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Context:
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.
Mental health is about enhancing competencies of individuals and communities and enabling them to achieve their self-determined goals.
For all individuals, mental, physical and social health is closely interwoven, vital standards of life. As our understanding of this interdependent relationship grows, it becomes ever more apparent that mental health is crucial to the overall well-being of individuals, societies and countries.
Unfortunately, in most parts of the world, mental health and mental disorders are not accorded anywhere the same importance as physical health. Rather, they have been largely ignored or neglected.
Mental health should be a concern for all of us, rather than only for those who suffer from a mental disorder. Mental health problems affect society as a whole, and not just a small, isolated segment. They are therefore a major challenge to global development. No group is immune to mental disorders, but the risk is higher among the poor, homeless, the unemployed, persons with low education, victims of violence, migrants and refugees, indigenous populations, children and adolescents, abused women and the neglected elderly.
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 behavioural 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.
Mental health services depend primarily on trained human resources rather than sophisticated equipments.
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.
Furthermore, often people are admitted to and treated in mental health facilities against their will. Issues concerning consent for admission and treatment are often ignored, and independent assessments of capacity are not undertaken. These Persons with mental disorders often suffer a wide range of human rights
violations and social stigma. In many countries, people with mental disorders have limited access to the mental health treatment and care they require, due to the lack of mental health services in the area in which they live or in the country as a whole.
The failure of society to acknowledge the burden of mental disorders on affected families means that very little support is available to them. Expenses for the treatment of mental illness are often borne by the family because they are generally not covered by the State or by insurance.
Family members may need to set aside a significant amount of their time to care for a person with a mental disorder. Unfortunately, the lack of understanding on the part of most employers, and the lack of special employment schemes to address this issue, sometimes render it difficult for family members to gain employment or to hold on to an existing job, or they may suffer a loss of earnings due to days taken off from work. This compounds the financial costs associated with treating and caring for someone with a mental disorder.
To meet the mental health needs of the community, The Mental Health and Substance Abuse Unit (MHS) of the WHO Regional Office for South-East Asia (WHO/SEARO) has suggested a two-pronged strategy: one is to promote mental well-being taking a positive approach to mental health promotion and prevention of mental illnesses; and the other is to assist Member States in developing community mental health services which reach out to the community.
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.
Those delivering health care in the community has to be trained to identify and manage these conditions. In addition, affordable and appropriate medications has to be made available in the community. Finally, such programmes need to address psychosocial issues such as stigma and rehabilitation.
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.
An attempt would be made through this project to reach out to the community and in developing community based mental health programmes that would address the mental health needs of the people.
1. Objectives:
• Promote mental health among people.
• Early identification of mental health problems and initiation of treatment.
• Stigma reduction and promote social inclusion.
2.Core strategy:
2.1.Mental health literacy:
2.1.1: Identification and mapping of stakeholders:
• Panchayat leaders
• Village administrative officers
• Health workers
• ICDS workers
• Teachers
• Students
• Traditional healers
• Non allopathic practioners
• Representatives of CBO's.
2.1.2: Organizing mental health literacy programmes:
In order to develop the mental health capacity of the people and the stakeholders, the community facilitators would be piloting the mental health literacy programmes.
Planned activities:
• Mass awareness campaigns
• Distribution of leaflets, brochures and posters.
• Specific input sessions for the stakeholders
• Celebration of mental health festivals in the villages - cultural events,
Speeches, video presentations and an exhibition would be organized as part of the celebration.
It is planned to have 4 community facilitators( two for each revenue divisions )to initiate activities that will promote mental health in the area, refer those with mental health problems to the mental health consultation centre and do the necessary follow up. It is planned to organize a minimum of two programmes in a week in each revenue division in the district.
The field guidance would be offered by the District lead facilitator.
All the activities would be organized in collaboration with local Rotary Clubs. The presence of the members of Rotary Clubs and the display of Rotary sign boards, banners and standees in all the locations would help the public understand the social commitment of Rotary clubs.
2.2.Early identification and intervention:
Series of mental health literacy programmes in the community are expected to result in early identification of mental health problems and referral for the Taluk level mental health consultation centre where further assessment would be done by a Psychologist and based on the assessment, medical and counseling support would be provided.
It is also planned to organize 4 mental health camps in a month in the project area with the support of the local Rotary clubs. In Madurai District, there are 20 Rotary Clubs with which it is planned to collaborate. The possibility of local Rotary clubs in sponsoring the cost of medicines to be used in the camps would be explored. The Trust would be using the Bus fitted with facilities for Tele consultation during such camps.
People would have the option of attending the mental health camps or approach the community consultation centre directly.
Based on the consultation, whether the patient requires hospitalization or can be treated as an outpatient would be decided. Those patients who need hospitalization would be referred to the hospital run by the Trust for further management and those who need rehabilitation would be admitted in the rehabilitation centres of the trust without any charges.
Those who can be treated as an outpatient would be given medicines free of cost with the active support of Rotary clubs.
Besides the management of mental health problems, the centre would also offer counseling support for those with relationship problems (marital, family) and for children with problems in academics.
Tele consultation:
People, who visit the community consultation centre for treatment, would be assessed initially by the community facilitator and would be put to the Psychiatrist at the Tele consultation centre that would be operating from the premises of the trust.
The facilities for tele consultation are already created with the support of Hewlett Packard Health Care Division, Mumbai.
2.3.Resources Mobilisation:
The district lead facilitator would be spearheading the resources mobilization efforts in the district. He / She would be mapping the financial. Social, physical, natural and human resources available in the project area and would initiate action in consultation with support teams to mobilize the required resources that would help sustaining the project activities.
3. Project coverage:
The Project would be implemented in Madurai District on a pilot basis.
Mental health Consultation centre would be established in two places in Madurai District.
Community facilitators would be facilitating the mental health activities in the district.
Structure of the project:
Project implementation Project support and monitoring
Tele consultation centre Project management team
Mental health consultation centre Community support team
Tele consultation centre:
The existing facility of the Trust would be used for tele consultation.
A psychiatrist would be available here during stipulated hours for tele consultation and tele prescription.
Community consultation centre:
The community consultation centre would be established in two locations in Madurai District.
Functions:
• Awareness building and social support mobilisation.
• Early identification.
• Mental health assessment
• Counseling
• Tele consultation with the Psychiatrist
• Resources mobilization and coordination
Community support teams:
Community support teams would be formed in two divisions of the district with the representatives of the following stakeholders as members:
• Local bodies
• Teachers
• Business networks
• Self help groups
• Students
• Youth networks
• Care givers of the persons with mental health problems.
• Non Governmental organizations.
These teams would be giving guidance and support to the community mobilization activities.
Project management team:
This team would be formed with the following as members:
• Present Governor of Rotary District as Chair person.
• Past Governor and the Governor elect as members.
• Representative of the Trust
• Consultant Psychiatrist
• Representative of the Government.
This team would provide the leadership for the project and monitor the project activities.
4.Sustainability :
It is planned to collect a nominal user charges from those visiting the community consultation centre. On an average, it is expected to have a minimum of 20 to 30 patients every day and it is expected to rise over a period of time, once the project becomes more visible to the population.
Local well wishers, philanthropist, social networks, Business establishments and educational institutions in the locality would be identified and motivated to support the operation through donations, sponsorship.
The resources available with the Rotary clubs in the area of operation would be explored and utilized in organizing awareness camps and in the free distribution of medicines.
6.Indicators:
• Increased Mental health literacy
• Number of people identified and referred for consultation.
• Number of people visited the consultation centre.
• Number of patients under treatment and recovery.
• Number of follow ups.
Summary budget:
1 Mental health tele consultation centre 4,44,000 (Details Given Below)
2 Community mobilization 15,80,000 (Details Given Below)
3 Total 20,24,000 (Aprox 34,000$)
Budget for Mental health tele consultation centre:
1 Professional charges for Consultant Psychiatrist 1 x 12 months x Rs.30,000 3,60,000
2 Maintenance of the facility 12 months x Rs.5000 60,000
3 Contingencies 12 months x Rs.2000 24,000
Total 4,44,000
Budget for Community Mobilisation:
1 Professional charges for District lead facilitator 1 x 12 months x Rs.20,000 2,44,000
2 Conveyance for the Distict lead facilitator 1 x 12 months x Rs.3000 36,000
3 Honorarium for the community facilitators 2 divisions x 2 facilitators x 12 months x Rs.8000 3,84,000
4 Conveyance for the facilitators 2 x 2 facilitators x 12 months x Rs.1500
72,000
5 Mental health literacy campaigns 2 divisions x 4 programs x 12 months x Rs.2000
1,92,000
6 Mental health camps 2 divisions x 2 camps x 12 months x Rs.7000
3,36,000
7 Rent for community consultation centre 2 x 12 months x Rs.5000 1,20,000
8 Office maintenance 2 x 12 months x Rs.3000 72,000
9 Furnitures 2 x Rs.10,000 20,000
10 Computers 2 x Rs.40,000 80,000
11 Miscellaneous 12 months x Rs.2000 24,000
Total 15,80,000
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