Mental health is more than the mere lack of mental disorders. The positive dimension of mental health is stressed by WHO which includes the concepts of subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence and recognition of the ability to realize one's intellectual and emotional potential.
It has also been defined as a state of well-being whereby individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities.
The World Health Report 2001 clearly pointed out that mental and neurological conditions cause a significant amount of morbidity all over the world. As many as 450 million people suffer from a mental or behavioral disorder. Nearly 1 million people commit suicide every year. Four of the six leading causes of years lived with disability are due to neuropsychiatric disorders (depression, alcohol-use disorders, schizophrenia and bipolar disorder).
One in four families has at least one member with a mental disorder. Family members are often the primary caregivers of people with mental disorders. The extent of the burden of mental disorders on family members is difficult to assess and quantify, and is consequently often ignored.
However, it does have a significant impact on the family's quality of life. In addition to the health and social costs, those suffering from mental illnesses are also victims of human rights violations, stigma and discrimination, both inside and outside psychiatric institutions.
A large proportion of these people live in developing countries, including the WHO South-East Asia Region. It is estimated that the burden of disease from neuropsychiatric conditions measured by DALY's will increase from 9% of the total disease burden in 1990 to 14% in 2020.
It is also known that a substantial proportion of people with neuropsychiatric conditions, particularly in developing countries, do not get appropriate treatment. This is referred to as the mental-health gap or treatment gap for mental health.
It is very unfortunate that the treatment gap in developing countries can be as high as 80-90%.Traditionally, neurological and psychiatric services have been concentrated in tertiary-care hospitals. Thus, large segments of the population, particularly those who live in rural and remote areas, have been deprived of such services. This is despite the fact that both neurological and psychiatric conditions are common in these communities.
In India, the prevalence estimates vary between 5.82 to 7.3%. In terms of absolute number suffering from mental illnesses, the prevalence estimate throws up a huge number of about 7 crore persons. Indian council of Medical Research (ICMR) study on the prevalence of severe mental disorders shows that 1% of the population have severe mental illness (SMI).
With regard to the availability of mental health professionals, number of psychiatrists in India is only 0.2 per 100,000 population compared to a global median of 1.2 per 100,000 population. Similarly, the figures for psychologists, social workers and nurses working on mental health is 0.03, 0.03 and 0.05 per 100,000 population compared to a global median of 0.60, 0.40 and 2.00 per 100,000 population, respectively.
Since these professionals practice only in urban areas, their services are accessible mostly to the urban population. The rural population, especially the rural poor has no access to these professionals and poor awareness about symptoms of mental illness, myths and stigma related to it, lack of knowledge on the treatment availability and potential benefits of seeking treatment also contribute to the treatment gap.
Talking about mental disorders means talking about stigma and human rights conditions. For example, there have been documented cases of people being tied to logs far away from their communities for extensive periods of time and with inadequate food, shelter or clothing.
It is essential to develop programmes capable of delivering at least the basic minimum level of services for neuropsychiatric conditions to everyone, everywhere. Ideally, such services need to be delivered within the community rather than expecting people to travel long distances to tertiary-care hospitals. For this purpose, primary health care system has to be utilized.
Broadly speaking, community mental health care programmes imply that ALL mental health and well-being needs of the community are met in the community, using community resources and the primary health care system. It goes MUCH BEYOND ONLY TREATMENT and includes:
• Promotion of well-being and mental health promotion
• Stigma removal
• Psychosocial support
• Rehabilitation of those in need
• Prevention of harm from alcohol and substance use
• Treatment of the ill using the primary health care system
Although it may not be possible to implement all these components in every community, whichever component is relevant and accepted by the community has to be implemented using community resources.
As a response to the distressing scenario, the RI Districts of 3000,5340 and 2730 with M.S.Chellamuthu Trust and Research Foundation as a Technical partner launched the Mission Mental Health project with the support of Rotary Foundation.
The objectives of the project were:
• Promote mental health among people.
• Early identification of mental health problems and initiation of treatment.
• Stigma reduction and promote social inclusion.
The project was sanctioned for one year and is implemented in the following revenue districts that fall under RI District 3000:
Core strategies implemented:
Mental Health Awareness Building
Identification and Treatment
Resource Mobilization and Coordination
Status of the project:
In order to initiate mental health related activities, Mental Health Consultation centres were established in each district and is functioning well .
Staffing pattern of the centre is:
• Social worker
• Community Facilitators
• Community care workers
• Office Manager
Besides, each centre is also supported by a Psychiatrist and a Psychologist.
District support teams are constituted in each district with the Rotarians nominated by the District Governor. The team meets with the staff of the project every month, reviews the progress made and lends support in improving the quality of mental health care.
ACTIVITIES CARRIED OUT:
Awareness building activities:
These activities are targeted at the organised groups in the community, especially students, community workers, members of self help groups etc .
The community groups were sensitised about mental health, mental health problems and its management. They were made to understand that mental illness is preventable, treatable and curable if identified and treated early.
During these programs, members of the interested in the mission of the project were identified and were trained as volunteers of the project.
These volunteers help in identifying the persons with mental health problems and to ensure that the identified attend the camps and follow the medication.
Identification and treatment:
The participants of the awareness programs and the community volunteers help in listing out the persons with mental health problems living in their locality.
Once the list is prepared, the community care workers and the community facilitators make home visits to confirm and to assess the condition of the persons identified.
During home visits, the family members are explained about the project and are motivated to avail the mental health services offered through the project.
During these visits, family members expressed their financial and social concerns in visiting the Consultation centre for treatment and suggested that it would be good if the treatment is made available in their locality itself.
As a response to the concerns expressed, Community mental health camp approach was followed to reach out to those with mental health problems.
Mental Health camps are organised every month in two locations in each district where there is high percentage of rural population.
In each district, a local psychiatrist is engaged and the mental health team comprising of the Psychiatrist,Social worker, Psychologist, Nurse, Community workers conduct the camp every month. Besides, the Nursing trainees of the Nursing Institutions functioning in the locality are also sourced in to manage the camp effectively. The local community volunteers identified through awareness programs support the mental health team in managing the crowd and in the registration of patients.
Children with developmental disorders associated with psychomotor disability constitute around 50% of those attending the camp. These children need more of training and care giver orientation.
In order to ensure that these children also benefit from the camp, local physiotherapist is outsourced and physiotherapy is given to those children in need.
On assessing their condition, we realised the need for physiotherapy and hence the services of a local physiotherapist are also utilised.
Considering the plight of the family members who are poor, medicines are given free of cost to all those attending the camps.
In the beginning of the project, we were actually planning to collect user charges from the patients availing treatment, but the socio economic conditions of the family members who bring their children for the camp were so deplorable and hence we were much constrained to collect the planned user charges from them.
To attend the camp, they have to travel long distances and have to bear the travel and food costs apart from losing their daily wages.
Besides, Mental Health camps, outpatient clinics are also run in each district to those who approach the District mental health consultation centre for treatment.
Community resources are identified and mobilised to support the distribution of medicines.
Since medication adherence is very critical for recovery, follow up calls and visits are made to ensure that there is compliance and to ascertain issues related to compliance.
Such follow ups help in understanding and addressing the concerns of the care givers.
2) Cost of medicine and mobilisation of medicines.
3) Adherence to treatment.
4) Geographical area and the population to be covered.
5) Reaching out to villages which are remote.
Number of awareness program conducted : 540
Population covered through awareness program : 70,457
Number of community mental health camps organised: 97
Number outpatient clinics conducted: 52
Total number of patients under treatment: 2720
We have learned from our field experiences that bringing a change in the mental health scenario in the revenue districts will take few more years and hence, wish to continue the project for couple of years with few changes in the program components.
1. Promote mental health awareness among the stakeholders.
2. Identify persons with mental health problems and refer them for treatment.
3. Provide support to improve adherence to treatment.
4. Facilitate family and social reintegration through re skilling.
It is planned to continue the awareness building activities which will result in stigma reduction and social acceptance.
It is further planned to focus on children, adolescent, parents and the teachers with a hope that this will help in two ways:
1. Since the onset of mental health problems generally occurs during childhood or adolescence, it is planned to identify the mental health problems at this stage itself and initiate earlier treatment.
2. Once this segment of the population is sensitised, through them , it will be easy to reach out to the other population in the community and in identifying the persons with mental health problems living in the respective community.
Cchildren's mental health and wellbeing is of paramount importance which has not been given its deserved attention. Today, majority of the children and adolescents experience significant stress in some form or the other in their lives. Some stressors are part of the normal growing up while others are more environmental like parental conflicts, divorce, peer pressures, physical and sexual abuses and pressures on academic achievementt.
Children attempt to face these stressors with varying degrees of coping, resilience as well as social support. However, their success in overcoming these stressors which are significant barriers to learning is unpredictable. Thus, unfortunately, it is sometimes not possible to determine which child will be a victim to mental health problems before they develop it.
Infact, empirical studies have shown that nearly one in five children and adolescents will suffer from an emotional or behavioural disorder at some period during their younger ages regardless of where they live and how economically able they are (Bazheenova, Gorunova, Kozlovskaya & Skoblo, 1992).
Indian epidemiological studies report prevalence rate of behavioural and emotional problems among children as varying between 10.5% and 50.6%. Yet another study reports prevalence rates of psychiatric disorders in 4 to 16 years community participants to be 12%. However, only 37.5% of the families of these children perceived that their children had any problems (Srinath et al., 2005).
Majority of children with mental health needs rarely present for treatment (Sawyer & Patton, 2000). Only limited children with high levels of anxiety typically seek help from a mental health professional. Thus, despite the high prevalence of mental health problems among children and adolescents, these youngsters remain silent sufferers for a long time, with majority of the families being unaware or ignorant of the child's ongoing inner emotional turmoil.
Left unattended, these mental health problems during childhood and adolescence have the grave potential to turn in to a serious psychiatric illness/ disorder when these children become adults. This has also been proven by scientific studies which have shown that majority of adults with anxiety disorders reported that they have had suffered from anxiety symptoms as children (Last, Hersen, Kazdin, Francis, & Grubb, 1987).
Therefore, early identification of mental health problems and timely intervention, preventive efforts against mental health issues through promoting positive mental health could make a lasting change in the lives of these youngsters.
Thus, on one hand, there is a crucial need for addressing mental health of children and adolescence at large but on the other hand there is an undeniable vacuum with regard to the availability of services for providing mental health care.
According to World Health Report (2001), schools are becoming the most appropriate venue for health related interventions for children. The concept of school-based mental health programs emphasize the need for collaborative partnerships between parents and school professionals namely teachers and school psychologists to promote children's academic and mental health success and deal with factors that are barriers to effective student functioning (Hoagwood & Erwin, 1997).
According to World Health Organization (WHO, 1994), schools provide the best platforms for developing a comprehensive mental health program for children because:
1. Almost all children attend school at some period in their life time
2. Children's ability and motivation to stay in school, to learn and to use what they learn is strongly influenced by their mental well-being
3. Schools can act as a safety net, protecting children from dangers that impede their learning, development and psychosocial wellbeing.
4. When teachers are actively involved in mental health programs, the usefulness of the interventions can reach generations of children.
The objectives of this intervention:
1. Promote mental health awareness
2. Earlier identification of Mental Health problems and initiate treatment.
3. Promote positive habits to ensure mental well-being.
1. Mental health awareness
2. Problem Identification and referral.
3. Tele consultation with the mental health professionals
The community facilitators and the social worker will be initiating these activites with the support of the mental health professionals of M.S.Chellamuthu Trust and Research Foundation .
Awareness programs planned:
Number of Awareness Programs : 8 districts x 4 programs = 32 Programs in a month.
Target population: Students, Teachers and Parents. Special focus will be on the members of the Rotaract Clubs in each district.
Expected population coverage per month: 32 Programs x 100 = 3200 per month.
Core contents of the awareness program:
Mental health and its importance. Positive mental health.
Common mental health problems and its management.
Myths and Misconceptions about the problems.
Role of the individuals in the promotion of mental health.
The Government through State Mental Health Authority has launched the District Mental Health Program through which a Psychiatrist is appointed in each district.
The District mental health team visits the taluk Government hospitals once in a week and offers treatment to those with mental health problems during such visits.
Furthermore, the medical officers of the Primary health centres are all trained to screen patients for mental health problems and manage the symptoms.
So, this year, instead of giving treatment through mental health camps, it is planned to make use of this facility.
It is planned to sign a Memorandum of Understanding with the State Government of Tamilnadu in this regard.
The community facilitators and the Community care workers who work at the grass roots will identify the patients, motivate them for treatment and refer them to the nearby Primary Health Centres or Government Hospitals for treatment.
The follow up of those under treatment will be done by the Community Facilitator.
The purpose of the follow up visit is to ensure medical adherance and to address the concerns of the family members.
Day care centre :
In the mental health care continuum, rehabilitation plays an important role in facilitating the mainstreaming of those with mental health problems.
The focus of treatment is symptom reduction whereas the focus of rehabilitation is skills development.
Among those getting treatment, the persons who need rehabilitation will be identified and motivated to attend the program at the day care centre.
Proposed activities :
1. Functional assessment
2. Functional skills training
4. Livelihood training.
5. Follow up.
Based on functional assessment, individualized plan will be drafted and opportunities in the form of activities will be given to those attending the day care centres to develop their functional skills and improve their functional performance.
Physiotherapy services will be available for the children with mental retardation with associated physical disability.
Asset matrix will be drawn for each client and based on the assets availability; both in the family and the community, suitable livelihood initiative will be suggested and supported.
Further, the day care centres will act as the hub of Mental health care services in each district.
Proposed structure in each district:
Structure of the Project Coordination office:
Project Manager Monitor the performance of the day care centers.
Provide support to improve its performance.
Compile reports from the districts and submit report to the Project management team.
Liaise with the Government and Non Governmental organizations in the districts and mobilize support for the project.
Structure of the Day care centre:
Physiotherapist - Part time
Community Facilitator - 2
Care taker - 2
Office Manager - 1
Identification of the persons with mental illness and refer them for treatment.
Follow up for medical adherence.
Training on skills development for those under treatment.
Promotion of livelihood.
Presently, the following structure is in operation and this will be continued.
Project management team
District Support team at the level of the district
Number of Day care centres planned: 8 (one in each revenue district)
The project needs the Grant in support for two years to achieve sustainability in the third year.
It is planned to collect user charges from those availing the day care services.
Patient flow and user charges:
Period Number of beneficiaries User charges
First 3 months from the date of start of the project Nil Nil
3 to 6 months 5 5 x INR 1500 = INR 7500
6 to 9 months 10 10 x INR 1500 = INR 15,000
9 to 12 months 15 15 x INR 1500 = INR 22,500
12 to 15 months 20 20 x INR 1500 = INR 30,000
15 to 18 months 25 25 x INR 1500 = INR 37,500
18 to 21 months 30 30 x INR 1500 = INR 45,000
21 to 24 months 35 35 x INR 1500 = INR 52,500
Expected user charges from all the districts at the end of second year = 8 x INR 52,500 = INR 4,20,000
Other modes of Resources mobilization:
During this period:
Efforts will be taken to lobby with the Government for Grant in support to sustain the activities of the centre.
Community resources will be identified and mobilised
Explore corporate funds and lobby for the required support.
S.NO ITEM COST
Budget in INR
1. Honorarium for the Project Coordinator 1 x 12 x INR 25,000 3,00,000
2. 1 Honorarium for Social worker 8 districts x 12 months x
INR 15,000 14,40,000
3. 2 Honorarium for the Special Educators 8 centres x 12 months x
INR 10,000 9,60,000
4. 3 Honorarium for the Physiotherapist - Part time 8 centres x 12 months x
INR 10,000 9,60,000
5. 4 Honorarium for the Caretakers 8 centres x 2 x12 months x
INR 5,000 9,60,000
6. 5 Honorarium for the Office Manager 8 districts x12 months x
INR 7000 6,72,000
7. Honorarium for the office manager ; Project coordination office 1 x 12 x INR 7000 84,000
8. 6 Honorarium for the Community Facilitators 8 x 2 x 12 x INR 6000 11,52,000
9. 7 Rent for the Centres 8 centres x 12 months x
INR 7,000 6,72,000
10. 8 Centre Maintenance 8 centres x 12months x
INR 5000 4,80,000
11. Conveyance for the Project Coordinator 1 x 12 x INR 5000 60,000
12. 8 Conveyance for Social worker 8 x 12 x 3000 2,88,000
13. Conveyance for the community facilitators 8 x 2 x 12 x INR 2000 3,84,000
14. 9 Awareness Programs 8 centres x 4 Programs x
12 months x INR 1500 5,76,000
15. 10 Physiotherapy equipments 8 centres x INR 30,000 2,40,000
16. Special education materials
8 centres x INR 20,000 1,60,000
17. Furniture for two centres 2 x INR 50,000 1,00,000
18. Computer and accessories for two centres 2 x INR 40,000 80,000
19. 9 Miscellaneous 8 centres x 12 x INR 3000 2,88,000
20. Total (in INR) 98,56,000
21. Total (in USD) 150,000$