精神経誌（2010）112 巻 2 号

126

第回日本精神神経学会総会

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Breaking the Barriers―The Challenges
in Mental Health Care in India
Kalmane Sridhara Pavitra（Consultant psychiatrist,
Sridhar Neuropsychiatric centre Shimoga, Karnataka, India）

India is the seventh largest country in theofworld, and the second largest in Asia with an・Mental Health Institutes

area of 3.29 million square kilometers. It is also・Psychiatric departments in Government

the second largest populous country.

It ismultilingual, multicultural country and people

General Hospitals
・Private Sector‑clinics, nursing homes andthere are diverse in culture, and language,

corporate hospitals

geographic and climatic conditions. It consti-

Psychiatric training in India at undergradu-tutes 16% of worldʼ
s population.

ate level constitutes of clinical postings for amonth. Medical students often skip a psychia-

Psychiatric beds & professionals

try class. Psychiatry seems to be considered as

Though the number of psychiatric patienta non medical subject bymost students. Stigma

was estimated to reach 7.5 million, the mental

against psychiatrists, or against psychiatrichealth resources are far from satisfaction.

patients is highly prevalent among medical

Table 1 shows number of mental health re-students. In most cases,a new psychiatrist getssources per 10,000 population in India.

western style postgraduate psychiatric training.
However, for Indian young trainee psychia-

Mental health services in India

trists, the conceptual frameworks of western

M ental health services in India constitutepsychiatry are wholly foreign to the milieu ofhis birth and habitation. The type of patients,
the duration of contact and the service hisTable 1 The number of mental health resources
per 10,000 population in India

patient needs may be diﬀerent from what helearned.

Total psychiatric beds

0.25

When we look at Indian patients, they are

Psychiatric beds in general hospitals

0.05

full of expectations. They are ready to accept

Number of Psychiatrists

0.40

overt situational support. However, they have

Number of Psychiatric Nurses

0.04

great diﬃculty in understanding the western

Number of Psychologists

0.02

diagnostic methods. Most of them are skepti-

Number of Social Workers

0.02

cal about the need for long term follow‑up with

Number of mental hospitals

43

medication. By patients and medical profes-シンポジウム：Current Status of Psychiatry in Asian Countries

127

sionals, psychiatrist is often seen as a “Profes-workers could identify and report about exist-

sional” who has ability to do everything

ing cases easily. It was also noted that hospital-

through “talking”.

ization was rarely required. It was seen that
medical and non‑medical workers were able toStigma and help seeking patterns in India

learn how to manage major mental disorders in

Stigma against mental illness, psychia-

short term courses. Most of the patients withtrists, and psychiatric patients is highly ramp-

acute psychosis improved with short term

ant in India. M ental disorders are viewed as a

medications and subsequent rehabilitation werecurse,a result of bad deeds,or a understandable

also done also within their villages. Improved

predicament which has to be endured by thepatients were accepted in the mainstream ofpatient and the family .

life without stigma .

Epidemiological studies in 1970s showed

Lacunae in psychiatric training were alsothat mental morbidity was the same in rural

pointed out. There were few training centers.

and urban areas, but less care was available in

Focusing in undergraduate medical training

rural areas . The drop out rates after the ﬁrst

was inadequate. There was diﬃculty in im-

contact was very high. Ignorance, incorrect

plicating theoretical and tertiary practices inknowledge about psychiatric disease （e.g.

community.

beliefs of evil spirits, black magic, punishment
for past bad deeds）or lack of knowledge re-National M ental Health Programmegarding modern methods of treatment were the

NMHP―1982

main reasons for non‑use of psychiatric ser-

NMHP 1982 focused on prevention andvices. Lack of mental health resources andtreatment, quality of life and decentralization

shortage of the budget for this ﬁeld, whichof the mental health services .

forced the patient in the rural area to travelWorkshops at state and national level werelong to get the medical services costing a lot of

conducted as part of this.

money, is another reason.

health programmes were planned and devel-

These studies also revealed that the psychiatric care delivery systems were grossly inadequate. The number of trained psychiatrists was

District mental

oped.
Major diﬃculties identiﬁed in NM HP wereas follows.

far less from the requirement. They were not

・Health sector―the least priority areaabsorbed in government institutions.

・Mental Health―most neglected

There

were no posts for clinical psychologist, psychiatric social workers and psychiatric nurses ingovernment institutions.
The model psychiatric services in Sakalwara and Raipur Rani were two important
projects in 1980. They revealed that majority

・Non representation of psychiatrists in policy making bodies
・Utter ignorance and misconceptions about
mental health in administrators and policy
makers.
・No organized patient family groups.

of mentally ill patients ﬁrst went to traditional

It was noted in NMHP that professionals

healers. Psychoses and epilepsy were undetect-enjoyed working in their specialty hospitals but

ed for over 2 years. Key informants, healththey seemed to be uncomfortable in community

精神経誌（2010）112 巻 2 号

128

settings. They felt helpless when the resourceswere limited.

・Maintenance of mentallyill in a psychiatrichospital

General practitioners and primary care・Judicial inquisition regarding alleged men-

physicians could recognize psychiatric prob-

tally ill persons possessing property andlems in their patients.

management

But they were notequipped with the skills to manage them. They・Improved standards of mental health carelooked at psychiatry either as a mystery or as

・Provision for separate places for children,

time consuming, less useful ʼscienceʼ. Theypreferred to get rid of these cases by referringconvicted and substance use patients・Prohibition on any research without properthem to mental health professionals. Fear ofconsent

loss of work, identity and income hindered

Criticism of the act

appropriate and timely referrals.
NMHP pointed out that the societyhad notworked out the loss of man‑hours and cost of
not treating mentally ill. The society also did
not understand the burden theyshould carryon.
It was ready to invest for the care and prevention of heart disease and cancer. But not formental disorders.

・Licensing authorities do not have a doctor
・No incorporation of general hospital andcentres・Much stress on hospital admission anddischarge procedures・No provision for after discharge care andrehabilitation
・Diﬀerent news for government and private
hospitals

Mental health act―1987

・Complicated licensing process

M ental health act passed in 1987 was an
act to consolidate and amend the law relating

The Erwadi tragedy―2001

to the treatment and care of mentally ill per-The Erwadi tragedy in 2001 marked thesons, to make better provision with respect todeath of 26 mentally ill persons in a religious

their property and aﬀairs and for matters con-place where they were chained and met with annected therewith or incidental thereto. Howev-

accident . This raised concerns regarding theer it came in to practice only in 1993. It has 10

beliefs of the general population, the reasonschapters and 98 sections.

for chronicity and disability of mentally ill,theThe 10 chapters areneeds of the families and state responsibility

・Change of oﬀensive terminologies

and regulation of services.

・Procedures for establishment of mental
health authorities
・Guidelines for establishment and maintenance of psychiatric hospitals
・Procedures of admission and detention ofmentally ill
・Inspection, discharge, leaves of absence
and removal of mentally ill
・Protection of human rights in mentally ill

Facing challenges ahead
Dedicated, culture sensitive and culturally
educated psychiatrists are the needs of current
Indian psychiatry. Alternatives to institutionalcare have been utilized which constitute of out
reach services‑Camps held in rural areas oncein 3 months. All types of treatment including
ECT are given in outpatient set‑ups.

シンポジウム：Current Status of Psychiatry in Asian Countries

Integration mental health services into primary health careThis has been thought to be the most feasi-

129・Became better and felt no need for follow‑
up（19%）
・Caring for other family members（19%）

ble strategy. This would involve screening of・Long wait to meet the doctor（16%）

patients,education of primary health care staﬀ,

・Side eﬀect of medications（8.3%）

delivering stepped care approach and active

・Expense of transportation（5.5%）

collaboration of mental health professionals .

・Feeling worse since last consultation and

The barriers to this integration are multiple . They are

did not feel advice was useful（5.5%）
Psycho education as part of the MANAS‑Limited skilled mental health re-intervention was given at the onset in the fol-sourceslowing manner‑Vastly diﬀerent social and culturalcontexts

・Brief, emphasizing the connection between
stressors and symptoms‑Already constrained primary care・Delivered in an empathetic mannersystem・No stigmatizing terms‑Infrequent inadequate use of antide-・Group IPT delivered in community loca-

pressants

tions‑temple courtyards, local schools dur-

‑Frequent use of vitamin injections

ing evenings‑Low adherence to medication regi-

・Yoga as one of the group activities availa-

mens minimizing the gains of treat-

ble to all primary care attendees and staﬀ

ment

to de stigmatize the whole programme‑Inadequate use of psychosocial treat-

The role of The Health Counselorments because of scarcity of personnel with the time and skills to deliverthem

・M ost important human resource of
MANAS・Participants opined that this should be a
woman

MANAS intervention
As an eﬀort to integrate evidence based

・Fluent in local languages
・Good in communication skills

treatment for common mental disorders,

・Be available in clinics on a regular basis

MANAS intervention study was carried out in・Called as ʻ
Salagarʼto reﬂect local under-Goa, India . It constituted ofstanding and improve acceptability

・M ental health intervention involving healthcare workers
・Psychoeducation, interpersonal therapy,
antidepressants being the main interven-

Multiple roles of a psychiatrist
A psychiatrist in India has to fulﬁll multiple roles

tion strategies.

・As a clinician

The reasons for irregular follow ups or・As an educator to public as well as non‑dropouts were identiﬁed
・Engaged in work―cannot ﬁnd time to get
to treatment（50%）

psychiatric medical professionals.
・As a community worker
・As a communicator with policy makers,

精神経誌（2010）112 巻 2 号

130politicians and caress

problem children

・As a multipurpose worker
Care delivery also has been at diﬀerent
levels and approaches

Utilizing health workers
As a step towards integration of mental

・Short stay wards―From few hours to 48
hours

health services into primary health care training of grass root level,health workers has been・Subsidized drug supply

undertaken in the following ways.

・Satellite clinics in rural areas

・Training in basic mental health care・Identifying and referring mental retarda-

Counteracting stigma

tion

Education needs to be an important approach to counteract stigma,to identify mental

・Improving the child rearing practices
・Training student peer volunteers

health problems early and for primordial prevention through teaching life skills.

Our experience

Education can be

Our centre where I have been working as a・Through media television, radio, news
papersconsultant has been conducting outreach services in the community. To increase awareness・Patient information handouts

and to facilitate early recognition and treat-

・Back―referrals to the referring doctor

ment we started mental health camps at all

after managing the immediate crisis

villages with a population of 500‑1,000 every 5・Communicating with referring doctor

kilometers. Before each camp, local clinicians

We have been working on this throughare personally contacted from the samples

・Education―at individual and at communi-

given to consultants. Free medicines to thety levelpossible extent are given. Medications are also

・Instituting earlyrecognition and Successfultreatment

given at subsidized rates and free electroconvulsive therapy is given. Certiﬁcation for mentally

・Aiming at eﬀective Successful rehabilitation

retarded children for government beneﬁts areprovided in these camps. Camps are conductedin the vicinity of mercy healers, god places.

School mental health programmes
Another innovative strategy has beenschool mental health programmes.

Mentalhealth problems and learning problems related

Each camp would have an educating lecture programme. They also held street play
drama on mental health in local language anddistribute educational charts or pamphlets.

to schooling are highly prevalent but undetect-

In these camps more than 60,000 patientsed. Hence school mental health programmes

have been examined till today. These camps

have been devised tohave high follow‑up rates―up to 70%.

The・Conduct training programmes for teachers

referral rates from religious places and local

・Changing the attitude towards problem

doctors are increasing.

children・To encourage School reports in cases of

We have noted that
・Changes are possibleシンポジウム：Current Status of Psychiatry in Asian Countries

・Psychiatric OPD and referrals have increased by 60‑70%131multiple. The small number of mental healthprofessionals, the developing state of primary・Developing good rapport in minimal time ishealth care and welfare services,the low priori-a key factor and is an essential skill for thety for mental health in general health services,

clinicianfunding limitations and lack of public pressure

・Involvement of signiﬁcant others, local
doctors, religious healers is important
・We need to be service oriented rather thanstudy oriented
In urban areas where accessibility to men-groups are potential barriers to mental healthcare.
The universal focuses in clinical practice
are as follows.
・Promoting adherence to treatment

tal health services is easy but stigma is highly

・Rapport building

prevalent, the centre has diﬀerent strategy. A

・Clear and open but selective communica-

team of service oriented doctors in the centre
and from other hospitals have spent one day a
week.

This team oﬀers free consultation

tion
・Using destigmatizing culturally acceptableand useful therapy like Yoga

［diagnosis and referrals］ and counseling every

・Addressing psychosocial issues

Saturday. Patients are not given free medica-

・Practical options for psychosocial prob-

tions. User friendly and meaningful terms are
named for each service unit in local language‑
Kannada・Suicide prevention unit―Vimochanalems
・Psychotherapeutic techniques in clinicalpractice
India has been one of the countries to・Adolescent mental health unit―Ashraya

develop many innovative approaches to mental

・Addiction unit―Mukthi

health care. The advances in understanding the・Womenʼs mental health unit―M anini

human behaviour and mental disorders justify

・M arital Health unit―Paraspara

our optimism of developing meaningful and・Academic and examination related unit―

realistic mental health programmes.

Samveda・School mental health unit―M edha
The centre also has been conducting Student enrichment programmes with focus on

It ismandatory to bring the fruits of science to thetotal population of India.
There are no universal models for mental
health care. Even in countries with well‑devel-

・How to study

oped mental health programs,a wide variety of・How to learn better

problems exist. It has been pointed out that

・How to communicate

the development of mental health care will

・How to perform wellcontinue to be aﬀected by national, regional,

・Role of emotional factors in learningand local factors. Factors that will inﬂuence

decisions about which conditions are considered
Planning mental health caremental disorders are what constitutes a mental

Thus in planning mental health care advan-

health issue, where mentally ill persons will betages must be weighed against the limitations.

cared for and what amount of resources will be

In a large country like India,the challenges are

made available for these activities. It is fortu-

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精神経誌（2010）112 巻 2 号

132nate that the needs of mentally ill persons in

opment and evaluation of a pilot training programme.

rural areas are receiving special attention from

Indian Journal of Psychiatry, 24; 131‑138, 19825）Justice, M .o.l.a.: M ental Health Act―1987‑

national and international agencies. Such attention can provide opportunities for new programs and new initiatives.

Programmes toﬁght stigma and discrimination should address
the study of local experiences in diﬀerent

The Gazette of India Published by Authority. M inistryof Law and Justice, New Delhi, 19876）M urthy, R.: Status Paper on Delivery of M ental Health Services in India the Last 40 Years. ICM R,
New Delhi, 1982

groups using qualitative and quantitative meth-7）M urthy, R.: Lessons from the Erwadi. Trage-ods. The interventions should be group speciﬁcdy for mental health care in India. Indian Journal ofand the eﬀorts at mental health literacy should

Psychiatry, 43; 362‑377, 2001

focus on the understandability of mental phe-8）Sartorius, N., Schulze, H.: Reducing the stig-

nomena and on the ʻ
normalcyʼmodel rather thema of mental illness. Cambridge University Press,

deviance model.

Cambridge, 20059）Saxena, S., Sharan, P., Cumbrera, M .G.:
References

1）Bower, P., Gilbody, S., Richards,D.: Collaborative care for depression in primarycare.Making senseof a complex intervention : systematic review andmeta‑regression. Br J Psychiatry, 189 ; 484‑493, 20062）Chatterjee, S., Chowdhary, N., Pednekar, S.:
Integrating evidence‑based treatments for common
mental disorders in routine primary care: feasibility
and acceptability of the MANAS intervention in Goa,
India. World Psychiatry, 7; 39 ‑46, 20083）Chisholm, D., Sekar, K., Kumar, K.: Integration of mental health care into primary care. Demonstration cost‑outcome study in India and Pakistan.Br J
Psychiatry, 176; 581‑588, 2000
4）Isaac, M ., Kapur, R., Chandrashekar, C.: men
tal health delivery through rural primary care; devel-

World Health Organizationʼ
s Mental Health Atlas
2005: implications for policy development. World
Psychiatry, 5; 179 ‑184, 2006
10）Services, D.g.o.h.: National M ental Health
Programme―A Progress Report, 1982‑1990. DGHS,
New Delhi, 1991
11）Stuart, H.: Fighting the stigma caused bymental disorders: past perspectives, present activities,
and future directions. World Psychiatry, 7; 185‑188,
200812）WHO: Atlas: M ental Health Resources in theWorld 2001. WHO, Geneva, 200113）Wig,N.,Murthy,R.,Harding,T.: a model forrural psychiatric services; Raipur Rani experience.
Indian journal of psychiatry, 23; 275‑290, 1981