International Review of Psychiatry, April 2005; 17(2): 103–107

Community mental health care in India

R. PADMAVATI

Schizophrenia Research Foundation, Chennai, India

Summary
Recent times are witnessing methods in the various forms of community care for the mentally ill in India. Non-governmental
organizations (NGO) play a pivotal role in filling the gap in the existing mental health services in India and the substantial
need for these services. Various strategies that have been employed in community care have attempted to utilize existing
community resources for implementation. Informal manpower resources incorporated with specialist psychiatric care and
integrated with existing health care facilities have been general strategies. While the feasibility and cost-effectiveness of the
NGO operated community outreach programs for the mentally ill have been demonstrated, various factors are seen to
influence the planning and execution of such programs. This paper elucidates some critical factors that would need to be
considered in community mental health care in India.

Introduction continue to be inadequate, in terms of manpower as

well as infrastructure, as evident from the fact that
Mental illness has been reported in ancient Indian
there are only about 3500 psychiatrists, about 1000
medical literature as early as circa 600 (Namboodhri,
each of psychologists and psychiatric social workers
1986) and accurate descriptions of psychoses can be
and around 900 psychiatric nurses in the entire
found in the medical treatise of that period. Mental
country.
illnesses have been viewed as a ‘curse’, an infliction
Several community studies have demonstrated
or a sin of the past birth, and so forth. These
that one-third of the chronic mentally ill in the
explanations have been perpetuated through genera-
community remain untreated (Padmavati, Rajkumar
tions. While the mentally ill patients do elicit
& Srinivasan, 1998). Stigma associated with mental
negative responses such as fear, disgust, pity or
illnesses, inaccessibility of mental health care and the
hostility from society, families continue to care of
traditionally prevalent causative perceptions hinder
them. Temples and other religious institutions have
the utilization of existing services. Not more than
also helped shelter these patients, who are left there
10% of those who need mental health care are
by relatives who cannot cope. Rural communities
receiving the required help with the existing services
have offered refuge to many patients who have
(Murthy, 2004). The impetus for community care of
wandered into their localities. Thus non-institutional
the mentally ill, in the framework of modern
care, a core concept of community psychiatry,
psychiatric practice has come from the veritable gap
has always been practiced in India through the
in the existing mental health services and the
ages, although this has been rather disorganised
substantial need for these services.
in structure and in function (Chandrasekhar &
Parthasarathy, 1999).
More than 20 million people in India suffer from
History of community mental health in India
various forms of mental disorders, with over 9
million suffering from severe disorders. Government Community mental health in India had its origins
run Mental Hospitals and General Hospital prior to the initiation and implementation of the
Psychiatric Units (GHPUs) provide treatment for National Mental Health Program (NMHP) for India.
most of the mentally ill. Non-governmental organi- The experiments carried out by Dr Vidya Sagar at
zations (NGOs) and private services have comple- Amritsar Mental Hospital, the establishment of the
mented this effort, but these are located primarily in GHPUs, the rural mental health programs by
urban areas. Formal mental health care systems the National Institute of Mental Health, Bangalore,

Correspondence: Dr R. Padmavati, Schizophrenia Research Foundation, Chennai, India. E-mail: raman_padma@vsnl.com

ISSN 0954–0261 print/ISSN 1369–1627 online ß 2005 Institute of Psychiatry
DOI: 10.1080/09540260500073562
104 R. Padmavati

and the other premier institute at Chandigarh are The participatory training program used audio-
early examples (Kapur, 2004). Community care visuals, case demonstrations and discussions,
as an organized program was initiated in India in pamphlets and so forth. The trainees are
the mid-1970s, beginning with experiments in provided basic information to identify various
Sakhalwara in Karnataka (Chandrasekhar, Isaac & categories of mental disorders identified by the
Kapur 1981) and Raipur Rani district in Haryana National Mental Health Program. They are also
(Wig, Murthy & Harding, 1981). The National trained in motivating persons suffering from
Mental Health Program for India was a development mental disorders to take medical treatment and
of the concern for alternate care programs for the to refer them to the proposed mental health
mentally ill and the initial experiences of organizing camps in the locality. Reinforcing sessions are
mental health care for the needy. Based on the held periodically to sustain knowledge gains.
principles of decentralization and destigmatization, (2) Establishment of a mental health clinical service
the program aimed at integrating mental health care in the catchment area: Mental health camps are
with primary care. Significant components of this organized in selected areas at periodic intervals.
program aimed at training health care personnel at all A psychiatrist-psychiatric social worker team
levels at the primary health care centres (PHC), would visit these areas. The probable cases of
sensitising policy planners to mental health issues mental disorders, identified by the community
and promoting community participation in mental workers would be evaluated at these camps and
health service development. After about two decades, medication initiated. These camps also serve to
critical factors identified as detriments to progress sensitise the community workers in handling
were a uni-dimensional, top-down programme, day-to-day problems that may be faced by the
poor funding, inadequate human resources, uneven mentally ill persons and their families.
distribution of resources across states and the non- (3) Increasing awareness of mental health problems
implementation of the legal processes (Goel, Agarwal, in the general public: This is viewed as essential
Ichhpujani & Shrivastava, 2004; Murthy, 2004). for sensitising the general public to mental
The strong commitment to extending care into the health problems and their management.
community has resulted in the active involvement of Extensive use of folk music, dance, and drama
NGOs in community outreach (Patel & Thara, in rural areas, and street theatre in urban
2003). Several community mental health programs localities has ascertained the dissemination of
have been reported in various parts of the country information related to mental health and illness.
(Chatterjee, Chatterjee & Jain, 2003; Nadkarni, (4) Training the community workers to implement
1997; Thara & Padmavati, 1999). These programs, simple rehabilitation measures: The focus is on
operated by the voluntary agencies and non- a multi-disciplinary rehabilitation program
governmental organizations were demonstrated as using simple techniques, which could be
feasible and cost-effective (Chatterjee et al., 2003; implemented by the community workers. The
Murthy, 1998). Presented below is one such key components of these programs have been
programme of the Schizophrenia Research case management techniques and vocational
Foundation at Chennai. rehabilitation.
(5) Networking with other medical and develop-
ment organizations: Networking has emerged to
Community outreach programs at SCARF be important for resource mobilization for
community-based rehabilitation of the mentally
The Schizophrenia Research Foundation (SCARF,
ill persons.
India) is a non-profit voluntary organization in the
city of Chennai in South India. Over the past 20 While the feasibility and cost-effectiveness of the
years, SCARF has been involved in care, rehabilita- NGO operated community outreach programs is
tion, research, mental health education, training and documented, various factors appear to influence the
advocacy for the mentally ill. During the two planning and execution of these programs.
decades, SCARF has operated several community
mental health programs in urban as well as rural
areas. The components of community mental health The challenge
care have been:
The macro level planning of community mental
(1) Training of community volunteer workers: Lay health services is a challenge in any country. In India,
community volunteers who have completed while the National Mental Health Program facili-
their school level education are recruited and tated the foray on mental health care into the
provided training in recognition, identification community, effective implementation has several
and referral of persons with mental disorders. hurdles. Low priority to mental health services,
 Community mental health care in India 105

inadequate funding resources, lack of awareness disorders, has brought about a reduction in the
about mental health issues amongst administrators disturbing manifestations such as violent behaviour
and policy makers, failure in understanding mental and socially unacceptable conduct. The problems
health needs, and poorly organized support groups that have accompanied use of medication in the
have been major issues in the nationwide implemen- community outreach programs have been the cost
tation of community-based mental health care of drugs and the side effects caused by typical
activities. Active involvement of non-governmental antipsychotics, and tricyclic antidepressants. Recent
organizations for the implementation of the commu- advances have resulted in the development of
nity mental health programs in small geographical medicines producing greater visibility in improve-
areas appears to be a feasible initiative for reaching ment as well as fewer side effects. The newer
out to the mentally ill in the community. The medications have also resulted in the increase in
challenge lies in sourcing adequate fiscal support, economic productivity of the ‘sick person’ thereby
utilizing exiting community resources, research ensuring the acceptance of the long-term nature of
documentation and dissemination of methodology. treatment. However, the cost of medication does
continue to be a recurring problem faced by NGOs
operating such programs.
Community acceptance
The National Mental Health Programme has
Community acceptance is a critical issue in initiating taken into account and has involved the trained
and sustaining any community program. This is non-professional mental health workers in the
specifically important in mental health service treatment of chronic mental health disorders
delivery as mental health and illness continue to be especially in the long-term management. Patel et al.
shrouded in longstanding myths and conceptions (2003) have opined that affordable anti-depressants
regarding causation and manifestations. Involving should be the treatment of choice for common
lay community people belonging to the locality mental disorders in general health-care settings in
has promoted the acceptance of the program, both the community in India. With adequate supervised
in rural (Chatterjee et al., 2003; Thara & Padmavati, orientation and follow-up programs in the use of
1999) and in urban areas (Padmavati & Benjamin, anti-psychotic drugs, it is possible to effectively
1995). Several community programs have demon- involve the community health workers in the
strated the feasibility of training lay people, who have treatment of mental disorders (Thara & Srinivasan,
had a minimum formal education, in identifying 2004).
mental health problems. The initiative to train them Domiciliary delivery of medication is an impor-
in implementation of simple psychosocial rehabilita- tant strategy in the management of the mentally
tion strategies has also proven a useful mechanism ill in the rural community. The NMHP has
of reaching to the mentally disabled person and provided for training physicians at the level of the
family, simple strategies aimed at re-integration of Primary Health Centres (PHC) in every district
the person back into the community. and has also made available some basic medication
for the management of mental illness. However,
the reality has been medical officers at the PHC
Cultural factors
are not often willing to take on the additional task
Cultural factors are fundamental to the acceptance of managing mental health problems and psycho-
of any mental health care programme. While it is tropic drugs are very often inadequate in supply.
critical to create an awareness of the medical model Persons in remote villages often find it difficult to
of mental illness, change in community attributes access treatment facilities, regularly. Therefore,
and attitudes can only evolve through time. In a supplying medication at the doorsteps of these
recent experiment, a team of mental health profes- patients seems to be a practical option. In
sionals, paraprofessionals and community volunteers SCARF’s outreach programs, domiciliary distribu-
have been operating a mental health care service in tion of medication has been carried out through
the vicinity of a temple in the state of Tamil Nadu. the community volunteers, who receive training to
The co-existence of traditional religious ritualistic follow-up on patients and report to the psychiatrist
practices and adoption of a medical model on at the clinic. It is also emphasized that patients
management has proven to be successful should follow-up at the clinic at least once in three
(Gopalakrishnan, 2004, personal communication). months. This strategy has ensured continuity of
medication for patients.
The use of depot neuroleptic medication for
Management strategies
patients suffering from chronic mental illnesses is
Over the past 50–60 years, pharmacotherapy well established (Janicak, Davis, Peskorn & Ayd,
of mental illness, particularly severe mental 1993). The advantages of depot medications has
106 R. Padmavati

been best demonstrated in studies such as those program for a rural community (Thara, Islam &
conducted by Johnson (1984) under conditions that Padmavati, 1998).
most closely resemble community clinics. In a recent Networking is another important strategy, which
experiment at SCARF, the community psychiatrist- will allow for a multi-dimensional care and rehabil-
social worker outreach team has been administering itation process in community care for the mentally
depot injections for patients with schizophrenia in ill. SCARF has been actively networking with a
the community, who cannot access a mental health number of NGOs involved in social and develop-
service facility with ease. Preliminary observations mental activities, both in urban and rural areas.
indicate an improvement in clinical state and better These collaborations have been fruitful in several
functioning of these patients. ways. It has been an important approach to reach
Another important method in community out- out to a wide geographic area, with a shared econo-
reach for the mentally ill has been the domiciliary mic commitment of the collaboration—a limited
care programs. Patients suffering from schizophre- resource for most NGOs. Further, networking
nia, in an urban area were treated at home and promotes the effective use of locally existing com-
followed-up for six months. This group of patients munity rehabilitation alternatives. The collaborations
did better in clinical and social functioning that also provide opportunities for research in the field.
a group of patients not receiving home treatment A number of NGOs have demonstrated the feasi-
(Pai, Channabassavanna & Raghuram, 1985). bility of undertaking research producing adaptable
Intervention at home, carried out from SCARF has results.
been reported to be feasible and effective in reaching
out to patients and their families (Padmavati, 2004).
The new strategies announced by NMHP has Sustainability
since proposed a ‘supervised domiciliary after care
Sources of funding to operate community mental
program’ (Goel et al., 2004).
health programs are largely limited to time-bound
The occurrence of crisis circumstances such as
projects. This is a critical issue in the continuity
relapse of psychotic symptoms, violent, difficult
of care provided at the level of the community. Ways
behaviours and suicide attempts are not uncommon
of sustaining the programs need to be planned early
in mental health. Management has traditionally been
in the commencement of the program. Of particular
focused on isolation and restraint of the patient. Is
significance are the resources for provision of
the community mental health care system equipped
medicines, since this forms a major expenditure in
to deal with such situations? Currently operated
the program operation.
program planning does not offer optimum acute care
services. However, most community programmes
have established an active network with in-patient
Accountability
facilities in and around the area of operation to
facilitate short-term acute care management for most Most NGOs involved in mental health care do not
mental disorders. This seems to be the most practical often have an established mechanism for monitoring
option for NGOs in view of the considerable cost and evaluation through external sources (Patel &
and manpower resources required to operate such Verghese, 2003). Maintaining transparency in pro-
facilities. ject operations and financial management is critical
Essentially, most community-based mental health in sustaining not just public acceptance, but also with
care in the country has been a biomedical psychiatric funding sources.
service approach. However, community-based reha- Future projections of the Global Disability
bilitation, envisaged as an important component of Adjusted Life years (DALY) for the year 2020,
the community mental health care system, neces- (World Health Organization, 1999) shows that
sarily needs to be sensitive to social and cultural mental disorders are projected to increase to 15%
influences. The emphasis should be on the adoption of the global disease of burden and unipolar major
of simple psychosocial strategies rather than struc- depression could be the second leading cause in the
tured technical approaches. The scope of vocational disease burden after ischaemic heart disease. Yet,
rehabilitation is enormous in the large agro-rural the fact remains that the limited mental health care
community in India. The onus of initiating CBR services in the country is not going to increase
programs for the mentally ill has largely rested with sufficiently to meet the growing awareness and
NGOs. In conformity with the principles of the CBR demand for care. The public health implications of
model of developing a network of lay volunteers who mental health are enormous. The onus of care largely
are specifically trained to identify and provide first rests with the ‘community mental health system’.
level rehabilitative inputs, SCARF was able to The low priority accorded to mental health services
demonstrate the feasibility of implementing a CBR across the country is enough reason for the initiative
 Community mental health care in India 107

and active involvement of non-governmental Nadkarni, A. (1997). Outreach strategies in community mental
organizations. Interwoven with active community health. In Community mental health and Community based
rehabilitation. Proceedings of SCARF-IDRC seminar,
participation and support, the initiative can sustain Schizophrenia Research Foundation, Chennai, India.
the process of a successful implementation of a Namboodhri, V. M. D. (1986). Ancient Indian Systems. In M. S.
community-based program, which is more socially Menon & U. G. Das (Eds), Schizophrenia—Historical trends
and culturally relevant to the mental health needs (pp. 31–47). Madras, India: SCARF.
Padmavati, R., & Benjamin, F. (1995). SCARF Beatitudes
of India.
Mental Health Programme. Health Administrator, 6(1 & 2),
86–91.
Padmavati, R., Rajkumar, S., & Srinivasan, T. N. (1998).
Schizophrenia patients who were never treated: A study
References in an Indian urban community. Psychological Medicine, 28,
1113–1117.
Chandrasekhar, C. R., Isaac, M. K., & Kapur, R. L. (1981). Padmavati, R. (2004). Caring for schizophrenia at home:
Management of priority mental disorders in the community. Clinical and research perspectives. Paper presented at
Indian Journal of Psychiatry, 23, 174–178. the Sixth Biennial Conference of World Fellowship of
Chandrasekhar, C. R., & Parthasarathy, R. (1999). Community Schizophrenia and Allied Disorders (WFSAD), Chennai,
Psychiatry. In J. N. Vyas & N. Ahuja (Eds), Textbook of India, 2–4 November 2004.
post graduate psychiatry (2nd Edn, Chapter 75, Section 13, Pai, S., Channabassavanna, S. M., & Raghuram, R. (1985). Home
pp. 985–992). New Delhi: Jaypee Brothers Medical care for chronic mental illness in Bangalore. An experiment
Publishers. in the prevention of repeated hospitalisation. British Journal of
Chatterjee, S., Chatterjee, A., & Jain, S. (2003). Developing Psychiatry, 147, 175–179.
community-based services for serious mental illness in a rural Patel, V., & Verghese, M. (2003). NGOs and mental health:
setting. In V. Patel & R. Thara (Eds), Meeting the mental health Search for synergy. In S. P. Agarwal (Ed.), Mental health
needs of developing countries NGO innovations in India (Chapter 6, an Indian perspective 1946–2003 (Chapter 16, pp. 146–151).
pp. 115–140). New Delhi: Sage Publications. New Delhi: Directorate General of Health Services, Ministry
Goel, D. S., Agarwal, S. P., Ichhpujani, R. L., & Shrivastava, S. of Health and Family Welfare.
(2004). Mental Health 2003: The Indian Scene. In S. P. Patel, V., & Thara, R. (2003). Meeting the mental health needs of
Agarwal (Ed.), Mental health an Indian perspective 1946–2003 developing countries. NGO innovations in India. London: Sage
(Chapter 1, pp. 3–24). New Delhi: Directorate General of Publications.
Health Services, Ministry of Health and Family Welfare. Patel, V., Chisholm, D., Rabe-Hesketh, S., Dias-Saxena, F.,
Gopalakrishnan, G., & Rajendran, S. (2004). CBR of the mentally Andrew, G., & Mann, A. (2003). Efficacy and cost-effectiveness
ill through integration of spiritual and scientific models. of drug and psychological treatments for common mental
Personal Communication. disorders in general health care in Goa, India: A randomized
Janicak, P. G., Davis, J. M., Peskorn, S. H., & Ayd, Jr. F. J. control trial. The Lancet, 361, 33–39.
(1993). Principles and practice of psychopharmacotherapy (pp. Thara, R., Islam, A., & Padmavati, R. (1998). Beliefs about
93–184.) Baltimore: Williams and Wilkins. mental illness. A study of a rural south Indian community.
Johnson, D. A. W. (1984). Observations on the use of long acting International Journal of Mental Health, 27(3), 70–85.
depot neuroleptic injections in the maintenance therapy of Thara, R., & Padmavati, R. (1999). A community mental health
Schizophrenia. Journal of Clinical Psychiatry, 5, 13–21. program in rural Tamil Nadu. Asia-Pacific Disability
Kapur, R. L. (2004). The story of community mental health in Rehabilitation Journal, 10(1), 34–35.
India. In S. P. Agarwal (Ed.), Mental health an Indian perspective Thara, R., & Srinivasan, T. N. (2004). Management of
1946–2003 (Chapter 8, pp. 92–100). New Delhi: Directorate schizophrenia: Pharmacological and non-pharmacological
General of Health Services, Ministry of Health and Family approaches. In M. K. Mandal & H. S. Nizamie, Current
Welfare. developments in schizophrenia (Chapter 14). New Delhi: Allied
Murthy, R. S. (1998). Rural Psychiatry in developing countries. Publishers Private Limited.
Psychiatric Services, 49, 967–968. Wig, N. N., Murthy, R. S., & Harding, E. W. (1981). A model for
Murthy, R. S. (2004). The national mental health programme: rural psychiatric services: Raipur Rani experience. Indian
Progress and problems. In S. P. Agarwal (Ed.), Mental health Journal of Psychiatry, 23, 275–293.
an Indian perspective 1946–2003 (Chapter 7, pp. 75–91). World Health Organization (1999). The World Health Report
New Delhi: Directorate General of Health Services, Ministry 1999—Making a difference. Geneva: WHO.
of Health and Family Welfare.