The data collected is then
analysed inductively to generate new insights, patterns, and themes that can help to develop a
better understanding of the research question. This means that the researcher can modify the
research design and data collection methods as new insights emerge during the research
process. The focus is on gaining a deeper understanding of a particular phenomenon rather
than generalizing the findings to a larger population. Qualitative exploratory research design
can be useful in a range of fields, including social sciences, health sciences, and education,
among others. It can provide valuable insights into complex social and cultural phenomena
and can help to inform policy and practice in various domains (37).
This design is very much appropriate for the current study where the research questions or the
objectives are not well researched. The current study has collected the data from multiple
sources or participants such as DMHP team and primary health care physician and Village
Health Nurse (VHN)/ Accredited Social Health Activist (ASHA) workers. Also, it has used
in-depth interviews and focus group discussions and secondary data to answer the research
questions.
Cross sectional descriptive design with patients receiving mental health aid from DMHP as
the study participants was chosen to study about the secondary objective.
Participants:
The study included multiple service providing stakeholders such as psychiatrists, clinical
psychologists, psychiatric social workers, mental health nurse of DMHP and physicians and
VHN/ASHA workers at primary health care centres. The inclusion criteria for the DMHP
professional are: 1) at least 2 years of experience, 2) aged over 25 years old, and 3) should be
involved in providing mental health services as part of the DMHP program. Inclusion for
primary health care physicians was at least 25 years old, attended any orientation or training
program on DMHP and its implementation. The VHN/ASHA workers were included if they
have at least 2 years of experience and have got a basic orientation program on DMHP or
mental health orientation. The study included a total of 30 participants. Five each from the
DMHP team such as psychiatry, clinical psychology, psychiatric social work, mental health
nurse, and primary health care physicians. Research shows that 25 to 30 sample sizes would
be a good number for qualitative research (38). Also, the study included a total of 15 Village
Health Nurse/ASHA workers for two Focussed Group Discussion (FGDs). Researchers
20
suggest that two FGDs with participants ranging between 2 to 40 are good for data
saturation (39). Those participants who could converse well either in Tamil or English
languages were selected.
For secondary objective, patients receiving mental health services from DMHP staffs for
more than 3 months are recruited. In cases like chronic mental disorders, autism, ADHD and
differentially abled response are collected from patient attenders.
Study Setting:
The study is carried out in 6 districts of Tamil Nadu with functional district mental health
programme for more than 5 years. The districts are Karur, Namakkal, Salem, Erode,Tenkasi
and Tiruchirapalli. The District Mental Health Programme (DMHP) teams of these districts
(DMHT) work together to provide mental health services and support to people living in the
community especially the rural areas. The DMHP teams are part of a larger mental health
program in India called National Mental Health Programme that is aimed at improving access
to mental health services and reducing the treatment gap for people with mental illness. The
program is supported by the government of India, state government and respective districts
and various non-governmental organizations. The DMHP teams are comprised of
psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses with
other medical teams, who work together to provide a range of mental health services. These
services include screening and assessment of persons with clinical and sub-clinical mental
health conditions, counselling and therapy, medication management, and referrals to other
mental health services as needed. The DMHP teams also work to raise awareness about
mental health issues and reduce the stigma associated with mental illness. They conduct
community outreach programs and educational sessions to promote mental health and
wellbeing in the community especially at schools and colleges. Overall, the DMHP teams
play an important role in promoting mental health and wellbeing in the community and
providing much-needed mental health services to those in need. However, this study
specifically focused on how the DMHP teams of these 6 districts are involved in prevention
of suicides and promotion of mental health in the community. For secondary objective
patients receiving services from DMHP in Karur district alone are included considering the
distance and other issues.
Tools for data collection:
21
To explore the research questions, semi structured in-depth interview guides were prepared
for mental health professionals and also topic guides were prepared for focus group
discussions. These were face and content validated by two mental health professionals and
qualitative researchers. Additionally, these guides included research participants’ socio-
demographic profiles. The interview guides were explored the topics on DMHP team’s
involvement in suicide prevention and promotion of mental health with a mix of open and
closed ended questions.
A modified version of the questionnaire used in the 2008 ICMR “Evaluation of District
Mental Health Program” report was used for secondary objective. The modified questionnaire
included questions about the involvement of DMHP staffs such as psychologist, psychiatric
social worker and staff nurses in patients care and the nature of services offered by them to
the patients and patient’s perception about impact of the services offered.
Data collection:
The rationale for conducting the face-to-face interviews is non-availability or practical issues
in terms of mobilizing the DMHP team and physicians for FGDs. However, the FGDs were
conducted with VHNs considering the availability of them in the community. All the face-to-
face interviews and FGDs were audio recorded. The data was collected by two research
assistants who were trained in conducting qualitative interviews. Initially the interview guide
was pilot tested to understand the pragmatic issues during the data collection and to refine the
interview guide if necessary. The face-to-face interviews were conducted with psychiatrists,
clinical psychologists, psychiatric social workers, mental health nurses and primary health
care physicians. Two FGDs were conducted with VHNs in the community to explore the
research questions. 18 VHN from Mohanur Block of Namakkal district participated in the
first focused group discussion and as we couldn’t get the adequate number of VHNs from a
single block with willingness to participate, 15 VHNs representing different blocks in Karur
district participated in the second focused group discussion. All the staffs were interviewed
after obtaining permission from the concerned district Joint Director of Health
Services/Deputy Director of health services and permission of the Medical
Superintendent/Resident medical Officer/Block Medical officer was obtained to conduct the
interview in the premises of health institutions under their control and adequate care was
taken not to disturb the clinical services offered by the staffs.
22
For secondary objective, eligible DMHP beneficiaries in Karur District are recruited by
visiting the Taluk GHs and Block PHCs where mental health outreach clinics are conducted
by the DMHP staffs. Convenience sampling method was used. To represent beneficiary from all
over the district, samples are collected at least once from all the Taluk GH and Block PHC where
mental health outreach clinics are conducted by the DMHP team.
Data Analysis:
The audio recordings were transcribed and later translated into English texts. The transcribed
textual data was managed and coded with Atlas.ti version 9 (https://atlasti.com/). The two
research assistants were trained on qualitative data analysis and they have completed the
initial coding for a few participants and one FGD. Later the principal investigator and co-
investigators reviewed those codes and developed a coding framework which was emerged
from the data. The subsequent data analysis and interpretations were carried out by principal
investigator and co-investigator. To condense the large textual data the qualitative thematic
analysis proposed by the Braun and Clarke was adopted for this study (40). Specifically, the
inductive thematic analysis was used. It is a systematic and iterative process for identifying
patterns or themes in data, without the use of pre-existing coding frameworks or theoretical
models. The inductive thematic analysis approach is flexible, allowing the researcher to adapt
the process based on the data and research question. It also promotes rigor by emphasizing
transparency, reflexivity, and consistency throughout the process. The data analysis steps
adopted in this study consisted of: 1) Listening to the audio recorded interviews and
transcribing them to text. 2) Reading and rereading the transcribed textual data multiple times
for getting familiarity. 3) Inductive coding of two transcripts from face-to-face interviews and
coding of first FGD transcript. 2) Generating initial codes by conducting line by line open
coding in Atlas.ti. 3) Sorting, grouping, and searching for themes by collating all the codes
generated according to their meanings in Microsoft excel spreadsheet. Also, they were
checked against the codes, transcribed texts and audio recorded interviews for consistency. 4)
Fourth step involved reviewing the themes for their meaning and description, and 5) finally
the important themes consistent with the research questions were interpreted and reported.
The emerging disagreements related to the naming, renaming, and describing the codes and
themes were resolved with the discussion among the investigators and coders. To report this
study COREQ guidelines will be used wherever necessary (41).
23
Data analysis was conducted using Jamovi (v2.3.4) software. Since, a semi structured interview
schedule was used for data collection, the analysis consists of descriptive statistics such as frequency,
percentage, cross-tabulation, appropriate measures of central tendency and dispersions.
Ethical considerations:
All the research participants were thoroughly explained about the purpose of the research.
Written informed consent was sought. Strict confidentiality, voluntary participation and right
to withdraw at any point of time during the study was ensured. Anonymity was and will be
maintained while reporting the study finds, publications, and conference presentation. As
there are no interventional procedures carried out, no harm/risk to any of the subjects
involved in the study. Consent form in English and Tamil languages are provided in
Annexure 1 and 2
Results:
At the time of the interview the DMHP teams of Salem, Theni and Namakkal was headed by
a psychiatrist with a Doctor of Medicine (MD) degree in psychiatry and DMHP teams of
Karur, Erode and Tiruchirapalli district was headed by a psychiatrist with a Diploma in
Psychiatric medicine (DPM). Psychologist post in all 6 districts were occupied by candidates
with a Master’s degree (M.Sc.) in Psychology and psychiatric social worker post in 4 districts
were occupied by candidates with Master’s Degree in Social Work (MSW). Psychiatric
Social worker post remained vacant in the districts of Tiruchirappalli and Salem from the
dates of 1/4/2020 and 1/7/2022. All the staff nurses were having a diploma in general nursing
and midwifery (GNM). Staff nurse post under DMHP in Karur and Namakkal District
remained vacant from the date of 1/8/2020 and 1/4/2022. The vacant details were obtained
from the DMHP Psychiatrist of the concerned district. As per the information received from
the Hospital Superintendent of Salem district headquarters hospital at Mettur, they don’t have
a staff nurse post under the DMHP, which was surprising. We were able to interview totally
20 DMHP staffs and 6 PHC medical officers from all the six districts.
Duration of experience of the staffs working under the DMHP program is given in the table.
Table 1. Demographic details of the participants.

Designation Age Sex Qualification Total Experience in
Years Of DMHP or Trained
Experienc on mental health in
24
e in Years Year
Erode district
Psychiatrist 49 Male MBBS., DPM 15 13
Psychologist 42 Male M.Sc. (Psychology) 15 14
Social Worker 42 Female M.S. W 15 14
Staff Nurse 20 Female GNM 1 1
PHC medical 41 Male MBBS 12 2020
officer
Karur district
Psychiatrist 37 Female MBBS., DPM 7 7
Psychologist 33 Male M.Sc. (Psychology) 4 4
Social worker 37 female M.S.W., M.Phil. 14 7
Staff nurse Post Vacant from the date of 1/8/2020
officer
Namakkal district
Psychiatrist 35 Female MBBS., MD 2 2
Psychologist 34 Female M.Sc. (Psychology) 10 4
Social worker 41 Male MSW 12 11
Staff nurse Post vacant from the date of 1/4/2022
PHC medical 29 Female MBBS 3 2021
officer
Salem district
Psychiatrist 33 Male MBBS., MD 7 2
Psychologist 33 Female M.Sc. (Psychology) 3 3
Social worker Post vacant from the date of 1/7/2022
Staff nurse No Post sanctioned as per the Hospital Superintendent
officer
Tenkasi district
Psychiatrist 36 Male MBBS., MD 7 7
Psychologist 36 Male M.Sc. (Applied 5 4
Psychology)
Social worker 43 Male MSW 8 3
Staff nurse 33 Female GNM 7 2
officer
Tiruchirappalli district
Psychiatrist 54 Male MBBS., DPM 15 10
Psychologist 43 Female M.Sc., M.Phil. 15 3
Social worker Post vacant from the date of 1/4/2020
Staff nurse 47 Female GNM 20 15
officer
Training for DMHP staffs
25
Table.2 List of subthemes and code under the theme “Training”
Theme Subtheme Code
Training Orientation training for Duration and frequency of
DMHP staffs at the time of Training
joining the team No training
Upskill Training for Duration of training
DMHP staff And frequency of Training
No training
Orientation Program for DMHP Staffs
Psychologist and Psychiatric social worker working under Erode DMHP reported that they
were given orientation about DMHP at the time of joining the program. The program was
conducted at NIMHANS in 2008 for a period of 3 months. Psychiatrist in Theni DMHP
reported that he had attended one day orientation program at DMS Office, Chennai in 2015.
All other DMHP staffs including the staff nurses answered that they didn’t receive any
orientation program at the time of joining.
One Psychiatric social worker said, “We were appointed in 3 batches (2008, 2012, and
2015). For 2008 batch they were given training. For 2012 batch there was no training given.
For 2015 batch we were sending request letters through our sangam for our trainings. But
only after 3 years we were given 3 months compulsory training in IMH. We learnt much in
that”
One Psychologist said, “So in Tamil Nadu around 25-30 people whoever have joined along
with me were not given any kind of training.”
Upskill Training for DMHP staffs
8 of the DMHP staffs reported that they had attended at least one upskill training program
duration of which ranged from one day to 3 months and 11 of the interviewed staffs reported
that they didn’t receive any upskill training while working for the program. There were more
upskill training programs for psychologist and psychiatric social worker. Two staffs reported
they have attended 3 such training programs. One staff reported that he has attended up to 4
training programs. Some of the training program conducted are as follows
26
1) Job Master of Life Skill Trainer, conducted for 2 days in June, 2018, for psychiatric
social worker and psychologist by IMH, Chennai
2) Job training for psychiatric social worker for 3 months from May 2018 to July 2018 at
IMH, Chennai.
3) Capacity building interventions on child and adolescent mental health and

psychosocial care for psychologist and psychiatric social worker (two days online
training for every week from January 2021 to May 2021 conducted by NIMHANS)
4) Disaster Management training for 5 days in February, 2022 at Salem by NIMHANS
5) Disaster management training for 5 days in April, 2022 at Madurai by NIMHANS
Some of the reason for variation in the number of staffs who have attended the program are
such as batch wise training program for the staffs to provide training program in Institutions
nearer to their work place to ease fund and logistic issues, trained staffs leaving the program
and subsequently newly recruited staffs had attended fewer program.
A psychologist said, “Actually we do have training for 3 months but since corona broke out,
we were not given any training. A known person of mine attended training and soon after it
they got relieved”.
Another psychologist said, “There are trainings. But we have not been given any training
still. Other district people have been given trainings”
One another reason is administrative difficulty in sending the staffs for training program. For
example, all the interviewed psychiatrist are District Psychiatrist/program officers, who in a
greater number of situations, stayed back to provide uninterrupted services at hospitals and it
was the mobile psychiatrists who attended the training program. All the three staff nurses
reported that they had not received any orientation program or training as a part of DMHP.
A staff nurse said “There was no training provided. 1 year before I joined in this centre but
they assigned me emergency ward. Just 3 months before I got to know I was posted here for
DMHP program”
Treatment Component
27
Table 3. List of Subthemes and codes under the theme “Services offered”
Theme Subtheme Code
Services Offered For patients with common Case source
mental illness OP service and Frequency
Inpatient Service
Teleconsultation Service
Treatment by PHC
medical officers
For patients at risk or with Identifying at risk
suicidal attempts Contact gap
Services for patients with
suicidal attempts
Role of psychiatric social
worker and psychologist
Follow up and suicide
prevention services
Strengthen referral Orienting PHC staffs and
component ICDS staffs
Treatment of mental disorders by DMHP Team
Case Source
Majority of new patients for DMHP comes through the old patients and through people
attending awareness programs like “Mana Nala Vzhyalan” which were conducted on every
Thursdays in all GH and PHC, who refer their relative with mental illness.
One staff nurse said, “As they get to know it, they tell their neighbours that it is happening in
this particular date and people do come to us through those patients. Our old patients even
refer new cases which are more in number.”
Other major source of case referrals is from PHC medical officers and staff nurse, village
health nurses, anganwadi workers, school and college teachers, self-help groups and NGO’s.
Few referrals were also coming through district child protection officers, mentally ill homes,
journalist, advertisements made through local TV channels and awareness articles published
in newspapers.
Outpatient service.
28
There are two Psychiatrist post under DMHP in each of the six districts. One psychiatrist
called district psychiatrist is based at the district headquarters hospital and looks after the
mental health services there. District psychiatrist manages the fund and coordinates all
activities under the program including attending review meetings. Other psychiatrist called
satellite clinic psychiatrist provides OPD services at taluk hospitals and block PHCs.
Outpatient services are provided in the district headquarters hospital of Tiruchi, Tenkasi,
Erode and Salem with a frequency of at least thrice a week.
A psychiatrist said, “Before 3 years there was only one psychiatrist in DMHP called district
psychiatrist. They have to cover entire district government hospitals and block primary
health centres. But now there are 2 psychiatrists in DMHP. They are district psychiatrist and
satellite psychiatrists. So now satellite psychiatrist will cover block primary health centres
and district psychiatrist will cover taluk and non-taluk hospitals”
However, district psychiatrist post of Karur is vacant and district psychiatrist of Namakkal is
on maternity leave. Satellite psychiatrist post in Tenkasi is vacant from the time of the post
creation in 2018. Hence these three districts are not able to provide the OPD services at
district headquarters hospital in a frequency as such provided in other 4 districts. In districts
of Karur and Namakkal, Advanced Tour Program (ATP) are planned in such a way that
psychiatrist, social worker and psychologist are visiting government hospitals and PHC
separately in order to maximise their coverages.
The same psychiatrist also said, “With respect to our district for the past 4 months district
psychiatrist post is vacant. Once the post is filled, they have to cover all this. Now twice in a
month we visit all government hospitals and once in a month we visit all primary health
centres in the fixed days”
Another psychiatrist said, “When we are two, we were covering all GH and PHC. Since the
other post is vacant, now I am covering GH and 7-8 PHC. To the remaining PHC either
psychologist or social worker separately make a visit.”
The frequency of such visits varied from one weekly visit to taluk government hospitals to
one monthly visit to Block PHC. In all health service centres, outpatient services are
conducted for a duration of 3 hours and the team engages in mental health promotion
activities after that. All patients are provided with free psychotropic drugs for a minimum of
15 days to maximum of 1 month and were asked to come for follow up. Outpatient
29
department visit registers are maintained at every GH and PHC. The patients were also issued
a record book with details containing their diagnosis and medications they are currently
receiving. Once symptom remission was achieved the patients seen in district headquarters
and taluk hospitals were being referred to PHC nearer to their home for further follow up by
PHC medical officers and the date and time of DMHP team visit to block PHC nearer to them
have also been informed.
A psychiatrist said, “We ask them to come here for one review alone and for the next time we
ask them to get the medicines from taluk GH or nearby PHC. This is to keep them in follow-
up.”
Inpatient services
Patients who need admission are managed at district headquarters hospital based on the
availability of infrastructures and human resources. Patients with psychosis, major depressive
disorder, bipolar affective disorder and alcohol withdrawal syndrome who couldn’t be
managed at home are usually admitted. It has to be mentioned that 4 patients benefitted from
Electro Convulsive therapy in Tenkasi district headquarters hospital in the year 2022 till the
month of September.
Teleconsultation services
Each DMHP team is also provided with a dedicated mobile help line number to provide
emergency teleconsultation services. DMHP help line is functional during the official hours
between 9.00AM to 4.00 PM and the responsibility of ensuring the availability of
teleconsultation services lies with the psychiatric social worker in most of the districts. In
addition to walk in patients at outpatient department, patients who are at emotional crisis/at
risk for suicide contacts the DMHP team through this helpline number.
A psychiatrist said, “So there is a separate helpline number for it. So, people with suicidal
thoughts can contact through that number. So, we motivate them and suggest them for nearby
mental health centres for their treatment. Everyday there are 1 or 2 two cases like this.
Mostly they solve 80% of their problem through calls only. Remaining come to the
headquarters.”
30
DMHP team also gets details of such high-risk patients in their district who contacted the
Tamil Nadu government run 104 helpline number for emergency crisis. In turn the DMHP
staffs should follow up those patients through phone or ask the patient to visit the health
service establishment nearest to the patient on the day of DMHP team visit to such centre.
A psychologist said, “We also get numbers from Chennai (Govt. Helpline number 104) to
contact. So, we call them and ask them to come and meet us in the centre. Very few turn up
meeting us. Because only few people listen to us but they won’t come in person to meet us
and few more is not even interested to listen.”
As per the statement of DMHP staffs, teleconsultation number is displayed in all GH and
PHC, has been handed over to school and college students and staffs and also to patients, in
case if they ask, to contact the treating team in emergency situation. However,
teleconsultation services are underutilized most of the districts are underutilized.
A psychiatrist said, “There is a district helpline number. But even if we try our best reach is
not there with the people and the people are not utilizing the helpline number.”
Another psychiatrist said “We have helpline number for us separately but we don’t receive
much calls in that.”
A psychologist said, “We provide our contact numbers. We display the details about us. They
can call us and inquire about the timings of our visit.”
3 DMHP staffs said that they usually they provide 104 help line number to patients since it’s
easy for them to remember and also due to the round the clock service availability with 104
helpline number.
A psychiatrist said, “We educate them about this (104) number because it is a universal,
standard and 24/7 contact number.”
Services offered for patients at risk for suicide or with suicidal attempts
Identifying patients at risk for Suicide
All patients who come for outpatient clinic and through district help line numbers are
evaluated for self-harm behaviour. Changes in social behaviour and biological functions,
history of past attempt, presence of depressive cognitions like hopelessness and worthlessness
31
and presence of death wishes or suicidal ideas are the most common response in descending
order of frequency given by interviewed staffs which they think will help them to identify
those at risk for self-harm/suicide decreased social interaction. Substance abuse, personality
issues and available psychosocial support are the other areas which the DMHP staff said that
they would focus to identify those at risk for suicide. One psychiatrist specifically mentioned
that she will explore, whether the patient has made or thought of any plans about harming
themselves.
She said, “If they approach us and even if they did not any sign we would ask them how they
are feeling sad or depressed, do they have any suicidal thoughts , even if it not that extreme
do you have thoughts of harming yourself, in cases if you get these ideas then how often are
you getting these ideas, have you ever thought or planned to do it, some may have planned
some may not, how far are their activities, are they showing any difference in their routine
life, communicating well or feeling withdrawn or dejected, feeling invaluable, so we ask all
these things in risk assessment. In case, if they have attempted then we assess the intensity,
lethality and things”
Contact gap
Once stabilized in emergency departments, patients with attempted suicide will come in
contact with DMHP team through referrals from GH and PHCs. The average contact gap of
such patients who got admitted in district headquarters hospital ranged from one to two days.
Patients with suicidal attempts who were admitted in taluk GH and block PHCs have to wait
till the next scheduled visit of DMHP team to those health institutions. Most of those patients
with suicidal attempts getting admitted in taluk GH and block PHC gets discharged without
receiving any psychological aid and were informed to attend when the next DMHP team visit
happens there.
A psychiatrist said, “If patient gets admitted in block PHCs or taluks GH etc., the message I
give them is our day of visit to be displayed. So whatever PHC, taluk hospitals I visit I go on
constant days. So basic message given is to visit the subsequent psychiatry OPD for suicidal
cases admission. Example if he is discharged on 10 th of this month, then he is advised to
attend the next psychiatric OPD in next month in the same GH or PHC. Because they might
not wish to travel or visit mental health hospitals. So, we say them on what date they have to
32
come. This is what is insisted. In some areas it is followed where in other areas it is not. But
a register is being kept to document details of patients with suicidal attempts.”
Services for patients who attempted suicide
In few districts DMHP team provides tele counselling to patients under admission in taluk
GH and PHC based on the information handed to them by the concerned health establishment
where the patient was admitted and were asked to follow up with next scheduled DMHP team
visit to those institution.
A psychiatric social worker said, “So if they have attempted suicide in nearby town, they will
be referred to us here. In case if they have taken admission there and if they find it to be
difficult in treating them there, they will be sent to us here. And if the patient has taken
admission there and discharges from there, we receive their reports alone. Reports will be
about their problems and it will be sent to us. We will not have the chance of seeing those
patients in person. We will see only their reports. We will get their numbers and contact them
through mobile. It will be like mobile counselling”
The assessment part focus on identifying the stressor, intent and lethality of the attempt,
personality, substance abuse and social support. Most of the suicidal attempts are in the
teenage and early adulthood category ranging from 15 to 40 years of age and are impulsive
acts as a retaliatory response to a stressful event.
A psychiatrist said, “I have seen that there is more suicide because of impulsive act, in
between the age group of 20 – 40 years and also would be in schools and colleges”
Alcoholic spouse, financial crisis, relationship failure, stomach pain and academic pressure
are the major cause reported for suicide. Treatment services offered for patients with suicidal
attempts range from treating underlying psychiatric conditions (if any) with
pharmacotherapy, electroconvulsive therapy (ECT) for patients with active suicidal ideation,
psychotherapy tailor-made to every individual focusing on rectifying the cognitive distortions
and improving the coping skills and family therapy.
A psychiatrist said, “After that, if the intent is less, we give supportive psychotherapy and
then we do phone follow ups. Even if there are no stressors, we follow up on first and third
33
months concurrently. If the intent is high then we ask them to come directly and provide
treatment. If they are doing good then we do first month follow up then 3rd month follow up.”
Another psychiatrist said, “If we find patients with depressive symptoms, we hold back them
as in-patients for observation.”
A psychologist said, “In day-to-day work I use more of psychotherapy depending upon the
cases I receive. If there any stressors that is bothering them like psychiatric issues or any
family disputes or there is suicidal attempt, I will handle them accordingly”.
A psychiatric social worker said, “We identify patients from OPD and get to know about their
problems. If they are depressive, we find their needs and suggest them to admit here for at
least 2 days and provide counselling.”
To prevent any attempt in future, more importance was being given to psychoeducation of the
patient and their family members regarding the symptoms, diagnosis, need for treatment,
continuous follow up. Family members were engaged to improve the psychosocial support
available for the patient and they were educated on expressed emotions and how they can
manage them so that the patient can benefit in long term.
A psychiatric social worker said, “If the person has a problem, we will talk about it to their
family. We convey the reason to their circle. We ask them to be kind towards them if it is
related to studies. We ask them to talk in appropriate way to the patient. We usually talk to
them about the Dos and don’ts.”
Role of psychiatric social worker and psychologist
Psychologists and psychiatric social workers are utilized to provide psychosocial

interventions as mentioned above to the needy ones. Their services were also utilized for
disability assessment, pre-marital counselling, child guidance service, counselling to school
and college students, working with NGOs for occupational rehabilitation of patient once the
patients are discharged, planning and making home visits and coordinating placement of
wandering mentally ill in nearby Emergency Care and Recovery Centres (ECRC).
Treatment of mental illness by PHC Medical Officer
34
Except for the PHC Medical officer representing Salem district all other PHC Medical
Officers reported they have attended one training program provided by DMHP with duration
ranging from one day to 3 days. Three medical officers reported the duration of training was
for 1 day only. Medical officer representing Salem district reported that she was trained twice
and the training duration was 5 days each time.
She said, “Training was a renovating because they took us to mental asylum where there is a
classification of all mental disorders in Madurai. The patients were staying there, so we
understood how they got refreshed and cured from the disorder and how they are leading a
normal life including work. They took us to 2 – 3 places and made us understand”.
4 of the PHC medical officers reported that they can prescribe medicines and provide
psychological support for patients with minimal symptoms of anxiety, depression, behaviour
issues, and intent with suicide. They mentioned that if the symptoms were severe or if the
symptoms worsen in the follow up, the patients will be referred to the DMHP team. They also
added that any patient with suicidal attempt will be referred to DMHP team.”
A PHC medical officer said, “Previously whenever we receive a psychiatric case in our PHC
they have to visit district headquarters hospital for taking medicines. But now for small
diseases like anxiety disorder, we consult them here itself. We don’t have counsellors. So, we
brief them ourselves about the disease. We guide them to take proper treatment and prevent
them from going in wrong direction. Every month 2nd Tuesday psychiatrists visit here. So,
we ask the patient to come on those particular day and give them medicines. If OP patients
go to district headquarters hospital without this knowledge, DMHP team divert them and
give them medicines here”
Another PHC medical officer said, “Yes we are able to treat them. Whoever comes to us we
are able to guide and treat them. To follow them we take the help of VHN, etc.”
With respect to treatment of a patient with suicidal attempt a PHC medical officer said “In
such cases with suicidal attempts we don’t involve much. In case, if we find cases with such
symptoms, we refer them to higher centres. They go there for treatment, and if the prescribed
drugs are available here, we give them the medicines in PHC itself in follow up.”
One of the PHC medical officer working under Rashtriya Bal Swasthya Karyakram (RBSK)
scheme, reported that her primary duty was to identify children with issues and refer them to
35
higher centre for treatment. She said, “We do only referrals. During our visit if we notice
someone with psychiatric problems, we refer them to GH. If people come to us with any
disease or any psychiatric illness all we do from our side is refer them, we refer them to the
nearby GH.”
One PHC medical officer reported that if the patient is already on psychiatric medications and
maintaining well he will prescribe them the same and in case there is worsening of symptoms
or new patients with psychiatric symptoms he said, “I will refer them to DMHP team.”
Strengthening referral services
Orienting field level staffs
Once the OPD services are over the DMHP team engages in promotion of mental health
related activities. All GH and PHC staffs in the cadre of medical officers, staffs nurse and
village health nurses, Makkalai Thedi Maruthuvam(MTM) workers and ICDS anganwadi
workers are oriented on the importance of mental health. They were explained about the
common psychiatric disorders, their signs and symptoms and the need for early identification
and treatment for better outcome. Main purpose of these activities is to strengthen the referral
mechanism at grass root level as these staffs are usually engaged in providing services at door
step and can easily identify people with psychiatric complaints in the community itself. Once
such patients are identified they will be given appropriate directions on accessing the mental
health services nearer to their home.
A psychiatrist said, “So when we visit the centres, we usually attend the OPD cases till 12
pm. Then we will start by giving orientation to the hospital staff and then through them to the
community on stigma discrimination. Mainly we are targeting VHNs, anganwadi workers
and recently MTM worker. In GH majorly we tell all the staff not just for suicide, but also we
ask them to refer any patients with psychiatric symptoms to us.”
Another psychiatrist said, “We train all the PHC level medical officers, paramedical staffs
and non-medical staffs related to mental health awareness whenever we visit the fields.”
With regard to providing assistance and training to PHC level health care workers on
providing health care services, one psychiatrist was noted to have a different opinion when
compared to others.
36
A psychiatrist who has attended the orientation program about DMHP said “We act as a basic
resource person for those who enquire. When doctors ask about some psychiatric conditions,
we being a specialist in that field we solve that. We clarify the disease related query to
anyone including doctors, community members etc.”
Another psychiatrist who didn’t had orientation program at the time of joining said,
“According to me, the people in the district should be aware and register psychiatrists face
in their minds. We cannot train people and ask them to reach to the community. In my
personal opinion I think it wouldn’t work”
Promotion of mental health
Table 4.List of subthemes and codes under the theme “Promotion of mental health”
Theme Subtheme Code

Promotion of mental Activities on important Public rally and street
health days drams
Articles in news papers
Pamphlet distribution
Competition in schools
Content for the activities.
Mass media and social Activities in social media
media Activities in mass media
including FM and TV
Mana Nala Vzhyalan Target audience
Activity content
Activity method
School and colleges Frequency and coverage
Empowering teachers
Empowering students
Targeted interventions on Police personnel
stress management Sanitary workers
Major working-class
population
Government staffs
Working with key Experience on working
community members and with community leaders
groups like village head/panchayat
head/politician
Experience on working
with self-help groups and
NGOs
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Activities on important Days
Planned promotional activities are usually carried out whenever there are funds available.
Such planned activities are carried out in important days related to mental health like world
mental health day, world suicide prevention day, antidrug addiction day etc. Contents are
chosen specific for the day and activities conducted varied for each district. Some of the
commonly employed activities are street rallies, taking pledges, drams and role play on
important streets and bus stand, awareness pamphlet distribution and competitions for school
and college students with themes focusing on importance of mental health.
A social worker, with respect to the activities carried in her district said, “On days like world
anti-drug day, schizophrenia day, mental health day, suicide prevention day, we conduct
rallies, awareness programs, distribute materials and pamphlets, make students to take
pledges, install stalls etc. and these things will be covered by media.”
A psychiatrist said, “Since 2016 or 2017 we’ve been conducting competitions like drawing,
essay writing competitions, speech competitions, etc. On mental health day, de-addiction day
etc. the themes like ‘mananalamey udal nalam’ will be given for essay writing and speech
competitions. And if it’s a de-addiction day then we will display a picture of alcohol
consumption and ask them to write an essay or poem about it.”
Activities are chosen based on the involvement and commitment from the DMHP team staffs
and their perception about the reach and impact that the activity has on the public. Details
regarding such activities will be picked by news reporters and got published in newspapers.
A psychiatric social worker said, “2 days back we did a rally on suicide prevention. It was a
mass awareness. Around 200 people were involved in that but the reach was among 1000
people at least”
Utilization of mass media and social media
In addition, information about mental illness with respect to signs, symptoms and treatment
availability will also be published as articles in newspapers.
A psychiatrist said, “Whatever awareness we provide, we give it to the newspaper to publish

and through which we get few cases.”
38
Around half of the DMHP staffs reported using social media like twitter, Facebook and
WhatsApp for promotional activities such as circulating e-pamphlets and information about
the services available under DMHP, while the other half reported they don’t use social media.
A social worker said, “We use Facebook, WhatsApp etc. In Facebook we promote the
programs that we do in district. We don’t use Instagram. But we use Facebook and
WhatsApp.”
All the districts reported that they had done at least 1 program in local F.M channels as a part
of mental health promotion. In districts of Salem, Erode, Tiruchirappalli and Tenkasi district
psychiatrist participated in the FM program. In districts of Namakkal and Karur, psychologist
and psychiatric social worker had participated in the FM program respectively. One district
psychiatrist reported he had done a program for students preparing for NEET regarding stress
management in a TV channel with state wide coverage.
A psychiatrist said, “We have done 2 programs in FM on topics such as mental health and
de-addiction. It happened for 2 subsequent years. Both were live programs. One was like a
question and answers with the radio jockey and the other was with questions from audience”
Two districts reported that they had done paid advertisement about DMHP services in
theatres and local TV channels in the past. Due to lack of funds, such activities have been
stopped now.
Mana Nala Vzhyalan
DMHP team and medical officers on every Thursdays conduct mental health awareness
sessions called “Mana Nala Vzhyalan” in every GH and PHC for the general public visiting
the health institutions for general health ailments. Sessions usually consist of speech by a
DMHP staff or medical officers on important topics such as symptoms of common mental
ailments and the treatment availability, availability of treatment for addiction disorders,
stigma eradication, stress management and suicide prevention. Display boards, posters and
information pamphlets on various metal illness are utilized to make the sessions easily
understandable for the public.
39
A psychologist said, “Every Thursday we conduct Mana Nala Vyazhan in all PHC. In that
program we educate them regarding psychiatric illness for patient, general patient and PHC,
staff nurse.”
Promotional activities in Schools and Colleges
As a part of promotional activities, awareness programs are conducted in government schools

and colleges. There is gross variation in the number of schools and colleges covered by the
DMHP teams.
One district psychiatrist said, “Monthly once or twice we do awareness program in schools
and colleges related to substance abuse.”
Another district psychiatrist said “I am not so particular about numbers. However, in recent
times due to Covid-19 all the activities were stopped, but before that monthly 7 to 8 schools
we will cover.”
As a part of mental health promotional activity, all DMHP staff reported that separate
training programs are conducted for school teachers to impart life skills training so that they
are empowered to teach the same to students. The teachers are also taught about the
symptoms and signs of mental illness such as depression, anxiety, learning disorders, and
oppositional defiant and conduct disorders so that students with such symptoms can be
referred to DMHP team through the district teleconsultation number provided to them.
A psychiatrist said, “These trainings would help the teachers to identify if a student is dull or
low. Then they would call a psychiatrist. We share our number to all the teachers so at least
one responsible teacher would notice the difference in the child and call us.”
Awareness programs for students in schools and colleges usually focuses on problem solving,
resilience building, exam stress management, and suicide prevention, prevention of drug
abuse and sex education. When facilities are available power point presentations are used and
sessions are made as interactive as possible to obtain student’s attention. Drams and role
plays are also done to maximise the impact. Based on availability of time, counselling
sessions to needed students are also provided.
A psychiatrist said, “Stress management, suicide prevention, resilience building, problem

solving and coping skills are the topics majorly from suicide and mental health.”
40
Work place stress management Sessions
During Covid-19 pandemic, sessions on stress management for government servants working
under health and revenue departments has been conducted by all DMHP teams. 4 districts
informed that they had done mental health awareness and stress reduction programs for
police personnel. Stress management sessions are conducted for working class population
like textile workers (in Erode and Karur) and lorry drivers (in Namakkal). DMHP staffs of
Tenkasi, Erode and Namakkal has said they had done target intervention program on
substance abuse and treatment availability to corporation sanitary workers, who at risk for
substance abuse.
Experience on working with community level groups and local leaders.
Few of the DMHP staffs reported that they had worked with local leaders like village
head/panchayat head. Their help is sought for obtaining permission to conduct the awareness
meeting/program in government buildings/public places like bus stand for Mahatma Gandhi
Rural Employment Guarantee Act beneficiaries (100-day workers). In few places they are
invited as guest for the program.
A psychologist said, “For carrying out programs among the 100 days of guaranteed wage
employees, the district psychologist speaks with the respective panchayat head and seeks
permission and then we coordinate the program for them.”
Experience on working with NGO
More than half of the interviewed staffs reported that they work with or join with NGOs like
Lions club or Rotary Wings since they will take care of all organisational activities including
funds needed for a promotional camp/program. However, frequency of such interactions are
not regular. Few staffs had reported working with women self-help groups and transgender
for mental health promotion
A psychiatric social worker said, “Mostly we do programs in collaboration with NGOs.

There is a Grama Iyakkam here. So, they invite us for providing awareness whenever they
organize a program. There is an NGO related to alcohol de-addition near Trichy. We join
with them for programs. We also organize programs in collaboration with an NGO called
HEADS. They also refer patients.”
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Challenges
Table 5. List of Subthemes and codes under the theme “Challenge”

Theme Subtheme Codes
Challenge Training Not able to do assessments
Underutilization of service Lack of awareness on treatment availability
Hesitant to approach due to stigma
Preference for native treatment
Irregular follow ups Poor cooperation from patients
Poor cooperation from PHC staffs
Treatment of mental illness Lack of human resource
Lack of infrastructure facilities like wards
Suicide intervention and Poor cooperation from family members due to
prevention stigma and legal issues
Human resource shortage and workload
Poor referral system in PHC and GH
Difficulty to retain the patient in follow up
Easy availability of pesticides
Promotional activities Shortage of fund for travel and awareness
activities
Human resource shortage
Poor cooperation from public/community
leaders/politicians
Schools and colleges Lack of Infrastructure
Lack of awareness and cooperation from school
staff
Lack of proper referral mechanism to report
students with self-harm behaviour
For medical officers Not confident to treat
No time in OPD
For VHN Not adequately trained to identify mental illness
Preoccupied with reproductive and child health
activities
Training
Due lack of training, two DMHP staffs reported that they are not able to carry certain tasks.
Though disability certificates are issued for intellectual disability, patients are not provided
with assessment results. Same scenario prevails for students with learning disability.
A psychologist said, “As I have not completed any training, I have this restriction that I am
not able to make assessment. So only when I am able to do all the work myself, I will be
satisfied and happy. So, lack of training is a barrier for me”.
42
Underutilization of services and irregular follow ups
Lack of awareness about mental illness and treatment availability has been a major reason for
underutilization of mental health services. Even people who are aware about mental illness
are hesitant to approach hospitals secondary to the stigma attached to it. One another reason
is unnecessary fear about medication side effects. All these reasons push majority of patients
to seek native treatment from faith healers. Irregular follow up has been another major
concern.
A PHC medical officer said, “What people think is mental health problems are likely to be
schizophrenic, or roaming in roads with some mental illness. People only consider such
patients as psychiatric patients and only they have to be sent for treatment and given
attention”
A staff nurse said, “Unnoticed cases, even if we insist them to come, they are not coming. It is
because of the stigma that mental health holds. Even the mental health patients are not
comfortable in showing their yellow book. They wrap it in a bag and bring it secretly. So,
there is still lack of awareness on mental health and stigma attached to mental health in the
community.”
A psychologist said, “We are trying our best. Some people get angry, when we say you need
to take treatment for this. They get aggressive. But we understand their ignorance toward
mental health, but stigma still prevails in the community”.
A psychiatrist said, “They are satisfied with 50% improvement. They still don’t have the
awareness of taking treatment for a period of 3-6 months”
A psychologist said, “The major problem here is after 1 or 2 months of medication the
patient starts feeling better. So they stop their medication without our knowledge. We have
given them enough advice not to stop it on their own. We do insist them to consult with us in
order to stop or reduce medication. But they never follow this. So automatically after 6
months they again go through the same problem.”
One more important challenge is poor cooperation from filed workers particularly in the
cadre of VHN, with respect to tracking of patients who doesn’t come for follow up.
43
A psychiatrist said, “Not just for suicide cases, even for general cases if I tell them there are
cases in your area and I have prescribed drugs to them. Can you follow up and update me?
Mostly they are not doing anything till my next visit. So, we have to trace out the case, get the
number and contact the patients with the help of psychologist and social worker. Through
VHN, we are not able to mobilize because they don’t provide their cooperation. So, we
cannot do it.”
Lack of separate psychiatric wards
Aggressive patients are usually referred to medical colleges since all the districts except
Erode doesn’t have a separate psychiatric ward. Available DMHP staff nurses are usually
posted on general ward duties. With the district headquarters hospital of Salem and
Tiruchirappalli located in the periphery of their district, the concerned DMHP teams are
facing challenge in motivating the patients for admission there, as the patients have to travel
more distance.
A psychiatrist said, “We cannot handle cases like violent patients. Why we can’t handle is
that we don’t have wards. Why we don’t have wards is that we don’t have psychiatrist nurse.
They do general duties and even if I put a nurse, they will question us. Another issue is
distance. I cannot tell them to travel 3-4 hours to get admitted in a hospital and we don’t
have bed or ECRC facility available in our centre. So, we have to refer and shift them to the
main hospital because we don’t have the support we need. All calls come to us and we are
helpless. We are just doing referrals or diverting them to hospitals. Frankly that is what we
are doing. I can go and see the patient for 2 days but it is not possible to admit them after the
camp so we refer them to middle college. We are not able to admit here”
With government protocol strictly insist on no restrain of patients, the DMHP teams doesn’t
have the particular resources to manage aggressive patients. One district psychiatrist said that
they don’t have the equipment to provide ECT.
Another psychiatrist said, “The main concept of DMHP is 10-bed ward at the headquarters
hospital. The sanctioned man power is 1 staff nurse. If we are running a 10-bed ward, then
we need a minimum of 4 staff nurse. Only then we can make shifts and run the wards. Here
we will have people with special needs also. They will not be stable and they can be
aggressive. So, all patients can’t be cared by 1 staff nurse. In that case human resource,
equipment and infrastructure facilities are less. Protocols for the management of aggressive
44
patients are being given already. Government protocol is not to restrain the patient. But
without restraining, we can’t handle the aggressive and irritable patients. We don’t have that
particular equipment or facilities with us. Only we have the protocol. If it’s some other ward
we can handle by talking with them. But when their complaint itself is aggressiveness, then
for sure he has to be restrained. So, nothing can be done without proper equipment and
facilities. ECT machine is available in all areas. There will be shortage of oxygen in all
areas”
Challenges for suicide intervention and prevention.
Due to lack of awareness about the severity, stigma and fear about legal issues associated
with the suicidal attempts, majority of family members are not willing to cooperate when the
DMHP staffs visit patients to provide assistance. Patients are forced by family members to
give false reasons such as stomach ache or any other physical ailments as the cause for
suicide attempt.
A psychologist said, “Some parents tell us the truth and others lie to us because people get
scared when we approach them. One common fake reason they give is stomach ache. Only
when we talk to the patient alone, we understand the honest reason for committing suicide.”
Another psychologist said “They fear, if they open up, it might become a police case. In case
if an 18-year-old girl commits suicide, their parents fear that other will speak badly about
them and humiliate them. So, they say their daughter would have committed suicide for
stomach ache”
Most of the hospitals doesn’t have separate psychiatric ward or counselling room to ensure
confidentiality which further makes the patients uncomfortable to open up.
A psychiatric social worker said, “So when we see the patient in ward they don’t open up
because of prestigious issues. But at the same time if we have separate chamber and if we
interact with them there they will open up and share everything.”
Busy ATP schedule and superimposed disability camps also keep the DMHP staffs occupied
so that they are also not able to allot ample amount of time for each patient to provide the
needed psycho social interventions.
45
A psychiatrist said, “Even if we have wards with inpatients, I cannot make regular visits to
the ward because my schedule is already packed”
A psychiatrist said, “If they go to a private hospital therapist sit around 40 - 60 minutes with
a single patient. If I sit with the suicidal patients then I won’t be able to focus on patients at
OPD. So to be frank with the short time I have, I cannot build rapport or break the ice with
the patient and also for the patient also, it is not comfortable.”
As mentioned previously some of the patients who got admitted in taluk GH and PHC with
suicidal attempts are being discharged without any psychological assistance. Such patients
are provided with the details about the next visit of DMHP team to their institutions and
discharged. A large number of these patients won’t come for follow up. Even with repeated
instructions to document the contact details of patients with suicidal attempts in nominal
registers, GH and PHC staffs are not cooperating for the same. Hence a number of patients
with suicidal attempts goes unnoticed.
A psychiatrist said, “Even if we take from the nominal registers from PHC and GH, we do
have cases with no numbers to contact. So, I cannot assure you that I am addressing 100
percentage of cases here. Maybe I can cover up to 60 percent of the cases here, remaining 40
percent is still unnoticed because we are not able to trace them and nominal details are not
maintained properly. So, 50 -60% of cases I am covering, remaining are unaddressed. Our
team keeps on working, but still I have to keep on monitoring the number of cases received. If
I don’t look for 10 days then the number of cases being registered will reduce. So apart from
our team, PHC and GH staffs also should consider it as a routine procedure. Instead of that,
in-charge ward staff wants the wards to be free and already the patient will be eager to go
home and these staffs without our consultation they will discharge them. So, when they go
like this, we lose that patient”
A psychologist said, “By the time we go to a particular PHC the patients would have been
discharged. So, we request the nurse to get their contact numbers, even if not the address at
least a phone number, for patients with suicide attempt and mental health cases as it would
be helpful for us in the follow up process. But they never do that. We are feeling very
challenging in that aspect as we won’t be able to reach out the patients without their
numbers”. When asked about his chance of seeing those patients, he replied “We’ve never
seen those patients. Staff insufficiency is also one of the main reasons.”
46
Since the family members are not sensitized about the severity of such suicidal attempts
during the stay in hospital, they refuse to accept interventions from DMHP team when
provided later. Also keeping the patients in follow up in one another major challenge with
respect to suicide prevention the DMHP staffs face. Inadequate staff strength and lack of
time due to excess workload are perceived to be the major reason which prevents the DMHP
staff from contacting a patient who had missed his/her follow up visit.
A psychiatrist said, “If it is an in-patient then their parents will be with them or one parent
or husband or wife or guardian will be with them bedside. When we contact through phone
then sometimes their parents lift the calls and sometimes the patient themselves pick the
calls. So, when we follow up through phone the involvement of family member is less only”
A psychologist said, “Most of the patients referred through 104 are usually followed by them
and when they didn’t get proper response from them, 104 people refer those cases to us. They
don’t give them directly without following. Most of the cases I receive are like that. So, when
I call them, they will be like “why are you calling us often and disturbing sir? So, we don’t
get a proper co-operation.”
Another psychologist said, “Asking them to come back for another session is the biggest task
and very challenging”
Another psychologist said, “When we wanted him to come for 5th visit, his family started to
avoid us. I even tried calling from my personal number because they recognized my official
number. But we didn’t have any response”
Another psychologist said, “Patient not coming for follow up is only high. Because they think
that they are cured. Everyone’s thought is like that only.”
Easy availability of pesticides in village side has been another major challenge while working
for suicide prevention. A PHC medical officer said, “Hoverer the main reason is that
poisons are easily available in their fields itself since it’s a village.”
Challenges for promotional activities
Inadequate fund for travel
47
More number of DMHP staffs reported that whatever funds provided for travel are
inadequate. DMHP programs of Salem, Tiruchirapalli and Tenkasi are functioning from the
district headquarters hospital located in Mettur, Manaparrai and Tenkasi. These towns are
located almost at the periphery of the concerned district. More time and amount are spent for
travel itself, if the teams are supposed to visit a PHC or Taluk GH located at the other end of
the district.
A psychiatrist said, “Because whatever vehicle expenditure we are given is same as that of
RBSK expenditure. But RBSK is a single block expenditure. That is within a block they will
ride 1500km with a maximum of Rs.30000 cap. But DMHP is for a district. But the same
regulations are given for both. It is a known matter. It will not be applicable if they imply the
same for a district.”
Shortage of funds for promotional activities
Two DMHP staffs from a district reported there has been shortage of funds with respect to
the promotion of awareness activities. They also said that funds are delayed or not available
at right time. A psychiatrist from other district reported that officials in their concerned Joint
Director offices are delaying the paper works to release funds.
A psychiatrist said, “If funds are there, we can plan more activities like we planned. Bus
stands will have announcement speakers. So, through that we can create awareness. All these
things we have thought and kept it aside due to lack of fund for promotional activities”
A psychiatrist said, “Initially we did. We used to telecast ads in all local channels. But now
we don’t since there are no funds.”
Another psychiatrist said, “With respect to travel allowance, they are delaying to give us.”
Shortage of human resource
As per the DMHP staffs, shortage of human resource is a major challenge and they are
currently managing a lot of work, which hinders them to do adequate promotional activities.
Also, all DMHP teams are functioning without the sanctioned strength. In addition to that,
DMHP staff nurse and psychiatrist are deputed to general ward duties and also for disability
camps. Morning sessions are usually spent in providing outpatient services and DMHP teams
are able to do promotional activities only in afternoon. Absence of field level staffs
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specifically designated for DMHP is one more concern expressed by three of the
interviewed psychiatrists.
A staff nurse said, “1 year before I joined in this centre. But they assigned me emergency
ward. Just 3 months before I got to know I was posted here for DMHP program”
A psychiatrist said, “Apart from this, when they start involving us in general duties at
headquarter hospital, psychiatry outpatient services and in-patient services also start
suffering. Finally, the field visits also suffer completely. As per DMHP and NMHP provisions
district and satellite psychiatrists have to be exempted from general and post-mortem duties.
But it is not followed strictly in all areas”
A psychiatrist said, “We are asked to conduct disability camps in the community. I was asked
to involve in that and my maximum time is spent there. So roughly around one and a half
month, I was not able to do my regular works like general OP and mental health awareness
activities. Though the disability camps are a part of the program, it should not affect my
daily routine works”
A psychiatrist said, “Workforce of DMHP team is less. It is district centred. Since the
headquarters hospital is at district headquarters and the requirements of the district is so
enormous, it becomes a challenge to reach the field where the requirements is also
enormous. Example if we take leprosy cases there are 1 or 2 NMS given per block but in
general the total number of cases will be only in 10s or 20s. So for such a less prevailing
disease there are adequate resources. But whereas mental illness is a huge problem and the
stigma is also very high”
Another psychiatrist said, “For example the success of programs like TB, leprosy was,
mainly because of the field level staffs. They have staffs like HI (health inspector) to monitor.
For us there is no separate filed level staffs. That is the major problem”
Challenge while working with Community level groups/Local Leaders.
Most of the DMHP staffs reported that they haven’t worked with panchayat
leaders/politicians to promote mental health. Lack of awareness about mental illness among
local leaders have been a major challenge for engaging them in mental health promotional
activities.
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A psychiatrist said, “Yes. I went and met the panchayat president. But what they are asking
is to come on their program day or day convenient for them or some other day which is very
far in time”
A psychiatrist said, “If we directly approach the local leaders, we might not get a good
response”
A social worker said, “There is no awareness among those leaders. Other reason is they are
not educated. Moreover, when we call them for some awareness, they are more concern
about free food and money. They don’t care about what we are saying. Only if it’s their
relatives they refer us.”
A psychologist said, “Even they do not have knowledge on mental health. So we first make
them understand the importance of mental health and also give them an idea about district
mental health program. If we go again, we won’t get any response.”
Challenges in schools and colleges
Due to lack of awareness and stigma attached to mental health, almost half of the DMHP
team staff teams report they faced poor cooperation from school and college Staffs, when
they try to conduct awareness programs.
A psychologist said, “Yes, we face some challenges. Like, while doing programs in schools
they ask for permission letter. Generally, they see us with a different notion because it is
related to mental health and also, we also lack mental health awareness in India. Because of
this, they avoid such programs thinking that they are healthy”.
A psychiatric social worker said, “There were many problems even after getting permission
from Chief Educational Officer (CEO). In certain boys schools the head master was not
allowing us. They treat us strangely. They don’t welcome us properly. They address us like
“mental group” instead of mental health group. They don’t even give us chairs to sit”
Lack of projectors hinders the utilization of power point presentation in schools. One more
challenge experienced by DMHPs staff is that only few of the teachers are actively involved
in referring the children with issues at the right time. Students with intellectual
disability/dyslexia are usually referred to mental health professional only when they reach
10th standard so that the student can get permission to write the public exam with scribe.
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A psychiatrist said, “If we organize a program in 20 places, we will have the facility to
display power point presentation in only 4 to 5 places”
A psychiatrist said, “Maybe teachers are finding it difficult to identify the mental health
problems among students and the other thing is students may not open up very easily due to
reasons like lack of care by teachers apart from education”
A psychologist said, “Only if we give training to teachers then the benefits will reach
students. The teachers are unaware of it. For example, they are not even able to identify
learning disability. Without recognising that they come up to 10 th standard. They don’t find it
in early stage. Even now there are 3 students and the school has referred to us now.”
Large number of self-harm/suicidal attempts in schools and particularly in colleges are not
reported due to the lack of proper referral mechanism
A psychiatrist said, “The impulsive suicide attempt cases are more compared to cases with
true suicide intent. Maximum number of the impulsive attempt cases would be college or
school students. Here we aren’t able to meet them”
Challenges for PHC Medical officers and VHN
Two of the PHC medical officers reported that they are not confident or adequately trained to
treat disorders and 5 of the medical officers reported that they don’t have adequate time to
spend with the patient in outpatient department.
A PHC medical officer said, “As a medical officer, we don’t have that much time. We can’t
achieve anything by speaking for about 2-3 minutes with patients”
Another PHC medical officer said, “Once we receive any cases with severe symptoms, we
refer them to higher centre. They will do the further follow-ups.”
Challenges for VHN
In both the focussed group discussion, village health nurses said lack of adequate knowledge
on mental illness and pre occupation with reproductive and child health related activities are
the major challenge which prevents them from actively contributing to the mental health
program
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A VHN who participated in FGD said, “We have more work so we don’t have time to do all
these extra works when we are on field”
Another VHN added, “We are not experts in it. So, we don’t know much about it.”
Strategies
Table 6. List of Subthemes and codes under the theme “Strategies Utilized”
Theme Subtheme Codes
Strategies To increase case load Train teachers
Train PHC staffs and get their cooperation
Communicate the date and time of DMHP team
outreach visits to public in advance
To handle human Utilize other directorate psychiatrists
resource shortage
For Suicide intervention Ensure good rapport and confidentiality
and prevention Psychoeducation of family members
Improving psychosocial support
Treating underlying psychiatric illness
Adequate follow up
Emergency teleconsultation services.
For promotion of mental Do more awareness activities
health Focus on treatment availability at nearby GH and PHC
Focus on the community need and correct timing
Interactive sessions and pamphlet distribution
Adequate utilization of social media
Approach the community through the right source.
For schools and colleges Interdepartmental coordination at higher level to obtain
permission
Interactive sessions with audio visual aids and
pamphlet distribution to gain attention of students
More focus on resilience building and stress
management
Anonymous question and answer session
Strategies to increase case load
Train teachers and PHC staffs
Strengthening the referral mechanism at grass root level by training more medical officers,
staff nurses, VHN, anganwadi workers and teachers is the most commonly employed strategy
to increase case load in outpatient clinics. Frequent sensitization of PHC staff nurses and
village health nurses yielded better cooperation from them with respect to mental health
related activities.
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A psychiatrist said, “We do awareness program in schools and colleges related to substance
abuse. We educate both students as well as teachers regarding personality disorders. We
educate teachers to identify people with IQ problems, dyslexia”
A psychiatrist said, “For example we have mental health Thursdays. So, we send them (PHC
staffs) IEC materials. To get the report from them was a big task for us. Now it is becoming
better, maybe with more sensitization we would be able to achieve.”
One recommended strategy to get VHN cooperation is to restructure their performance report
so that it includes mental health indicators and also the report has to be reviewed by officials
like Deputy Director of health services, working under the directorate of public health.
The same psychiatrist also added, “Deputy Directors or Block Medical Officers don’t ask
these reports or happenings of DMHP in the VHNs review meeting. So if they make it a point
to ask them, maybe VHNs might take extra effort in doing it.”
Communicate the date and time of visit to public in advance
Few DMHP staffs reported that small steps like displaying the details about their visit in front
of the hospitals, repeated reminding of village health nurse and PHC medical officers over
phone and circulating pamphlets in social media groups few days prior to a planned visit
helps them to get more cases.
One Psychologist said, “We give them the date and timings in which we will be visiting a
particular hospital. Those days we visit only that government hospitals. Only few cases we
used to receive then. But now in 8 years people have gained awareness and people have
started coming in search of us to find solutions to their problems”
A psychologist said, “Sometimes even the doctors and staff nurse might forget that we will be
visiting. So even for them to remember it easily, we have pasted our schedule in the centre of
PHC. Some BMS who are active on field will publish the dates in the local media and gather
the people who need treatment”
Strategies to overcome human resource shortage.
With support from Joint Director of Health Services, Salem DMHP team has added another
government psychiatrist working in a Gangavalli taluk GH in Salem district to provide
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mental health care services in around Attur health unit district. This help the Salem DMHP
team to save time and money as the Attur GH, Pethanaikampalayam GH, and Gangavalli Gh
covered by third psychiatrist is located about 1oo kms from Mettur district headquarters
hospital. District psychiatrist said "We can also focus on general health services on few days
and this help us to relax"
Another recommended strategy is to utilize all psychiatrist in a district working for the
government irrespective of their directorates so that unexpected workload like special
disability camps won’t affect the routine DMHP activities.
A psychiatrist said, “So now these disability camps are specially organised. In that time if we
could seek help from general psychiatrist, it would be better. My opinion is through proper
communication and coordination it can be done efficiently. In addition to the two of us in
DMHP, we have 3 more psychiatrist in medical college and one more psychiatrist working in
********** GH. If there are 6 camps if we include all psychiatrist from DMS and DME,
each one has to do one camp only. Then the major workload will be reduced and I can focus
on my routine.”
Strategies for suicide intervention and prevention.
More promotional activities are conducted focussing on stress management and suicide
prevention. When combined, simple strategies such as good rapport with an empathetic
approach, ensuring confidentiality and psychoeducation about the illness severity to the
patient at risk for suicide or with suicidal attempts and their family members yielded better
results with respect to obtaining proper history and consent from them for treatment.
A psychiatrist said, “We need to approach them empathetically. Then only they build trust
with us and open up. Also, then only they will come for follow ups if we call them”
A psychologist said, “We speak to every person separately instead of speaking to everyone at
a time. Like speaking with attender separately, with patient separately.”
Another psychiatrist said, “So we give a personal report about the patient mental health and
inform about the need for admission to the patient family members. Basically, we need to
spend more time with the family members. We need to make them understand that suicide
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attempt is due to mental illness and it is common these days and we should increase the
awareness.”
More importance are paid to identify and treat underlying psychiatric cause such as
personality issues, depression and substance abuse. Strengthening the patient’s psychosocial
support through psychoeducation of family members like continuous monitoring of patient
and family therapy also helps to prevent any suicidal attempts in future.
A psychologist said, “After a certain stage when the students realize that they can’t meet
their parent’s expectation or when no one is ready to listen to them, they try committing
suicide. Sometimes there might be problems within the family like disputes between mother
and father and the students don’t know to whom they should share all these. Under these
situations also they commit suicide. So, we need to address all these things.”
Most of the DMHP staffs felt ensuring adequate follow up is one more strategy which helps
to prevent suicidal attempts. Patients with high risk are followed for a period of about 6
months or till the treating team feels the patient is better. Teleconsultation services numbers
are provided to patients so that they can reach the DMHP team in case of any emergency.
A Psychologist said, “Follow-up is the main useful strategy. I would follow all patients to a
stage where they would say I would never take such a decision in my life. So that much
follow up I do and call them a lot of times. For some of the severe or risky cases, I would call
them daily. This is very helpful and now it has become a habit. If they are low or not okay,
then I call them even more repeatedly and keep them engaged.”
A psychologist said, “If their thought is intense, we encourage them to call 104 or call us for
help.”
Strategies for promotion of mental health
Most of the DMHP staffs said the number of awareness programs/activities to promote
mental health should be increased. With respect to the content of the program more staffs
recommended highlighting about signs and symptoms and treatment availability while others
have recommended to focus on stress management and suicide prevention. More staffs
preferred for promotional activities like dramas, street play, interactive sessions and
distribution of pamphlets than open talk as they had elicited more interest from community.
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Only few staffs are interested in promotion of mental health through social media due to lack
of clear guidelines with respect to the contents that should be promoted.
A psychiatrist said, “A sustained information regarding the treatment system is required.

They should know where they can get their problems solved. So, people should be aware of
this. Then they will reach out for sure”
Another psychologist said, “We do songs and psychodramas in the community and schools. I
feel that has better reach among the people. People are attentive, when we perform
psychodrama and also, they understand the concept better as we are performing it to them
rather than giving a speech. Few people even participate in the psychodrama and one more
thing is we can break the stigma very easily when it comes to psychodrama”
A psychologist said, “Up to me the best practice is to use social media, because through
social media a wide group of people can be reached at a time”
Another psychologist said, “For me the best practice is to use pamphlets. Somehow it will be
visible to someone, so it has the better reach.”
With respect to gaining the attention of the community or its key leaders, promotional
activities have to focus on community needs and has to be timed at the right time for
maximum impact.
A psychiatrist said, “We usually address if there are cases of schizophrenia or suicide
attempts in the community. We address according to the need of the community by planning
with the doctors prior to the visits and in few visits, we decide at the last moment”
A psychologist said, “We also go to the community and understand their issues. Then we
address it accordingly. For example, we came across a village where alcoholism is at its
peak. So, we went and created awareness on alcoholism and encouraged them to seek
treatment.”
Few districts have found that by involving the district administration (revenue) it’s easy to
obtain permission or co-operation for conducting awareness activities from village panchayat
heads.
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A psychiatrist said, “Even in collector’s office if we speak to their PA, they will arrange and
give us permission to conduct promotional activities on mental health. So the programs can
be conducted easily rather than us going from person to person. They provide us permission
and we go and conduct sessions”
However, some of the DMHP staffs are of the opinion that co-operation of common public
and local leaders for mental health promotional activities can be easily obtained if we
approach them through a known person/local person.
A psychiatrist said, “Specifically when block medical officers organize a program, it is

effective. If we directly approach the local leaders, we may not get a good response. If we
inform the block medical officer, they will help us arrange the meeting with the local
panchayat leaders.”
Strategies for schools and colleges
Most of the DMHP teams obtain permission from District CEO prior to visiting schools to
secure the school staff cooperation.
A social worker said, “We get a letter from CEO in prior before visiting schools for backup
so that they (School administration) don’t make any problem”
A psychiatrist said, “So we contact their education official and make him understand the
importance of the session. Now one college which denied us permission first is now
approaching us to take the session. So only through networking we are able to get it”
If projectors are available, power point presentation (PPT) are utilized for mental health
promotional activities in schools and colleges. Information pamphlets are distributed. The
sessions are designed to be as interactive as possible with some teams utilizing role plays and
dramas to gain the attention of students. Anonymous question answer sessions are conducted
at the end of the program to clear student’s doubts.
A psychologist said, “We use PPT in colleges, in schools we don’t have PPT. So, it’s just
talk. But we conduct activities depending on the age group like asking them to write in a
paper anonymously if they have any problems, stressors, family issues. We ask them to write
it individually. Then we collect the papers and we will be open for a session. Those students
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who have issues approach us for help. If required we call the parents and give them
counselling too.”
A psychiatric social worker said, “We assemble 9th, 10th, 11th, and 12th students together.
We make them understand the importance of education and about the adverse effects of drug
abuse, love affair etc. and ask them to approach us if they have any problem related to that.
We conduct psycho-dramas with students. They have a great reach.”
Another psychiatric social worker said, “We also do presentations in schools and colleges as
they don’t concentrate much on us as they do for the PPTs. So according to them we do it in
a picturized way for creating psychosocial awareness. If it’s for 10th-12th STD students we
add pictures related to their age level. Those pictures should be familiar to them like the ones
they see in Facebook or Instagram”
A psychiatrist said, “So maximum we have interactive sessions with the students and
teachers and we encourage the students to speak or the teachers to speak”
Due to rise in suicidal attempts at the time of exam results now DMHP teams have started
provided resilience building and stress management sessions one or two months before exam
date. School staffs are more receptive towards the idea of conducting stress management
program when approached at that time.
A psychologist said, “So what we did is that even before the exam we conducted sessions on
exam anxiety and stress management. So, what we do is we make them understand even if it
goes sideways there is a life. So, we will open that door for them and we will also tell them
the possibilities of what they can do to overcome the fear of failure. When we do this, the
exam stress is also reduced and suicidal rates are also reduced.”
Need of the DMHP staffs and community
Table 7. List of subthemes and codes under the theme “Need of DMHP Staff &
Community”
Theme Subtheme Code

Need Community Need Mentally ill homes
De-addiction centres
Stress management sessions
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DMHP staff need for treatment and Suicide Training
Prevention Infrastructure
Human resource
Cooperation from PHC and school
staffs
DMHP staff need for Promotion of mental Fund
health Human resource
Administration support
Need of DMHP staff nurses Work in psychiatry wards
Need of Medical Officers More training on treating psychiatric
disorders
Needs of the public
As per few of the DMHP staffs, facilities to admit their family members who are suffering
from chronic mental illness and intellectually disability and facilities to treat addiction
disorders are the common demand from public. Also, sessions on stress management and
suicide prevention has been the topic of demand in schools and colleges.
A psychologist said, “When we treat patients with disability, their parents say that they are
stressed after looking after them. They have gone into depression and were taking tablets to
come out of depression. They are asking us to do something for them also. They said that
Rs.1000/ Rs.1500 is not sufficient. You give only bus pass to us. What else is government
doing for us? We have referred those patients to many homes. For the cases Salem
surroundings like Nethimedu our psychiatrist will refer them to mentally ill homes. So, these
are the needs from patients’ side”
Another psychologist said, “Patients family members ask us to take the patient and go”
A social worker said, “People are not financially stable to take care the patient. People are
not ready to rent houses for mentally retarded patients. There are chances of abuses in cases
of female patients”.
A psychiatrist said, “Whatever topic we present to them they would ask for stress
management sessions for students’ group to handle exam stress and even suicide prevention”
Need of the DMHP staffs with respect to treatment component
More Training
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Two of the interviewed psychologists and all the interviewed social workers said that they
need more training with respect to assessment part and about managing cases with severe
symptoms. All DMH P nurses wants to work specifically in psychiatry wards. A staff nurse
working under DMHP and 2 interviewed PHC medical officers also said it would be
beneficial if they receive more training.
A psychologist said, “They have processed a list of names for three months training now. If it
goes through it will be very helpful, then I can officially do complete assessment and provide
proper intervention.”
A psychiatric social worker said, “We’ve been trained only with counselling. So, we feel it as
the impactful strategy. So maybe in future if they train us with other techniques”
A PHC medical officer said, “Currently personality disorders such as borderline disorders
can’t be addressed by our self. In case if we are given training in a broad spectrum, it will be
helpful in addressing these issues”
Adequate Infrastructure
All the DMHP staffs pointed out the need to have a separate ward for psychiatry in district
headquarters hospital and a counselling chamber for them in all healthcare institutions to
provide therapy.
A psychiatric social worker said, “There is no separate ward for psychiatry. We don’t have a
special ward. There are no staffs allocated for us. They are in common only. Since we don’t
have a separate psychiatry ward, we put the patient in either male or female ward. If
separate ward is given to us, it will be helpful.”
Another psychiatric social worker said, “We need a separate chamber for us. We’ve been
recognised as social worker, psychologists etc. but we don’t have a separate chamber. We
have chairs but it is common. We need privacy. If we need to give counselling, we don’t have
privacy to do that. Even it’s the same with district headquarters hospital. We need a personal
chamber for counselling.”
More human resource
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All the interviewed DMHP staff nurses expressed their interest to work exclusively in
psychiatry wards to maximize their contribution to the program. All the cadres of DMHP
staffs said they want the government to increase the strength of sanctioned post for their
respective cadres.
A staff nurse said, “Whatever help we can do within the ward we do. Counselling and care to
patients is not done properly. If we are able to be with the patient full time, it could be better.
If we are given shifts only for psychiatry wards it will be better”
Another staff nurse said, “If they let us work in our own ward it would be helpful but they are
not letting us”
Another psychiatrist said, “The psychologist who is working right now will see through
follow ups and make follow up calls and if she finds any follow up that requires attention
then she brings it to my knowledge. So, she is handling all things by herself. Though she has
all the contacts, there are chances that it can be missed. If we can appoint one more
psychologist, I feel things will be handled better.”
A psychiatric social worker said, “It is good that people are getting aware but in order to
attend them completely we need more human resource. It is not possible to handle them with
1 social worker and 1 psychologist. Higher officials ask us to train people but that won’t
work because how much ever we train them they’ll not get the professional touch. So, we
need more man power. It will be better if separate staffs are assigned to look after
headquarters and taluk”.
Cooperation from PHC and School staff
DMHP staffs expect more cooperation especially in the cadre of staff nurse and village health
nurse working in PHC and teachers working in schools and colleges with regard to case
identification at community level, referral and follow up.
A psychiatrist said, “In tribal areas here, all ASHA workers work effectively on field. Here
VHNs have so many other responsibilities. If they could support us in mental health care in
each area, I think it would work better.”
A psychiatrist said, “During discharge of a patient with suicidal attempt, it should be

registered in the suicide register or psychiatric OP register along with their address and
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phone number. So, when our team goes there they can call and enquire about their condition.
So instead of going into the community if we are able to give better follow up to the ones that
we receive itself means we are doing well”.
A PHC medical officer said, “The respective class teachers can address the students, because
we visit the school yearly once so it is hard to follow up with a huge time gap. Class teachers
will be there with the students on a daily basis. If they can address the students on regular
basis and try to identify the symptoms among students, they can refer the students to us”.
Needs of DMHP staff with respect to promotional activities
More funds for travel and awareness activities
Most of the interviewed DMHP staffs said they need more funds for travel and awareness
activities to promote the program further.
A psychiatrist said, “If they increase the travel allowance it will be better. So we can reach in
community level still more efficiently.”
Another psychiatrist said, “If they hike our travel allowance then our field activities can be
better “
A psychiatrist said, “If funds are there, we can plan more activities like we planned. Bus
stands will have announcement speakers. So, through that we can create awareness”
A psychologist said, “We need fund to advertise our activities. That is also a challenge
because on special days like mental health day we do advertise our activities. We cannot
advertise everything we do because we don’t have that much funds to prioritise
advertisements.”
More human resource
As mentioned earlier all cadres of DMHP staffs say that they are already working without
their sanctioned strength and are preoccupied with routine PHC and GH visit, disability
camps and school and college level activities. For better reach of promotional activities at
community level they want additional staffs to promote mental health activities.
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A psychiatrist said, “To be frank if I have one more psychiatrist at district headquarters
hospital to take care of outpatient and inpatient services, I can go for promotional activities
and outreach psychiatrist will cover taluk GH and PHC.”
Another psychiatrist said, “We have two psychiatrists in our district. If I have one more
person then we can make frequent visits rather than visiting once a month and we can spend
more time on field for promotional activities.”
Administration Support
More than half of DMHP staffs reported that they need more support from the district and
state level authorities with respect to rectifying the challenges they face.
A psychiatrist said, “Even in our monthly report we write and send them. Even last month we
said that the fund for target intervention is not sufficient and we also asked regarding the
psychiatric nurse. Also, from this month we don’t have a social worker too. We have been
asking JD sir also. We asked them during every monthly review. We can go only up to that
level and we are trying our best. We ask in review meetings too and what they say is yes okay
we will see. This is the status for 4-5 zoom meetings. Nothing happened”
Another psychiatrist said, “I’ve been representing man power shortage. For the last 2-3
years the satellite psychiatrist post is vacant. But there is no response”. He also added “As
per DMHP and NMHP provisions district and satellite psychiatrists have to be exempted
from general and post-mortem duties. But it is not followed strictly in all areas. In all areas
the cooperation’s of JDs are there. But there are challenges unique for each district. We can
manage those challenges. If we disrupt the established protocol for any reason then the
entire system will collapse’
Expectations of DMHP staff
Most of the interviewed psychologist and psychiatric social workers felt that they are
underpaid, not given proper increments and kept as temporary servants for a long time. Few
of them pointed out the discrepancies in salary between the psychologist and psychiatric
social workers who have joined on the same date and also that they don’t get salary on the
month end and also being a contract servant, they are not allowed to take compensatory leave
for working on government holidays. They want all these issues to be rectified.
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A psychiatric social worker said, “It will be better if we have a hike in our salary.”
A psychiatric social worker said, “They can provide us something like compensatory leave
for us”
Another psychiatric social worker said, “It will be better if we have a hike in our salary” He
also added, “if it’s a permanent job it will be better”.
Secondary Objective
We are able to recruit 47 female and 30 male beneficiaries (n=77) for the secondary
objective, which is about 9.3% of the 824 patients who had obtained consultation for mental
health related issues(patients with seizure disorder are excluded), from Karur DMHP staff in
the month of April 2023. Name of the health care institution and the number of beneficiaries
recruited are given in the following table.
Table 8. List of Health Care Institutions visited to recruit participants for secondary objective
Name of the Institution Number of beneficiaries recruited

Government Hospital, Manmangalam 15
Government Hospital, Velayudampalayam 12
Government Hospital, Aravakurichi 5
Government Hospital, Pallapatti 6
Government Hospital, Krishnarayapuram 4
Government Hospital, Mylampatti 4
Government Hospital, Kulithalai 9
Block Primary Health Centre, Thogaimalai 4
Block Primary Health Centre, Panjapatti 5
Block Primary Health Centre, Chinnadharapuram 8
Block Primary Health Centre, Inungur 4
Block Primary Health Centre, Kaniyalampatti 1
Block Primary Health Centre, Vangal Nil eligible beneficiaries
Block Primary Health Centre, Uppidamangalam Nil eligible beneficiaries
Block Primary Health Centre, Malaikovilur Nil eligible beneficiaries
The mean age of the patients was 48.4±15.5. 8 or 10.4% of them are unmarried. 46 or 59.7%
of them are married and staying with their spouse. 11 or 14.3% of them are separated or
divorced and 12 or 15.6% of them are widows. 4 or 5.2% of patients live alone and the
64
remaining 73 or 94.8% of the patients live with their family members. 19 or 24.7% of
patients are illiterate. 15 or 19.5% of patients had formal education up to 5 standard. 30 or
th
39% of patients are educated up to the 10 standard. 9 or 11.7% of patients are educated up to
th
the 12 standard. 4 or 5.25% of patients are graduates. 24 or 31.2% of patients are

th
breadwinners for their families and other 53 or 68.8% are dependent on their family
members.
Table 9. Sociodemographic Profile of Patients
Measure/Variable Frequency Percentage Mean±SD Max/Min

value
Sex
a) Female 47 61.0
b) Male 30 39.0
Age 48.4±15.5 Min:21
Max84
Educational Status
a) Illiterate 19 24.7
b) Primary Level 15 19.5
c)Secondary Level 30 39.0
d)Higher Secondary 9 11.7
e) Graduate 4 5.2
Marital Status
a) Single 8 10.4
b) Married 46 59.7
c)Separated/Divorced 11 14.3
d)Widow 12 15.6
Living
a) Separately 4 5.2
b)With family 73 94.8
Breadwinner
a) Patient 24 31.2
b) other family 53 68.8
member
Diagnosis and pharmacological management
27 or 35.1% of patients reported they have first approached a private psychiatrist for
consultation. 19 or 24.7% of patients reported that a psychiatrist in a government medical
college is their first point of contact while seeking consultation for their issues. 12 or 15.6%
of patients reported their first contact for consultation is the DMHP psychiatrist visiting a GH
nearer to them and 6 or 7.8% reported their first contact for consultation is the DMHP
psychiatrist at District Headquarters Hospital. 2 or 2.6% of patients reported that they first
65
met a DMHP psychiatrist visiting PHC while seeking mental health care for their problems. 8
or 10.4% and 2 or 2.6% of patients reported that they have approached a doctor (other than a
psychiatrist) working at a GH and a doctor (other than a psychiatrist) working at a PHC
respectively for first consultation about their problem. 1 patient reported that he/she first met
a doctor (other than a psychiatrist) at District Headquarters Hospital while seeking a solution
for his/her mental health issue. All the patients who have contacted a doctor (other than a
psychiatrist) reported that they have been referred to the DMHP psychiatrist, irrespective of
the level of the health care institution.
The frequency of diagnosis in descending order is major depressive disorder (29 or 37.8%),
schizophrenia (22 or 28.6%), bipolar disorder (7 or 9.1%), panic disorder (5 or 6.5%),
somatization disorder (5 or 6.5%), unspecified anxiety disorder (3 or 3.9%), alcohol
dependence syndrome (2 or 2.6%), adjustment disorder (1 or 1.3%), obsessive-compulsive
disorder (1 or 1.3%), schizoaffective disorder (1 or 1.3%) and intellectual disability (1 or
1.3%). The mean distance travelled by the patients from their home to the health care
institution where DMHP services are offered and to get back home is 4.71±4.61 kilometres
and the mean amount spent by the patient on such travel for a single consultation with the
DMHP team is 15.3±12 rupees. None of the patients reported that they have been referred by
the DMHP team to any other higher centres. 76 or 98.7% of patients reported that they will
usually visit the DMHP team staff once a month for treatment purposes and all patients
reported that they would usually meet the same DMHP psychiatrist/psychologist/psychiatric
social worker during their visit. 10.4% or 8 patients reported that they could not meet the
psychiatrist/DMHP staff or their appointment was cancelled or changed without prior
intimation. All patients reported that they are provided free medicines and none of the
patients reported that they have to come back on another day due to non-availability of
medicines or have been asked to buy medicines on their own.
Table 10. Details related to diagnosis and pharmacological management
Measure/Variable Frequency Percentage Mean±SD

First point of contact for seeking mental health
consultancy
a) VHN/ASHA Nil
b) Doctor (Other than a psychiatrist) at PHC 2 2.6
c)Doctor (Other than a psychiatrist) at GH 8 10.4
d)Doctor (Other than a psychiatrist) at District 1 1.3
Hospital 2 2.6
e) DMHP Psychiatrist visiting PHC 12 15.6
66
f) DMHP Psychiatrist visiting GH 6 7.8
g) DMHP Psychiatrist at DHQ Hospital 19 24.7
h) Psychiatrist in Medical College 27 35.1
i) Private Psychiatrist
If the first contact for consultation is with a doctor
(other than a psychiatrist) then
a) Treated 0
b) Referred 11 100
Diagnosis
a) Major Depressive Disorder 29 37.7
b) Schizophrenia 22 28.6
c) Bipolar Disorder 7 9.1
d) Panic Disorder 5 6.5
e) Somatization Disorder 5 6.5
f) Unspecified Anxiety Disorder 3 3.9
g) Alcohol Dependence Syndrome 2 2.6
h) Adjustment Disorder 1 1.3
i) Obsessive Compulsive Disorder 1 1.3
j) Schizoaffective Disorder 1 1.3
k) Intellectual Disability 1 1.3
Mean Distance travelled by the patient for a single 77 4.71±4.61
consultation
Amount in Rupees spent on travel for a single 77 15.3±12
consultation
Referred to any higher centre by the DMHP team
a) Yes 0
b) No 77 100
Number of visits to hospital/month to see the DMHP
team/member
a) Once a month 76 98.7
b) Twice a month 1 1.3
During the visit to the hospital, you could not meet
the psychiatrist/ appointment cancelled or changed
a) No 69 89.6
b) Yes, it happened once/appointment was 8 10.4
cancelled/ changed
During the visit to hospital
a) Often meet the same psychiatrist/ DMHP staff 77 100
b) Often meet different psychiatrists/ DMHP staff 0
Provided Free Medicines
a) Yes 77 100
b) No 0
Have to come back on another day to collect
medicines due to non-availability?
a) Yes 0 0
b) No 77 100
Non-Pharmacological Management
67
Table 11. Details related to non-pharmacological services provided
Measure/Variable Frequency Percentage

Type of services provided
a) Only pharmacological(drugs) mode of management provided 15 19.5
b) Both pharmacological and non-pharmacological (counselling) 62 80.5
mode of management provided
c)Non-pharmacological (Counselling) mode of management only 0
Non-pharmacological services provided by
a) DMHP psychiatrist. 3 4.8
b) DMHP psychologist, 35 56.5
c) DMHP psychiatric social worker 24 38.7
Details of Non-Pharmacological management
a) Motivational enhancement therapy 2 3.2
b) Cognitive behaviour therapy 11 17.7
c)Psychoeducation to patient and family members about the 23 37.1
illness and role of social support and handling expressed
emotions 26 41.9
d)Stress management
Number of sessions availed
a) Less than 3 times 43 69.4
b)3 – 5 times 19 30.6
Did you find this counselling session to be helpful?
a) Yes, definitely 21 33.9
b) Yes, to some extent 41 66.1
Assessment report/ therapy summary provided
a) Yes 0
b) No 62 100
Home visit by DMHP staff
a) Yes 0
b) No 77 100
Assistance in securing a admission/placement in a mentally ill
home
a) Yes 1 1.3
b) No 76 98.7
Any assistance /help in Securing jobs
a) Yes 1 1.3
b) No 76 98.7
15 or 19.5% of the patients reported that they received only pharmacological mode of
management (treatment consist of only drugs). 62 or 80.5% of the patients reported that they
also received non pharmacological services as part of their care (treatment consist of both
drugs and counselling). Stress management (26 or 41.9%), psychoeducation to patient and
family members about the illness and role of social support and handling expressed emotions
(23 or 37.1%), cognitive behaviour therapy (11 or 17.7%) and motivational enhancement
68
therapy (2 or 3.2%) are the various services provided to those patients (in descending order of
frequency). These services are usually of less than 3 sessions for 43 or 69.4% of such patients
and about 3 -5 sessions in 19 or 30.6 % of such patients. 21 or 33.9 % patients who received
those non pharmacological services found them to be definitely useful and 41 or 66.1% of
such patients found them to be useful to a certain extent. Non pharmacological services are
provided to 35 or 56.5% of the patients by DMHP psychologist, 24 or 38.7% of the patients
by DMHP psychiatric social worker and 3 or 4.8% of the patients by DMHP psychiatrist. All
the patients who received non pharmacological services as part of their treatment reported
that they were not provided with any written assessment report or details related to their
therapy. 1 patient reported that he was provided with assistance by the DMHP team in getting
admission in a home for mentally ill while he was symptomatic and also, they helped him to
secure a job nearer to his home after he recovered. None of the patients had any visits by the
DMHP team to their home.
The patients were also asked to rank their satisfaction on a scale of 1 to 10 about their
interaction/communication with DMHP staff on various aspects related to treatment and also
on the overall trust and satisfaction they have on the DMHP team. Score of 1 means “No
satisfaction at all/trust” and a score of 10 means absolute satisfaction/trust. The mean score
on various aspects related to communication of DMHP staff with the patients and their family
members are given below in Table 12. 22 or 28.6% of the patients reported their current
mental health condition is excellent, 35 or 45.5% reported their mental health condition to be
very good, 18 or 23.4% reported their mental health condition is good and 2 or 2.6% of the
patients reported their mental health condition to be fair at the time of interview.
Table 12. Mean score on various aspects related to communication of DMHP staff with
the patients and their family members
Measure/Variable Mean
Score±SD
DMHP staff treating the patients with courtesy and dignity 8.90±0.77
DMHP staff listening to patients concern carefully 8.86±0.77
DMHP staff examining the patients in privacy 5.99±1.98
DMHP staff explaining things in a way patient could understand 8.84±0.76
DMHP staff meeting the patient as when required 8.86±0.75
69
DMHP staff explaining need and role of medicines prescribed 8.84±0.76
DMHP staff explaining about probable complications of medications 8.84±0.74
DMHP staff giving assurance for future help 8.86±0.73
DMHP staff having transparent communication with the patient’s family 8.86±0.75
members
Overall rating for the care, patient received from mental health service 8.87±0.80
Rating for trust the patient has on the DMHP team 8.88±0.81
Discussion
One of the main objectives of NMHP was to ensure the availability and accessibility of
minimum mental health care for all, in the foreseeable future, particularly to the most
vulnerable and underprivileged sections of the population. 2015-2016 NMHS survey states,
the treatment gap for various mental disorders ranged between 70% and 92%. One of the
main reasons for such a high treatment gap is the limited trained human resources available to
provide mental health care to the vast population of India.
As per published reports a minimum of 3 psychiatrists per 1, 00,000 population is deemed to

be a sufficient number to provide mental health services in India. An equal number of
psychiatric nurses, psychologists and psychiatric social workers is also required (42). A
research article highlighted that it would take 42 years to meet the required number of
psychiatrist and also a minimum of 70 years to reach the required number of psychiatric
nurses, psychologist and psychiatric social worker (43).
Table.13 Time in years required to reach 3 mental health human resource per one lakh
population
Sl Human Req At Require The Huma Years

. Resources uire prese ment for deficit n requir
N d nt the 130 for 130 resour ed to
o per numb crores crores ces reach
Pop ers populatio populat produc the
ulati are n ion ed per desira
on year ble
numb
ers
1 Psychiatrist 3 9000 39000 30000 700/ 42

per year years
lakh
70
2 Psychiatric 3 2000 39000 37000 500/ 74
Nurses per year years
lakh
3 Psychiatric 3 1000 39000 38000 500/ 76

social per year years
worker lakh
4 Clinical 3 1000 39000 38000 500/ 76

Psychologist per year years
lakh
*Table from Cost estimation for the implementation of the Mental Healthcare Act 2017 (43)
Government approach to provide mental health services
To counter this human resource shortage, a specific strategy suggested as a part of NMHP is
integration of basic mental health care into general health services. Main objective of DMHP
is also to provide sustainable mental health services to the community and to integrate these
services with the primary health care services. In order to achieve this, DMHP lays key
importance to train the grass root level health workers like PHC staff (44).
NIMHANS in its 2011 report highlighted that the DMHP in Tamilnadu is a specialist driven
program and integration of mental health service into primary health care has not taken
place (33). As per the data from NMHS, only 11.76% of the public health sector doctors and
3.20% of the public health sector nurses in Tamilnadu are trained in providing mental health
care (36).
The 2022 National suicide prevention strategy published by the Government of India aims to
reduce the current mortality due to suicide by about 10% in 2030. One of the objectives of
NSPS is to enhance the capacity of existing health services to provide mental health services.
For the same, one of the strategies advised are to train more health workers, AYUSH
workers, school teachers and police personnel on early identification of mental health issue
and suicide prevention so that they can provide psychosocial support to those with mental
disorders and substance dependence disorders. Also, there should be short term training
program for non-specialist doctors, nurses and community health care workers so that
71
comprehensive primary health care services including mental health care can be provided in
the upcoming Ayushman Bharat Health and Wellness Centres (AB-HWC) (45)
A lot of training programmes are being conducted for the DMHP staffs at frequent intervals
to improve their skills. It would be better if such training programmes also includes revised
objectives and strategies of government programs on mental health. For example, one of the
interviewed psychiatrists expressed that he doesn't believe that training health care workers to
deliver mental health services will work. Hence it is of vital importance to update the DMHP
staffs regarding the rationale behind the aims and objectives of DMHP, NMHP and NSPS.
Current Scenario in Tamilnadu
Outpatient Services
It feels good to know that currently more than half of the interviewed medical officers said
that they are able to manage common mental illnesses like depression and anxiety disorders
with pharmacotherapy.
Some of them also said they can even manage patients with behavioural issues and intent
with suicide. Also, other cadre of health care workers such as staff nurse and village health
nurse are oriented by the DMHP team in identifying patients with mental illness and
substance abuse disorders.
Still, major mode of mental health services is provided through the outreach clinics
conducted by the DMHP teams in GH and PHC. With the planned concept of Ayushman
Bharat – Health and Wellness Centres which are being created by upgrading existing sub
health centres and primary health centres to provide universal primary health care services
including mental health services relies mainly on the field level health care workers to
provide psychosocial support for persons with mental illness and substance use disorders, it is
of urgent need to increase the training for health care workers at PHC. Health Activity
Program, where psychosocial support provided through lay counsellors was found to reduce
suicidal thoughts/attempts in patients with moderate to severe depression. and was also found
to be very cost effective also (46). Due importance has to be given to explore the usage of
such model programs under DMHP
72
As mentioned in the result part, the training programmes for primary health care medical
officers are of shorter duration and there are no refreshing courses. We can also see from
our results related to secondary objective, all the 11 patients who have first contacted a doctor
(other than psychiatrist for) for their mental health issues reported that they are referred to the
DMHP team and their weekly/monthly outreach conducted in GH and PHC. This model of
one-time class room based top-down training sessions have been criticised for only
improving the knowledge of primary health care doctors and didn’t increase their confidence
in mental disorders.
There is also expressed need from the interviewed medical officers for more training on
mental health. NIMHANS has developed tele based and bidirectional “Primary Care
Psychiatry Program” to achieve furthermore with respect to integration of mental health
services into primary health care services (47). “On-consultation training” feature, where the
location of training to primary care doctors is shifted to their busy general consultation room,
will be of immense help and provide the busy and committed PHC doctors with assistance
from psychiatrist in treating mental illness. Hence consideration has to be given to utilization
of these new models of training for medical officers.
There are currently no indictors/year wise updated indicators to assess the number of training
programs conducted each year to monitor the progress of training or to quantify the number
of counsellors/health care workers in each health care institutions trained in providing
psychological first aid for patients with suicidal attempts. There is also a high attrition rate of
PHC doctors trained on mental health secondary to transfer and going for post graduate
education. Hence these indicators would be helpful to simplify the monitoring process.
Lack of awareness about mental illness and treatment availability, stigma associated with
mental illness, unnecessary fear about medication and orientation towards native treatment
secondary to cultural and religious factors have been identified as major challenges by
DMHP staff with respect to mobilisation of cases for treatment. These challenges have been
highlighted in multiple international studies (48,49). It is appreciable that a lot of activities
like training PHC staffs, anganwadi workers, school teachers and NGOs to identify and refer
patients with mental illness, conducting awareness programs like “Mana Nala Vzhyalan” for
common public, advertising about the services offered under DMHP in social media and
mass media has been carried out by DMHP staffs to increase case load in PHC and GH. The
importance of privacy and trust in therapist-patient relationships also has been well
73
documented and stigma and fear related to disclosure of personal information has been noted
to have a negative effect on help seeking behaviour in patients with mental illness (50,51). As
per the statements of multiple DMHP staffs ensuring the privacy of the patients is a huge
challenge as outreach clinics are usually conducted in outpatient blocks, which are usually
busy with providing services to patients with physical health related ailments. Due to the
same, the patients are also hesitant to open up about their issues and seek help. The mean
score of 5.99±1.98 given by the patients with respect to the aspect of DMHP staffs ensuring
privacy during their conversation with the patients is also lower when compared to other
aspects of communication. Adequate steps should be taken to resolve this important issue.
One of the other challenges highlighted by the DMHP staff and PHC medical officers is to
retain the patients in follow-up. Those patients with severe mental illness and worsening of
symptoms are usually referred by the PHC medical officers to the DMHP outreach clinic
conducted in taluk GH or Block PHC. There are also no mechanisms to ensure whether the
patient has actually visited those outreach clinics and got treatment there or not. There are no
statistics or data base maintained with respect to the number of patients who have completed
the recommended course of treatment at PHC level or District level. International
Classification of Disease codes are also not available which make it difficult to extract
information related to the severity and type of treatment availed for illness such as major
depressive disorder. All these deficiencies have been pointed out in previous studies (33).
Small steps taken to rectify these issues would help us to find out those patients who didn’t
turn for follow up and these data can be transferred to field level workers like village health
nurses to ensure their follow up. We would be also able to quantify the total number of
patients who have completely benefited from the program.
From our secondary objective results, we can infer that medicine availability is strictly
ensured, all patients are provided with free medicines, the mean distance travelled by patients
for a single consultation and the amount spent for the same is low when compared to the
2008 ICMR study and psychologist and psychiatric social workers are engaged in role
appropriate task as they are currently providing non-pharmacological services majority of
patients.
Inpatient Services.
74
In-patient care is an essential component in the management of patients with substance
dependence disorders and psychiatric conditions, which puts the life of the patient or others at
risk. With respect to an ideal inpatient psychiatric setup empathetic approach of the ward
staff like devoting time to the patients and being cared, loved and respected by them are the
characters which received highest rating from the patients who are admitted in psychiatry
wards among others such as staff competence, patient co-influence, treatment content, ward
atmosphere and activities (52). Spending adequate amount of time and providing adequate
information to the patient about the treatment has been noted to shape the patients experience
in a positive way during admission (53). It is good to note that strategies such as empathetic
approach, psychoeducation of patients and family members about the illness are utilized by
the DMHP staff to gain the trust of patients and their family members. Past studies have
indicated that inpatient services are available at district headquarters hospitals (31,33).
Except the district of Erode, all other district DMHP teams are facing significant challenges
with respect to running in-patient services. In most of the districts patients with mental
illness are admitted along with patients who have physical ailments. Except the district of
Tiruchirappalli, there is only one staff nurse post available under DMHP in other districts.
Even these staff are deputed to general ward duties. This particular issue is faced by all the
DMHP staff nurses as it is clearly evident from their statement. Few of the interviewed
psychiatrists reported that due to busy outreach clinic schedules, promotional activities and
superimposed disability camps, they are not able to visit the wards on a day-to-day basis or
spend quality time with the patients admitted there. This issue is particularly prominent in
districts where one of the two psychiatrist posts in DMHP is vacant. Ensuring that the DMHP
teams are functioning at full strength and are working with services related to mental health
will help to improve the quantity of time they spend with the patients which can get
converted into quality of care. Lack of privacy to collect history and to provide
psychotherapy in wards of health care institutions have been pointed out by the DMHP staff,
especially by the psychologists and psychiatric social workers. Lack of privacy and
overcrowding in the wards are noted to adversely affect the outcome of treatment and patients
experience on treatment (54). Minor infrastructure modifications to include counselling
rooms in the wards will be of most helpful as patients will be comfortable in opening up
about their problems in enclosed space and in the absence of family members. Also,
indicators such as bed turnover rate, average length of stay and bed occupancy rate have to be
employed as these simple indicators could be used as optional metric for evaluation of
75
resource utilisation and hospital efficiency (55). With insurance coverage available for
common and severe mental illness including intellectual disability under the Chief Minister
Comprehensive Health Insurance Scheme (CMCHIS), incentives received can be utilized for
further improvement of resources available in wards.
Interventions for patients with suicidal ideations and attempts.
A research paper on assessment of suicide risk and the challenges associated with that
highlighted the importance of a proper clinical examination in identifying those at risk for
suicide. The author also documented that utilisation of a structured assessment tool that focus
on identifying the risk for suicide and protective factors will be of immense help as these
details will help us to create a risk management strategy for every patient (56). Most of the
suggested areas in that paper have been covered by the DMHP staffs in their clinical
interviews to explore patients’ risk for suicide except for the assessment scale. Patients with
suicidal attempts are also provided with the tailor-made evidence based therapeutic services
such as pharmacotherapy, electro convulsive therapy, psychotherapy and family therapy.
Also, due importance is paid by the DMHP staff to treat the underlying mental conditions like
depression and substance abuse disorders. It will be better if a uniform structured risk
assessment questionnaire is also included as a part of the assessment process.
Financial crisis, relationship issues, academic pressure, alcohol related causes, personality
issues are the most common cause of suicide reported. The importance of psychosocial
interventions in such cases are of high importance. However, it has been pointed out by the
DMHP staffs that are more chances for patients who are getting admitted with suicidal
attempts/self-harm behaviour in taluk GH and PHC to get discharged without any
psychological first aid. As mentioned in the results part the reasons cited are inadequacy of
the information provided by the PHC staffs, weekly once or monthly once visit by DMHP
staffs to such GH and PHC and poor cooperation from patient and family members when
contacted on later date as they are not sensitized about the importance of the interventions at
the time of stay in GH or PHC.
Zero suicide model is an integral component of the National Strategy for Suicide Prevention
released by the U.S Action Alliance with the belief that death by suicide for those receiving
care from health systems is preventable (57,58). It is based on the observation that majority of
the patients who die by suicide have visited a health care institution in the year prior to death
76
and 50 % of them made the visit within 4 weeks (59). These people have felt through the
cracks in the fragmented and distracted health system at the time of crisis.
Currently those patients who come in contact with the DMHP team are followed up to a
maximum period of six months by the DMHP Staff. Also, there are no information about the
ones who didn’t come in to contact with DMHP team or about the number of people who are
availing regular services from DMHP with respect to suicide prevention. With the current
model of specialist driven outreach clinic based mental health service delivery we may not be
able to address the prevailing huge treatment gap of more than 80% for suicide
behaviours (36).
Guidance has been provided by the NSPS about how to resolve these issues (45). To reduce
the treatment gap, we have to no other option except to increase the number of health care
workers who are trained in providing psychological first aid and psychological support for
those who attempted suicide and those bereaved by suicide. NSPS advices to maintain regular
contact and provide psychological support for at least 18 months with those people who have
attempted suicide or have been bereaved by suicide by to them. Alcohol use was noted to be
associated with a 94% increase in the risk of death by suicide (60). WHO has highlighted that
“Brief intervention” services provided by primary care doctors can improve the overall
outcome including suicide reduction in patients with alcohol abuse (61). NSPS also lays more
importance to observe and treat suicidal behaviour in patients with substance use disorder.
Hence adequate measures have to be taken to implement these strategies so that the concept
of Zero Suicide Model can also be implemented in our state. Indicators such as number of
people who attempted suicide/bereaved provided with regular contact and percentage
reduction in the number of persons with dependence disorders who die by suicide would help
us to track performance of the services offered as these are the indicators designated in the
NSPS to track the performance once these strategies and associated action plans are carried
out.
Enhance Surveillance
NCRB data has been criticised for underreporting the total number of suicides in our
country (62). Surveillance and reporting of incidents related to suicide/self-harm has to be
enhanced at all level of public and private health care institution so that a data poll on patients
with suicidal attempts/self-harm behaviour can be created. Objective 4 of the NSPS
77
specifically speaks about this and the need for timely analysis and dissemination of data for
effective planning and implementation of suicide prevention strategies (45). Such a district
wise data poll will be immense help to track patients at high risk for suicide by DMHP team
so that Zero Suicide model can be implemented.
Promotion of mental Health and Prevention of mental illness.
A better understanding of the concept of mental health intervention spectrum, proposed by

the 1994 Institute of Medicine (US) Committee on Prevention of Mental Disorders, will help
us to focus our efforts on the promotion of mental health to have maximum impact with the
restricted resources available. The mental health intervention spectrum has four components:
promotion, prevention, treatment and maintenance.
Mental health Promotion is defined as “Interventions aim to enhance individuals’ ability to

achieve developmentally appropriate tasks (competence) and a positive sense of self-esteem,
mastery, well-being, and social inclusion, and strengthen their ability to cope with
adversity.”
Prevention includes services offered to the general population or a group of population

identified to be at risk for developing a disorder and these services are designed to reduce this
risk and hence caseload. Preventive services are further classified into universal, selective and
indicated based on the severity of risk the targeted audience have. Universal preventive
services such as school-based programs offered to school children to avoid substance use can
be implemented to a larger population at low cost. It has also to be documented that most of
the universal preventive services also have mental health promotional benefits. Selective
preventive services are offered to those at moderate risk of developing a mental disorder such
as programs offered to children who have lost their beloved ones or have witnessed parental
divorce and are of higher cost when compared to universal preventive services. Indicated
preventive services are offered to those with much higher risk of developing a mental
disorder and presenting with subthreshold symptoms such as people with personality
disorders. Indicated preventive services are of much higher cost when compared to selective
preventive services. The treatment component consists of case identification and provision of
standard treatment and the maintenance component consists of efforts to ensure compliance
and rehabilitation (63).
78
A lot of effort has been put forward by the DMHP teams to promote the mental well-being of
school and college students by employing both promotional and universal preventive
strategies. DMHP teams are also noted to provide selective preventive interventions such as
stress management and substance abuse prevention programs for people at high risk to
develop a mental illness such as factory workers, armed personnel, and sanitary workers,
which are also the perceived need from the public side.
Though children with intellectual disabilities are provided with disability certificates, most of
them are not provided with assessment reports. Multiple studies have highlighted those early
interventions targeting the child and parents are noted to have a significant positive impact on
the quality of life of children with intellectual disabilities (64). Hence indicated preventive
services for such children needs to be enhanced with proper evaluation and timely
interventions.
From the statements of DMHP staff, most of the funds allocated for promotional activities are
spent on advertisements and refreshments for participants in promotional activities. There has
been no uniformity with respect to the promotional activities chosen or spending of the
amount allocated for promotional activities or indicators to assess the impact of the programs.
Districts of Erode and Salem are noted to predominantly utilize cost-effective methods such
as public rallies, street plays, and mass media to increase the mental health literacy of the
common public. Some DMHP teams are noted to utilise the services of NGOs such as Lions
Club and Rotary in organising mental health promotional camps. Recent studies have
highlighted the advantages of utilization of social media such as low cost to promote mental
health (65). With limited resources available, it will be better if the DMHP teams consider the
cost-benefit ratio of the promotion and preventive strategies such as paid advertisements on
TV and Theatres.
One of the main challenges with respect to providing treatment and promotion of mental
health is shortage of human resource and funds for travel. All these issues have been pointed
out in past studies and have been documented to be secondary to the outreach model of
service delivery (31,33). One strategy recommended by the DMHP psychiatrist to overcome
human resource shortage is to utilize psychiatrists available in medical colleges in individual
districts. With the support of the Joint director of health services, Salem DMHP was able to
use the service of an additional psychiatrist working in taluk GH for providing mental health
services to 3 GHs, each of which are located at a minimum of 100 kilometres from their
79
District head Quarters Hospitals. With this approach, the DMHP team was able to save a lot
of time and money, which were directed towards other needs. With the availability of medical
colleges with full-fledged psychiatry departments in the district headquarters of most of the
districts of Tamil Nadu, the DMHP teams have already started to function from the district
headquarters hospital located in another taluk or revenue district. Hence adequate
consideration has to be given to evaluate the advantages and disadvantages of combining the
manpower available under different directorates in each district to provide mental health
services.
DMHP teams are noted to be facing a huge challenge to engage the key community members
such as village head, politician and self-help groups in the promotion of mental health. Even
some school and college staff are hesitant to provide permission to conduct mental health
promotion in their schools. Easy availability of pesticides in villages has been cited by
DMHP staffs as one of the challenges for suicide prevention. With proper leverage from
block medical officers and coordinated efforts by involving other government departments
heads at the district level DMHP staffs are able to overcome few of these challenges.
As outlined in the implementation framework of NSPS, if district level officers of various

government departments such as school education, information and broadcasting, agriculture
and farmers welfare, labour welfare are able to direct the block level officers working under
their departments to coordinate and implement suicide prevention programs, it will be of
immense help to the DMHP staffs.
High levels of job discontinuation have been noted in the category of psychiatric social
worker and psychologist. Though salary rise and permanent job has been a common
expectation, immediate considerations can be given for fulling the expectations with respect
to increments and salary on proper time.
Limitations and Implications of the Study:
 The study is conducted in six districts. These districts could be different in

demographics, health infrastructure, and human resource in comparison to other
districts of Tamil Nadu. Since, the DMHP programme is implemented in about 692
districts in India, it would be good if the same study is replicated to other districts of
Tamil Nadu and also other states of India to evaluate the same objectives.
80
 The study explored DMHP personnel and primary health care personnel involvement
in suicide prevention and promotion of mental health. It would be good to see the
impact of their activities in bringing down the suicidal rates and promotion of mental
health.
 The DMHP teams are involved in several activities such as targeted interventions and
coordination with NGOs for mental health promotion. Hence, it would be good to
explore the process, impact of those activities on the community mental health.
 Community capacity building where DMHP trainings on mental health outcome is

another area to be discussed. In this regard how the capacity building programmes of
the DMHP is bringing down the suicidal behaviour among the community.
 It would be good if the longitudinal studies are conducted to assess the suicidal
prevalence and incidence in DMHP catchment areas.
 Also, culturally sensitive interventions can be tested to prevent the suicides and
promote the mental health. Hence, future research should focus on intervention
development.
Conclusion
The importance of having a national mental health policy to combat the rising burden of
mental illness was first recognised in the WHO Expert Meeting on Organisation of mental
health services in developing countries. A lot of progress and achievements have been made
in the field of mental health like in the last 50 years such as having our own National Mental
Health Program and National Mental Health Policy. Integrated care by providing mental
health services within the existing health care system using the primary health care approach
has been highlighted in both the National Mental Health Program and National Mental Health
Policy as the way to provide mental health services in India and District Mental Health
Program has been the face of it. Significant progress has been made since the 2011
NIMHANS study and 2015-16 NMHS survey to treat and provide psychosocial support to
patients with mental illness at community level through PHC medical officers and psychiatry
outreach clinic conducted by DMHP teams in taluk GH and block PHC. Restructuring the
81
referral mechanism at PHC to prevent case drops, improving the data base about the number
of patients benefitted from the program, utilisation of indicators to monitor inpatient service
utilization and hospital efficiency, strengthening the surveillance and reporting of suicidal
attempts/self-harm, introducing bidirectional tele based on-consultation training modules for
medical officers and healthcare workers at PHC level to provide psychological first aid to
those with suicidal attempts/bereaved by suicide, ensuring adequate follow up to implement
Zero Suicide Model and evaluating the advantages of combining the available mental health
human resources employed under different health directorates in a district are some of the
areas which needs to be improved or worked on in near future.
References
1. Omran AR. The Epidemiologic Transition: A Theory of the Epidemiology of Population Change.
Milbank Q [Internet]. 2005 Dec 1 [cited 2023 Mar 17];83(4):731–57. Available from:
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1468-0009.2005.00398.x
2. Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases
and injuries in 204 countries and territories, 1990â€“2019: a systematic analysis for the Global
Burden of Disease Study 2019. The Lancet [Internet]. 2020 [cited 2022 Oct 9];396:1204–22. Available
from: http://ghdx.healthdata.org/gbd-
3. Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders
across the states of India: the Global Burden of Disease Study 1990–2017. Lancet Psychiatry
[Internet]. 2020 Feb 1 [cited 2022 Oct 9];7(2):148–61. Available from:
http://www.thelancet.com/article/S2215036619304754/fulltext
4. Too LS, Spittal MJ, Bugeja L, Reifels L, Butterworth P, Pirkis J. The association between mental
disorders and suicide: A systematic review and meta-analysis of record linkage studies. J Affect
Disord. 2019 Dec 1;259:302–13.
5. Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet [Internet]. 2016 Mar 3 [cited 2022 Sep
24];387(10024):1227. Available from: /pmc/articles/PMC5319859/
6. World Health Organization. Suicide worldwide in 2019: global health estimates. World Health
Organization [Internet]. 2021 [cited 2022 Sep 22];Licence: CC BY-NC-SA 3.0 IGO. Available from:
https://apps.who.int/iris/rest/bitstreams/1350975/retrieve
82
7. ADSI-2021 | National Crime Records Bureau [Internet]. [cited 2022 Sep 24]. Available from:
https://ncrb.gov.in/en/ADSI-2021
8. Bachmann S. Epidemiology of Suicide and the Psychiatric Perspective. Int J Environ Res Public Health
[Internet]. 2018 Jul 6 [cited 2023 Mar 17];15(7). Available from: /pmc/articles/PMC6068947/
9. Hanschmidt F, Lehnig F, Riedel-Heller SG, Kersting A. The Stigma of Suicide Survivorship and Related
Consequences—A Systematic Review. PLoS One [Internet]. 2016 Sep 1 [cited 2022 Sep 23];11(9).
Available from: /pmc/articles/PMC5033475/
10. Lohan JA, Murphy SA. Parents’ Perceptions of Adolescent Sibling Grief Responses after an
Adolescent or Young Adult Child’s Sudden, Violent Death. undefined. 2002 May;44(3):195–213.
11. Lohan JA, Murphy SA. Family Functioning and Family Typology after an Adolescent or Young Adult’s
Sudden Violent Death. http://dx.doi.org/101177/107484070200800103 [Internet]. 2016 Jul 24 [cited
2022 Sep 23];8(1):32–49. Available from:
https://journals.sagepub.com/doi/abs/10.1177/107484070200800103
12. The World health report : 2001 : Mental health : new understanding, new hope [Internet]. Geneva:
WHO Press; 2001 [cited 2022 Sep 30]. Available from: https://apps.who.int/iris/handle/10665/42390
13. Mental health action plan 2013-2020 [Internet]. Geneva 27, Switzerland: WHO Press; 2013 [cited
2022 Sep 29]. Available from: https://www.who.int/publications/i/item/9789241506021
14. Comprehensive Mental Health Action Plan 2013-2030 [Internet]. Geneva: WHO Press; 2021 [cited
2022 Sep 29]. Available from: https://www.who.int/publications/i/item/9789240031029
15. Taylor M. Report of the health survey and development committee [Internet]. Delhi: Government of
India press; 1946 [cited 2022 Sep 30]. Available from:
https://www.nhp.gov.in/sites/default/files/pdf/Bhore_Committee_Report_VOL-1.pdf
16. Report of the health survey and planning committee [Internet]. Delhi: Government of India -
Ministry of health; 1962 [cited 2022 Sep 30]. Available from:
https://www.nhp.gov.in/sites/default/files/pdf/Mudalier_Vol.pdf
17. Khurana S, Sharma S. National mental health program of India: a review of the history and the
current scenario. Int J Community Med Public Health [Internet]. 2016 Dec 24 [cited 2022 Oct
4];3(10):2696–704. Available from: https://www.ijcmph.com/index.php/ijcmph/article/view/197
18. WHO Expert Committee on Mental Health & World Health Organization. (1975). Organization of
mental health services in developing countries : sixteenth report of the WHO Expert Committee on
Mental Health [meeting held in Geneva from 22 to 28 October 1974] [Internet]. World Health
Organization; [cited 2022 Sep 30]. Available from: https://apps.who.int/iris/handle/10665/38212
19. Sartorius N, Harding TW. The WHO collaborative study on strategies for extending mental health
care, I: The genesis of the study. Am J Psychiatry [Internet]. 1983 [cited 2022 Sep 24];140(11):1470–
3. Available from: https://pubmed.ncbi.nlm.nih.gov/6624994/
83
20. Harding TW, D’Arrigo Busnello E, Climent CE, Diop M, El-Hakim A, Giel R, et al. The WHO
collaborative study on strategies for extending mental health care, III: Evaluative design and
illustrative results. Am J Psychiatry [Internet]. 1983 [cited 2021 Nov 29];140(11):1481–5. Available
from: https://pubmed.ncbi.nlm.nih.gov/6624996/
21. Harding TW, Climent CE, Diop M, Giel R, Ibrahim HH, Murthy RS, et al. The WHO collaborative study
on strategies for extending mental health care, II: The development of new research methods. Am J
Psychiatry [Internet]. 1983 Nov [cited 2021 Nov 29];140(11):1474–80. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/6624995
22. Murthy RS, Wig NN. The WHO collaborative study on strategies for extending mental health care, IV:
A training approach to enhancing the availability of mental health manpower in a developing
country. American Journal of Psychiatry. 1983;140(11):1486–90.
23. Isaac MK, Kapur RL, Chandrashekar CR, Kapur M, Pathasarathy R. MENTAL HEALTH DELIVERY
THROUGH RURAL PRIMARY CARE—DEVELOPMENT AND EVALUATION OF A TRAINING PROGRAMME.
Indian J Psychiatry [Internet]. 1982 Apr [cited 2021 Nov 29];24(2):131. Available from:
/pmc/articles/PMC3012862/?report=abstract
24. Kalyanasundaram S, Isaac M, Kapur RL. Introducing Elements of Psychiatry into Primary Health Care
in South India. Indian J Psychol Med [Internet]. 1980 Jul [cited 2021 Nov 29];3(2):91–4. Available
from:
https://www.researchgate.net/publication/342842906_Introducing_Elements_of_Psychiatry_into_P
rimary_Health_Care_in_South_India
25. Chandrashekar CR, Isaac MK, Kapur RL, Sarathy RP. MANAGEMENT OF PRIORITY MENTAL
DISORDERS IN THE COMMUNITY. Indian J Psychiatry [Internet]. 1981 Apr [cited 2022 Sep
27];23(2):174. Available from: /pmc/articles/PMC3013172/?report=abstract
26. Wig NN, Murthy SR. The birth of national mental health program for India. Indian J Psychiatry
[Internet]. 2015 Jul 1 [cited 2021 Nov 24];57(3):315. Available from: /pmc/articles/PMC4623656/
27. Naik AN, Parthasarathy R, Isaac MK. Brief report: Families of rural mentally ill and treatment
adherence in district mental health programme. International Journal of Social Psychiatry [Internet].
1996 Jul 27 [cited 2022 Oct 1];42(1):68–72. Available from:
https://journals.sagepub.com/doi/10.1177/002076409604200108?url_ver=Z39.88-2003&rfr_id=ori
%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed
28. Nagarajaiah, Reddamma K, Chandrashekar CR, Isaac MK, Srinivasamurthy R. EVALUATION OF SHORT
TERM TRAINING IN MENTAL HEALTH FOR MULTIPURPOSE WORKERS. Indian J Psychiatry [Internet].
1994 Jan [cited 2022 Oct 1];36(1):12. Available from: /pmc/articles/PMC2972447/?report=abstract
29. Naik AN, Isaac MK, Parthasarathy R, Karur BV. THE PERCEPTION AND EXPERIENCE OF HEALTH
PERSONNEL ABOUT THE INTEGRATION OF MENTAL HEALTH IN GENERAL HEALTH SERVICES. Indian J
Psychiatry [Internet]. 1994 Jan [cited 2022 Oct 1];36(1):18. Available from:
/pmc/articles/PMC2972448/?report=abstract
84
30. REPORT OF EVALUATION OF DISTRICT MENTAL HEALTH PROGRAMME [Internet]. 2003 [cited 2023
Mar 18]. Available from: https://mhpolicy.files.wordpress.com/2011/05/nimhans-report-evaluation-
of-dmhp.pdf
31. Indian council of marketing research. Evaluation of District Mental Health Programme Final Report.
2008.
32. Sinha SK, Kaur J. National mental health programme: Manpower development scheme of eleventh
five-year plan. Indian J Psychiatry [Internet]. 2011 Jul [cited 2021 Nov 11];53(3):261–5. Available
from:
https://www.researchgate.net/publication/51847712_National_mental_health_programme_Manpo
wer_development_scheme_of_eleventh_five-year_plan
33. NIMHANS. REPORT OF EVALUATION OF DISTRICT MENTAL HEALTH PROGRAMS TAMIL NADU,
KARNATAKA, ANDHRA PRADESH AND MAHARASHTRA PREPARED BY DEPARTMENT OF PSYCHIATRY
NATIONAL INSTITUTE OF MENTAL HEALTH & NEUROSCIENCES, BANGALORE Introduction. 2011.
34. Roy S, Rasheed N. The National Mental Health Programme of India. International Journal of Current
Medical And Applied Sciences [Internet]. 2015 [cited 2022 Oct 4];7(1):7–15. Available from:
www.ijcmaas.com
35. Balamurugan G, Radhakrishnan G, Vijayarani M. Models and roles in National Mental Health
Programme. Indian Journal of Psychiatric Nursing [Internet]. 2019 [cited 2022 Oct 2];16(1):52.
Available from: https://www.ijpn.in/article.asp?issn=2231-
1505;year=2019;volume=16;issue=1;spage=52;epage=54;aulast=Balamurugan
36. G G, Varghese M, Benegal V, Rao G, Pathak K, Singh L, et al. National Mental Health Survey -2015-16
Summary. 2016.
37. Rendle KA, Abramson CM, Garrett SB, Halley MC, Dohan D. Beyond exploratory: a tailored
framework for designing and assessing qualitative health research. BMJ Open [Internet]. 2019 Aug 1
[cited 2023 Mar 19];9(8):e030123. Available from: https://bmjopen.bmj.com/content/9/8/e030123
38. Dworkin SL. Sample size policy for qualitative studies using in-depth interviews. Arch Sex Behav
[Internet]. 2012 Dec 1 [cited 2023 Mar 19];41(6):1319–20. Available from:
https://link.springer.com/article/10.1007/s10508-012-0016-6
39. Guest G, Namey E, McKenna K. How Many Focus Groups Are Enough? Building an Evidence Base for
Nonprobability Sample Sizes. Field methods. 2017 Feb 1;29(1):3–22.
40. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol [Internet]. 2006 Jan
1;3(2):77–101. Available from: https://www.tandfonline.com/doi/abs/10.1191/1478088706qp063oa
41. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-
item checklist for interviews and focus groups. Int J Qual Health Care [Internet]. 2007 Dec [cited
2023 Mar 19];19(6):349–57. Available from: https://pubmed.ncbi.nlm.nih.gov/17872937/
85
42. Garg K, Kumar CN, Chandra PS. Number of psychiatrists in India: Baby steps forward, but a long way
to go. Indian J Psychiatry [Internet]. 2019 Jan 1 [cited 2023 Mar 20];61(1):104. Available from:
/pmc/articles/PMC6341936/
43. Math S, Gowda G, Basavaraju V, Manjunatha N, Kumar C, Enara A, et al. Cost estimation for the
implementation of the Mental Healthcare Act 2017. Indian J Psychiatry [Internet]. 2019 Apr 1 [cited
2023 Mar 20];61(Suppl 4):S650–9. Available from: https://pubmed.ncbi.nlm.nih.gov/31040453/
44. Gupta S, Sagar R. National Mental Health Programme-Optimism and Caution: A Narrative Review.
Indian J Psychol Med [Internet]. 2018 Nov 1 [cited 2021 Nov 11];40(6):509–16. Available from:
https://pubmed.ncbi.nlm.nih.gov/30533946/
45. National Suicide Prevention Strategy [Internet]. 2022 [cited 2023 Mar 20]. Available from:
https://main.mohfw.gov.in/sites/default/files/National%20Suicide%20Prevention%20Strategy.pdf
46. Chowdhary N, Anand A, Dimidjian S, Shinde S, Weobong B, Balaji M, et al. The Healthy Activity
Program lay counsellor delivered treatment for severe depression in India: systematic development
and randomised evaluation. The British Journal of Psychiatry [Internet]. 2016 Apr 1 [cited 2023 Mar
20];208(4):381. Available from: /pmc/articles/PMC4816974/
47. Dinakaran D, Manjunatha N, Kumar CN, Math SB, Thirthalli J. The rationale and guiding principles to
design a psychiatry curriculum for primary care doctors of India. Natl Med J India [Internet]. 2022 Jan
1 [cited 2023 Mar 20];35(1):32–7. Available from: https://pubmed.ncbi.nlm.nih.gov/36039625/
48. Ali SH, Agyapong VIO. Barriers to mental health service utilisation in Sudan - perspectives of carers
and psychiatrists. BMC Health Serv Res [Internet]. 2016 Jan 27 [cited 2023 Mar 20];16(1). Available
49. Muhorakeye O, Biracyaza E. Exploring Barriers to Mental Health Services Utilization at Kabutare
District Hospital of Rwanda: Perspectives From Patients. Front Psychol [Internet]. 2021 Mar 22 [cited
2023 Mar 20];12. Available from: https://pubmed.ncbi.nlm.nih.gov/33828506/
50. Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. What is the
impact of mental health-related stigma on help-seeking? A systematic review of quantitative and
qualitative studies. Psychol Med [Internet]. 2015 Jan 12 [cited 2023 Mar 20];45(1):11–27. Available
51. McGuire JM, Toal P, Blau B. The Adult Client’s Conception of Confidentiality in the Therapeutic
Relationship. Prof Psychol Res Pr. 1985 Jun;16(3):375–84.
52. Hansson L, Björkman T, Berglund I. What is important in psychiatric inpatient care? Quality of care
from the patient’s perspective. Qual Assur Health Care [Internet]. 1993 [cited 2023 Mar 20];5(1):41–
8. Available from: https://pubmed.ncbi.nlm.nih.gov/8457687/
53. Ercis M, Seçkin M, Ayık B, Üçok A. Correlates of Patient Satisfaction in Psychiatric Inpatient Care: A
Survey Study from a Tertiary Hospital in Turkey. J Psychosoc Nurs Ment Health Serv [Internet]. 2021
[cited 2023 Mar 20];59(4):38–47. Available from: https://pubmed.ncbi.nlm.nih.gov/33301044/
86
54. Weber C, Monero Flores V, Wheele TP, Miedema E, White EV. Patients’ Health & Well-Being in
Inpatient Mental Health-Care Facilities: A Systematic Review. Front Psychiatry [Internet]. 2022 Jan 3
[cited 2023 Mar 20];12. Available from: https://pubmed.ncbi.nlm.nih.gov/35046849/
55. Aloh HE, Onwujekwe OE, Aloh OG, Nweke CJ. Is bed turnover rate a good metric for hospital scale
efficiency? A measure of resource utilization rate for hospitals in Southeast Nigeria. Cost Eff Resour
Alloc [Internet]. 2020 Jul 1 [cited 2023 Mar 20];18(1). Available from: /pmc/articles/PMC7329453/
56. Ryan EP, Oquendo MA. Suicide Risk Assessment and Prevention: Challenges and Opportunities.
https://doi.org/101176/appi.focus20200011 [Internet]. 2020 Apr 24 [cited 2023 Mar 20];18(2):88–
99. Available from: https://focus.psychiatryonline.org/doi/10.1176/appi.focus.20200011
57. Labouliere CD, Vasan P, Kramer A, Brown G, Green K, Rahman M, et al. “Zero Suicide” – A model for
reducing suicide in United States behavioral healthcare. Suicidologi [Internet]. 2018 May 2 [cited
2023 Mar 20];23(1):22. Available from: /pmc/articles/PMC6022755/
58. Brodsky BS, Spruch-Feiner A, Stanley B. The zero suicide model: Applying evidence-based suicide
prevention practices to clinical care. Front Psychiatry. 2018 Feb 23;9(FEB):33.
59. Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, et al. Health Care Contacts in
the Year Before Suicide Death. J Gen Intern Med [Internet]. 2014 [cited 2023 Mar 20];29(6):870.
Available from: /pmc/articles/PMC4026491/
60. Isaacs JY, Smith MM, Sherry SB, Seno M, Moore ML, Stewart SH. Alcohol use and death by suicide: A
meta-analysis of 33 studies. Suicide Life Threat Behav [Internet]. 2022 Aug 1 [cited 2023 Mar
20];52(4):600–14. Available from: https://pubmed.ncbi.nlm.nih.gov/35181905/
61. Babor TF, Higgins-Biddle JC. Brief intervention for hazardous and harmful drinking: a manual for use
in primary care. In: Brief intervention for hazardous and harmful drinking: a manual for use in
primary care. 2001. p. 52.
62. Vijayakumar L, Chandra PS, Kumar M, Pathare S, Banerjee D, Goswami T, et al. The national suicide
prevention strategy in India: context and considerations for urgent action. Lancet Psychiatry. 2021
Dec 9;1–9.
63. O’Connell ME, Boat T, Warner KE, editors. Preventing mental, emotional, and behavioral disorders
among young people: Progress and possibilities. Preventing mental, emotional, and behavioral
disorders among young people: Progress and possibilities. Washington, DC, US: The National
Academies Press; 2009. 562, xxix, 562–xxix p.
64. Guralnick MJ. Early Intervention for Children with Intellectual Disabilities: An Update. J Appl Res
Intellect Disabil [Internet]. 2017 Mar 1 [cited 2023 Mar 21];30(2):211–29. Available from:
https://pubmed.ncbi.nlm.nih.gov/26764896/
65. Latha K, Meena KS, Pravitha MR, Dasgupta M, Chaturvedi SK. Effective use of social media platforms
for promotion of mental health awareness. J Educ Health Promot [Internet]. 2020 May 1 [cited 2023
Mar 21];9(1). Available from: /pmc/articles/PMC7325786/
87
Annexure 1
Information Leaflet
Title: Analysis of District Mental Health and Primary Health Care Personnel's’ Involvement
in Suicide Prevention and Mental Health Promotional Activities: A community based
qualitative study
Principal Investigator: Dr.Murugaraja V(Ph.No.9739947056), Assistant Resident Medical

Officer, Govt. Karur Medical College and Hospital-Karur 639004
Co-Principal Investigator: Dr Amaresha C (Ph.No.9449603952), Assistant Professor of
Social Work, Department of Sociology and Social Work, CHRIST (Deemed to be
University), Bangalore-29
Aim And Outcome of the study: It would be good to understand the Knowledge and
perspectives of DMHP stakeholders on the strategies and mechanisms used to prevent the
suicides and promote the mental health in the community. This will help to understand the
best practices used by the DMHP team towards preventing suicides and promoting mental
health. Also, it helps us to understand the challenges experienced by the DMHP which should
be addressed on priority. Also feed backs from you will help us to understand about the
service delivery and help us to improve the service. Outcome of the study will pave way for
designing new suicide prevention modules which can be implemented all over Tamil Nadu
through existing DMHP resources.
Consent Form. Your consent to participate in the above-mentioned study is sought as an

index patient. You have the right to refuse consent or withdraw the same during any part of
the study without giving any reason. No monetary benefits will be provided. I/We undertake
to maintain complete confidentiality regarding the information obtained from the participant
during the course of the study. The information obtained from you will be maintained with
utmost confidentiality and will be used for research only. Data obtained in this research study
will be used in other research studies with the approval of the ethics committee. The
observation of this study might be published for scientific purpose/presented in science
conferences. In such situations, we assure you that all the data will be presented anonymously
without any reference to any subject’s name. If you have any doubts about the study, please
feel free to clarify the same. Even during the study, you are free to contact any of the
investigators for clarification if you desire.
I,……………………………………………………………….., the undersigned give my consent to be a participant of

this study
Signature of the participant

(Name and address)
Signature of the Doctor/investigator: Signature of the witness

Name and designation
Date: Place:
88
Annexure 2
தகவல் துண்டுப்பிரசுரம்
jiy¥ò: “j‰bfhiy jL¥ò k‰W« kdey nk«gh£L elto¡iffëš kht£l kdey« Â£l« k‰W« Mu«g
Rfhjhu ãiya¥ gâahs®fë‹ <LghL g‰¿a xU r_f« rh®ªj gF¥ghŒÎ” v‹gnj Ïªj MŒé‹ jiy¥ò
Kj‹ik MŒths®: Dr.KUfuh#h(Ph.No.9739947056), ARMO ,f%® muR kU¤Jt¡fšÿç ,

fhªÂ»uhk« f%®- 639004
Ïiz Kj‹ik MŒths® :Dr.mknurh(Ph.No.9449603952),cjé¥nguhÁça®, r_féaš k‰W« r_f
gâ¤Jiw CHRIST gšfiy¡fHf« bg§fqU-29
MŒé‹ neh¡f« k‰W« gy‹ : kht£l kd ey Â£l¤Â‹ Ñœ gâòçÍ« bghGJ nehahëfS¡F V‰gL« j
‰bfhiy v©z§fis jL¡F« bghW¤J jh§fŸ ifahS« mQFKiw/Í¡Âfis g‰¿ m¿tnj Ïªj MŒé‹
neh¡fkhF«. மேலும் உங்களிடமிருந்து(nehahëfël«) வரும் பின்னூட்டங்கள், சேவை
வழங்கலைப் பற்றிப் புரிந்துகொள்ளவும், சேவையை மேம்படுத்தவும்
எங்களுக்கு உதவும் Ïªj MŒé‹ _y« »il¡F« gy‹ nehahëfël« V‰gL« j‰bfhiy v©z§fis ifahs
ek¡F Ï‹D« Áwªj mQFKiwfis f‰W¤ju/têtF¡f cjéL«.
x¥òif got« : g§F bgwyhkh/ nt©lhkh vd KobtL¡f c§fS¡F KG RfªÂuK« c©L. ÏÂš g§F
bgWgt®fS¡F vªj C¡f¤bjhifÍ« tH§f gl kh£lhJ. fU¤J rh®ªj MŒÎ v‹gjhš j§fS¡F vªj éj ghÂ¥ò« V
‰glhJ. Ïªj MŒéš g§nf‰F« bghGJ j§fSila fU¤J¡fŸ “nl¥ bu¡fh®l® “ _y« gÂÎbrŒa¥gL«. Ïj
‰fhf Ú§fŸ x‹W mšyJ Ïu©L kâ neu« bryél nt©o tU«. j§fSila fU¤JfŸ j§fŸ bga® F¿¥Ãlhkš
MŒÎ¡fhf/MŒÎ nr®ªj f£LiufS¡fhf k£Lnk ga‹gL¤j¥gL«. jå eg® vtçlK« g»®ªJ bfhŸs kh£lhJ.
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eh‹ ___________________ Ïªj MŒéš g§nf‰¡f r«kÂ¡»nw‹
njÂ :
g§FbgWnth® bga® / ifbah¥g« :
MŒths® bga® ifbah¥g« :
rh£Á bga® / ifbah¥g« :
Annexure 3
89
Questionnaire for DMHP staffs and VHN/ASHA (Face-to face interview and focussed group
discussion)
Age:
Gender:
Designation/Role:
Education:
Total years of experiences:
Years of Experience in the current role:
List of trainings received during the current role:
1. How are you promoting mental health in this region or in your day-to-day work?
2. What specific strategies are you using to promote mental health?
3. How are you mobilising the community for mental health promotion?
4. How do you work with key community members to promote mental health?
5. How are you working with key community members to sustain the community mental health
promotional activities?
6. Could you explain your experience if you have engaged in any work with youth, women groups
and village heads in the community to promote mental health?
7. Do you use social media to promote mental health? If yes, how are you using it? Could you
explain? 8. Do you work with schools and colleges to promote mental health? If yes, how are you
engaging them in the mental health promotional activities?
9. Do you work with local panchayats? If yes, how are you working with them?
10. Can you explain what are the challenges you experience while working with all of the groups
mentioned above (youth, women groups, village heads, panchayats?
90
11. What are some of your best practises on prevention and promotion of mental illness in the
community? Any specific initiatives you have taken to promote mental health?
12. What are your met and unmet needs to work on mental health promotion in the community?
13. Can you explain what is your perspective on the reasons for suicidal deaths in this region if any?
14. How do you identify if a person is having a risk for suicide?
15. If a person comes with suicidal attempt how do you assess the person?
16. What is the average time between the suicidal attempt and the first contact with your team.
17. How does the patient comes in contact with your team (Through referral or OP consultancy or
through NGO)
18. If a person comes with suicidal attempt what strategies do you use to prevent further suicidal
attempts?
19. How do you engage the family and the community to prevent the suicidal attempts (for all
participants)? Could you explain any crisis intervention strategies (only for psychiatrists,
Psychologist, Psychiatric Social Workers and Nurse)
20. Could you explain any suicide prevention strategies that you have used which are successful or
considered as best practices? Any specific initiatives you have taken?
21. What are the strategies you utilise to keep the patients in follow ups?
22. What are the methods you are employing if a patient wants to contact you/your team in case of
emergency?
23. What are the challenges you experience while working for prevention of suicides? How do you
overcome or what strategies do you use for those challenges?
24. What are your met and unmet needs to work on suicide prevention in the community?
25. Your satisfaction about the funding (Salary, travel allowances, yearly increment)
91
Annexure 4
Questionnaire for DMHP beneficiary
1. What was your year of birth?
2. What is your/ patients’ gender? 1 = female 2 = male
3. How old are you/ patient? ____years old
4. What is your/ patient’s civil status? 

1 = single 2 = married 3 = separated/ divorced 4 = widow 5.Others
5. How many other people live in your/ patient’s household (together with you in the same
house)? [Do not count yourself.]
Under 18 years’ old_____ from 18 till 65 years old_______ Over 65 years old________
Total number of people living in your household (your self-included) ______
6. What is the highest level of education you have/ patient has completed?
1.Hoigher Secondary 2. Graduate 3. Post Graduate 4. Illeterate 5. Primary 6. Secondary
7. Who is the bread winner for the family?

1. Patient 2. Other family member.
8. What were symptoms of mental illness encountered by the patient, along with the month
and year?
Symptoms Onset (Month and Year)
Duration of Untreated Illness First Contact with DMHP
9. Name the first point of contact with medical institution for seeking consultancy, along with
month and year?
1 = ANM 2=Doctor at PHC 3 = Doctor at GH 4 =Doctor at District Hospital

5 =DMHP Psychiatrist at PHC 6=DMHP Psychiatrist at GH 7 =DMHP Psychiatrist at
district Hospital 8=Psychiatrist at Medical College 9=Private Psychiatrist
10.First contact being a doctor (non-Psychiatrist) means (Irrespective of institution)

1.Treated 2.Referred(Go to Question)
10. What was the illness diagnosed by the medical professional (in the medical institution)?
(Round only 1 which is appropriate in this case)
Acute Stress Disorder Depression Mania Bipolar OCD ATPD Schizophrenia Psychosis
NOS Delusional Disorder Somatization Disorder Hypochondriasis Psychosis Alcohol
92
Dependence Tobacco Dependence Cannabis Dependence ODD Conduct Disorder Intellectual
Disability SLD Dementia Others_____________________Dont know_______
11. Was the diagnosis clearly explained to you?
1. Not at all 2. Somewhat explained 3. Clearly explained
12. How long were you / the patient treated by the medical professional who treated first?
1. Less than 3 months 2. 3 - 6 months 3. 6 months – 1 year 4. Between 1 – 2 years

5. Between 2 – 5 years 6. Between 5 – 10 years 7. More than 10 years 8. Don’t know/
Can’t remember
13. Did the medical person treat you/ patient with respect and dignity?
1. Yes, definitely 2. Yes, to some extent 3. No
14. Were you given enough time to discuss your / patients’ condition and treatment.
15. Did you have trust and confidence on the medical personnel who treated first?
16. Was a member of your/ patients’ family or someone close to you/ patient given enough
Information from the medical personnel who treated about the patient’s mental health
problem?
17. Have you been provided any medicines by Medical personnel who treated you/ patient for
mental health problem?
1. Yes 2. No
18. Were the purposes of medication explained to you?

19. Were you told about the possible side effects of the medications?
20. How far is the hospital where you are getting the treatment? _________km
21. How much you had to spend in order to reach to the hospital. Rs.__________
22. Were you referred to some other hospital for higher level of treatment by DMHP team?
0. No
1. Yes
23. Tick whichever is applicable in your case, along with month and year.
By Whom To whom
PHC CHC
CHC District Hospital
93
District Hospital Mental Hospital
Month Year
24. How far is the hospital which was referred to you from your place? _________km
25. How much you have to spend in order to reach to the hospital. Rs.__________
26. How many times you visit the hospital to meet the Psychiatrist/ GP for the treatment?
1. Once in Month 2. Twice in month 3. Once in 2 months 4. Once in 3 months 5. other
(Specify____________)
27. Has it ever happened that when you reached the hospital you could not meet the
psychiatrist/ doctor or your prior appointment with the doctor was cancelled or changed to
later date?
1. No
2. Yes, it happened once/ appointment was cancelled or changed
3. Yes, it happened 2 or 3 times/ appointment was cancelled or changed
4. Yes, it happened 4 or more times/ appointment was cancelled.
28. Whenever you go to the hospital to meet the psychiatrist/ GP/ doctor, do you
1. Often meet the same psychiatrist/ doctor
2. Often meet the different psychiatrist/ doctor
29.Medicines provided
1.Free in the medical institution
2.Asked to buy on own
30.Have to come back on other day to collect medicines due to non-availability?

1.Not happened
2.Happened once
3.Happpened more than once (Specify _____)
31. Have you ever taken counselling session (e.g. therapy) from the hospitals you were
referred?
0. No (Go to question 32)
1. Yes (Go to question 30)
32. Counselling was done by

1.Psychiatrist
2.Psychologist
3.Social Worker
4.Staff Nurse
33.What kind of Counselling were you offered

1.Behaviour theraphy
2.Cognitive Behaviour theraphy
3.Family therapy
4.Stress Management
5.Motivational Enhancement therapy
6.Like skills training
94
7.Psychoeductation to patient and family members on improving social support
8.Others (Specify_____)
34. If yes, how many times.

1. Less than 3 times
2. 3 – 5 times
3. 6 – 10 times
4. > 10 times.
35. Did you find this counselling session to be helpful?

1. Yes, definitely
2. Yes, to some extent
3. No
36.Assesemnet Reports/Therapy Summary Provided?

1.Yes2
2.No
37.Home visits by DMHP staff?

1.Yes(Which member____________/Whole team)
2.No
38. How many visits

1.1 2.2 3.3
39.Assistance /help in placing at homes/Securing jobs

1.Yes 2.No
40.Any assistance /help in Securing jobs?

1.Yes 2.No
41. How satisfied were you on interaction with DMHP staff on following aspects?
A score of 1 to 10
Aspect Score
Treating with courtesy and
respect
Examination In
privacy(Confidentiality)
Listening your concerns
carefully
Explaining things in a way you
could understand
Meeting as and when required
Explaining need and role of
medicines prescribed
Explaining probable
complications
Giving assurance for future
help
Transparent communication
95
with the family members
42. How much trust did you have on team who treated you?
A score of 1 to 10 _______
43 Overall how would you rate the care you have received from mental health service?
A score of 1 to 10 _______
44. In general, how is your/ patients mental health right now?

1. Excellent
2. Very good
3. Good
4. Fair
5. Poor
6. Very poor
96

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Draft Report of the “Analysis of District Mental Health and Primary Care

Personnel's Involvement in Suicide Prevention and Mental Health

Institution: Karur Govt. Medical College.

CHAPTER PAGE NO.

NEED OF THE STUDY 17

LIMITATION AND IMPLICATIONS 79

ATP - Advanced Tour Program

ASHA - Accredited Social Health Activist

AYUSH - Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy

AB-HWC - Ayushman Bharat Health and Wellness centres

CEO - Chief Educational Officers

CHC - Community Health Centre

CMCHIS - Chief Minister’s Comprehensive Health Insurance Scheme

DALY - Disability Adjusted Life Years

DMHP - District Mental Health Program

DPM - Diploma in Psychiatric medicine

ECT - Electroconvulsive therapy

ECRC - Emergency Care and Recovery Centres

FGD - Focussed Group Discussion

GBDS - Global Burden of Disease Study

GNM - Diploma in General Nursing & Midwifery

ICDS - Integrated Child Development Services

M.Sc. - Master of Science

MBBS - Bachelor of Medicine and Bachelor of Surgery

MTM - Makkalai Thedi Maruthuvam

M. Phil. - Master of Philosophy

MSW - Master of Social Work.

NCD - Non communicable disease

NMHP - National Mental Health Program

NMHS - National Mental Health Survey

NSPS - National Suicide Prevention Strategy

OPD - Outpatient department

PHC - Primary Health Centre

PPT - Power Point Presentation

VHN - Village Health Nurse

WHO - World Health Organisation

YLD - Years Lived with Disability

1 Demographic details of the DMHP staffs

2 List of subthemes and code under the theme “Training”

3 List of subthemes and codes under the theme “Services offered”

5 List of subthemes and codes under the theme “Challenge”

6 List of subthemes and codes under the theme “Strategies Utilized”

8 List of Health Care Institutions visited to recruit participants for secondary

9 Sociodemographic profile of patients

10 Details related to diagnosis and pharmacological management

Details related non-pharmacological services provided

In epidemiologic transition theory Abdel R Omran states that economic development of a

Rise of Non-Communicable disease

As per 2017 Global Burden of Disease Study, percentage contribution of non-communicable

Relationship between Mental disorders and Suicide

Definition of Suicide and Global Suicidal Rate

Suicidal Rate in India and Tamilnadu

Causes for Suicide

Impact of Suicidal Death on Family

Importance of Mental Health

Global Mental Health Action Plan

PROMOTION OF POSITIVE MENTAL HEALTH IN INDIA

Bhore Committee report

Mudaliyar committee report

Mudaliyar committee recommended that in order to improve the curative services,

Challenges for mental health services in developing countries

In 1975, WHO initiated a multinational project involving countries of Brazil, Colombia,