COMMUNITY

PSYCHIATRY
PRESENTOR – DR.JENANI.J , POSTGRADUATE
MODERATOR – DR.SRIRAMADESIGAN , SENIOR
RESIDENT , DEPARTMENT OF PSYCHIATRY ,
SLIMS
SYNOPSIS

 HISTORY
 INTRODUCTION
 INDIAN SCENARIO
 COMMUNITY SERVICES
 NATIONAL MENTAL HEALTH
PROGRAM
 DISTRICT MENTAL HEALTH
PROGRAM
 TALUK MENTAL HEALTH PROGRAM
 COMMUNITY BASED
REHABILITATION
 MENTAL HEALTH ACT
 TELE-PSYCHIATRY
 NON-GOVERNMENTAL
 HISTORY
• The origins of community psychiatric movement in India can be traced back to a number of meetings of
the Indian Psychiatric Society (IPS).
• Notable among these is the first conference of Superintendents of Mental Hospitals at Agra in 1960.
• As early as in 1964, Satyanand D and Hussain SE, conducted psychiatric outdoor clinics at 4 villages in
Haryana.
• They also gave lectures on positive mental health to schoolteachers, block development officers staff,
panchayat officers etc.
• The other significant developments are the Madurai Conference on priorities in Mental Health Care held
in 1971, the WHO Workshop on community Action for Mental Health Care at Bangalore in 1973 and a
number of similar workshops at Wardha, and Trivandrum.
 HISTORY
• Notable among these are the programs to develop models of rural psychiatric services at Raipur Rani
near Chandigarh and Sakalawara near Bangalore.
• These initial attempts have been taken up in a bigger way by the Severe Mental Morbidity study of
ICMR since 1979, where the feasibility of training health personnel was examined at 4 centers namely
Bangalore, Baroda, Calcutta and Patiala.
• All these studies and experiences have made it possible to consider launching community psychiatry
programs in a bigger scale.
• The outcome of all these developments is the National Mental Health Programme (NMHP) which was
recommended for implementation by the Central Council of Health and Family Welfare in its meeting on
18-20 August 1982.
 INTRODUCTION
■ Community Psychiatry - “any activity related to mental health
that happens outside the premises of a mental hospital”

• To make sure that care reaches each one of the deserved patients at their
doorsteps and includes all such approaches that contribute towards this goal.
• Focuses on sensitizing the community, to understand the illness there by
reducing the stigma and decreasing the time taken for seeking treatment.
• And mental illness to be economically and effectively treated in their local environment using the
community resources
 INDIAN SCENARIO
 Any mental health related activity that occurs outside the premises of
hospitals can be brought under the purview of community psychiatry.
 Carried out by :
• Non- governmental organizations
• Rehabilitation centers
• Lay counsellors
• Alternative systems working towards mental health care,
• Role of families in caring for the mentally ill
• Mental health care that occurs in primary health centers.
PYRAMID OF PATHWAYS TO
MENTAL HEALTH CARE IN
DEVELOPING COUNTRIES

Source– Math and Srinivasaraju (2010)

 COMMUNITY SERVICES

Provision of psychiatric services to the patient within their community

environment with an aim to achieve full social integration.
1.Assertive Community Treatment (ACT)
• Full range of medical, psychosocial, and rehabilitation services by a community-based
team that operates seven days a week, 24 hours a day.
• Aims at keeping ill people in contact with services, reducing hospital admissions and
improving the outcome.
2.Case Management
• Coordination, integration and allocation of individualized care for PMI, which includes
ongoing contact with one or more identified key personnel.
• Provide education, crisis intervention, community support, personalized service plans (
money management, assistance in daily living, consumer advocacy ) and facilitates
access to psychiatric care.
 COMMUNITY SERVICES

3.Psychiatric Home Visit Service

• Done by the community psychiatry team or by a psychiatrist to evaluate and treat the patient
their house
• Enables the professionals to get a better context of the patient’s socio-cultural environment,
provides more accurate assessment of the patients daily living activities, leverage local
resources and plan suitable individualised therapy.
• Elderly with dementia, chronic mental illness, individuals with mental retardation, autism,
organic brain disorders.
 COMMUNITY SERVICES
4.Community Rehabilitation Centers (CRC ) Or Group homes
• Plays a role in preparing them to get back to the mainstream community.
• Provides Sheltered semi- supervised environments such as day care centers,
respite care, half-way home, long-term home, shared accommodation, sheltered
homes and vocational rehabilitation centers.
5.Community Support Groups
• Consists of family support groups, spouse support group, self-help groups and voluntary lay counsellor’s
groups.
• Enables the group in net-working, crisis management, socialization, recreational, advocacy and educational
activities of the mentally ill
• Helps the caregivers to come together, share their experiences, learn from each other and plan to net-work
better for the welfare of the mentally ill
 NATIONAL MENTAL HEALTH
PROGRAM
• Idea of developing National Programs for Mental Health started with World Health
Organization (WHO), mental health division under the leadership of Dr Norman
Sartorius.
• India was the first major country to adopt it at the national level .
• The first draft of the NMHP was prepared by the expert group in February 1981 in
Lucknow.
• The final draft was submitted to the meeting of Central Council of health on 18-20th
August 1982 and the NMHP was implemented all over the country in a phased
manner.
NATIONAL MENTAL HEALTH
PROGRAM
■ OBJECTIVES
1. To ensure the availability and accessibility of mental health care for all in the
foreseeable future, particularly to the most vulnerable and underprivileged
sections of the population.
2. Encourage the application of mental health knowledge in general health care
and social development.
3. Promote community participation in mental health services development and
stimulate efforts towards self-help in community.
NATIONAL MENTAL HEALTH
PROGRAM
■ STRATEGIES
1. Integration of mental health with primary health care through the NMHP
2. Provision of tertiary care institutions for treatment of mental disorders
3. Eradicating stigmatization of mentally ill patients and protecting their rights
through regulatory institutions like the Central Mental Health Authority
(CMHA) and State Mental Health Authority (SMHA)
 NATIONAL MENTAL HEALTH
PROGRAM- COMPONENTS
I .TREATMENT: Multiple levels

Village and sub-centre level - Multipurpose workers (MPW) and Health Supervisors (HS) , under the
supervision of Medical Officer (MO) to be trained for:
Management of Psychiatric Emergencies
Administration and supervision of Maintenance treatment for Chronic Psychiatric Disorders
Diagnosis and Management of Grand-mal epilepsy, especially in Children
Liaison between local schoolteacher and parents regarding Mental Retardation and behavioural problems in
Children.
Counselling problems related to Alcohol and Drug Abuse.
NATIONAL MENTAL HEALTH
PROGRAM- COMPONENTS
Primary Health Centre - Medical Officer aided by HS to be trained for :
Supervision of Multipurpose Health Worker (MPW) performance
Elementary diagnosis
Treatment of Functional Psychosis
Treatment of Uncomplicated cases of Psychiatric disorders associated with Physical disease.
Management of uncomplicated Psychosocial problems.
Epidemiological survey/Surveillance of Mental Morbidity.
NATIONAL MENTAL HEALTH
PROGRAM- COMPONENTS
District Hospitals -
It was recognized that there should be at least one Psychiatrist attached to every district hospital.
District Hospital should have 30-50 Psychiatric beds.
Psychiatrist in the district hospital have to devote a part of his time to clinical area and greater part in
training and supervision of non-specialized Health workers.
Mental Hospitals and Teaching Psychiatric Units- Major activities of these higher centres of Psychiatric
care includes:
Help in case of difficult cases
Teaching Specialised facilities like occupational therapy units, Psychotherapy etc.
NATIONAL MENTAL HEALTH
PROGRAM- COMPONENTS
II. REHABILITATION:
The components of this sub-program includes treatment of epileptics and psychotics at the community
level and development of Rehabilitation centres at both the district and high referral centres.
III. PREVENTION:
The component is to be community based, with initial focus on prevention and control of Alcohol
related problems.
Later on, problems like addiction, Juvenile delinquency and acute adjustment problems like suicidal
attempts are to be addressed.
DISTRICT MENTAL HEALTH
PROGRAM (DMHP)
• To overcome this limitation of NMHP, an initiative was taken where the district was the
administrative and implementation unit of this program.
• After 1990, based on the Bellary model of NIMHANS, the District Mental Health Program
(DMHP) was launched.
• Project demonstrated the effectiveness of the program and that it is feasible to deliver
mental health care services at the primary care level by training the ground level staff
with the help of DMHP team.
• DMHP team usually consists of a psychiatrist, a clinical psychologist, a psychiatric
social worker, a psychiatric / community nurse, a program manager, a program/case
registry assistant and a record keeper.
• DMHP have been implemented in 655/724 districts in India. Out of this, 550 districts
have operational DMHP.
DISTRICT MENTAL HEALTH
PROGRAM (DMHP)
■ OBJECTIVES
• Provision of mental health care in the community would essentially require
integrating mental health services into the primary health centres. Primary care
physicians play a crucial role in delivering services.
• To launch extensive information and communication activities about the nature,
course and the availability of treatment for mental disorders
• To facilitate adequate psychosocial care of the recovered mentally ill in the
community by making linkages with non-governmental organizations locally
• Initiate mental health promotional activities in schools and colleges
• To develop active public-private partnerships
 DISTRICT MENTAL HEALTH
PROGRAM (DMHP)
■ SALIENT FEATURES
• Preparatory phase - Each state should map the mental health resources in the private
and public sectors before applying for the project and identify the nodal and
programme officer .The programme officer undergoes training for three months before
the total grants are released.
• Adolescent and School Mental Health Programme – It involves health promotion through life skills
education for development of psycho-social competence using teachers as trained resource staff .
• College Mental Health Programme - Emotional distress, adjustment and substance use problems are
significant issues in college students that need attention. Trained teachers can effectively handle such
problems within the context of the college.
DISTRICT MENTAL HEALTH
PROGRAM (DMHP)
• Improvement in health manpower status - Development of 11 regional Institutes of Mental Health
with a one-time grant of Rs 30 crores for infrastructure development. Which lead to 24 centers of
excellence to start PG courses. It is also proposed to equip 30 medical colleges to start/strengthen their
post graduate programme in mental health.
• Research and Mental health
• IEC activities - Development of public awareness material such as video clippings, posters radio/ TV
messages and wall writings . Scientific methods to evaluate the impacts of these on the public have to be
initiated. Training material for undergraduate / postgraduates in the form of videos, interactive CDs for use
on the net / distant education have to be developed.
• Support money for implementation of the Mental Health Act 1987 - To allocate separate funds
to assist both the central and the state Mental Health Authorities.
 DISTRICT MENTAL HEALTH
PROGRAM (DMHP)
• Public-Private-Partnership - Efforts of government alone are inadequate to realize all the goals of
NMHP. Appropriate linkages between NGO activities as well as NMHP components by matching them can
increase efficiency.
• Monitoring - By central and state level monitoring committee on a monthly basis to plan mid-course
correction.
• Suicide prevention - Growing cause of premature mortality . Recognition of any underlying psychiatric
disorder and early treatment has the potential to prevent suicide.
• Stress management
DISTRICT MENTAL HEALTH
PROGRAM (DMHP)
TALUK MENTAL HEALTH
PROGRAM
■ TMHP is a public mental health program, covering a taluk/tehsil/block,
■ For deeper penetration of the public mental health initiative , TMHP is the
next logical step towards achieving it.
■ Started in 10 taluks of Karnataka , 2018-19.
■ Two of its functioning initiatives are :
• Community Interventions in Psychotic Disorders (CoInPsyD) Programs
• Primary Care Psychiatry Program (PCPP)
TMHP - Community Interventions in
Psychotic Disorders (CoInPsyD)’ Programs

■ Started in Thirthahalli taluk of Karnataka (Shivamogga district) with the aim of

identifying, diagnosing, treating and following up all patients with schizophrenia in the
taluk in 2005.
■ Similar program was started in Turuvekere taluk of Tumkur District and in Jagalur taluk
of Davanagere District.
■ Done by a Social worker and a Psychiatrist.
■ It involves scheduling follow-ups, tracking patients, making home-visits, co-ordinating
with the local health administration for smooth conduct of the programs, delivering
low-intensity psychosocial interventions (including basic psychoeducation,
rehabilitation counselling, vocation counselling, adherence counselling etc),
networking with other governmental and non-governmental agencies to facilitate
transfer of available (government or otherwise) benefits to patients/families.
TMHP - Community Interventions in
Psychotic Disorders (CoInPsyD)’ Programs

■ Psychiatrists make periodic visits either to the taluk hospital or the primary
health centres to conduct outpatient consultations
■ Results - Around three-fourth of patients with schizophrenia achieved clinical
remission, work-related disability was significantly reduced , patients with
moderate or profound disability reduced by more than 50% from baseline on
IDEAS.
PRIMARY CARE PSYCHIATRY
PROGRAM
■ Integration of mental health services at the primary care level has always been the crux of policy
makers including the WHO and NMHP of India.
■ The Primary Care Psychiatry Program (PCPP) is an initiative from the National Institute of Mental
Health And Neurosciences (NIMHANS), Bengaluru.
■ Aims to train Primary Care Doctors (PCDs) on screening, diagnosing and providing first line
treatment in addition to referral of psychiatric cases in situations of treatment resistance.
Functional Framework of the PCPP
COMMUNITY BASED
REHABILITATION (CBR)
■ A strategy for general community development that provides rehabilitation, poverty reduction,
equalisation of opportunities, and social inclusion for all people with disabilities, predominantly
using local resources.
■ Initiated by WHO following the Declaration of Alma-Ata in 1978.
■ Objectives for CBR programs according to the WHO (2003) :
• Reducing poverty, given that poverty is a key determinant and outcome of disability
• Promoting community involvement and ownership
• Developing and strengthening of multisectoral collaboration
• Involving disabled people’s organizations in their programmes
• Scaling up their programmes
• Promoting evidenced-based practice.
COMMUNITY BASED REHABILITATION
(CBR) MATRIX OF CBR PROGRAM
 COMMUNITY BASED
REHABILITATION (CBR)
Seven different components of CBR include:
• Creation of a positive attitude towards people with disabilities
• Provision of rehabilitation services
• Provision of education and training opportunities
• Creation of micro and macro income – generation opportunities
• Provision of long-term care facilities
• Prevention of causes of disabilities
• Monitoring & Evaluation
CBR BASED PROGRAMS
■ Thirthahalli (CoinPsyD) and Turvekere (TURVECARE) program run by NIMHANS –
Schizophrenia
■ Sangath foundation - Mental health needs of communities in Goa.
■ National Drug Dependence Treatment Centre (NDDTC) , under AIIMS New Delhi -
Opioid Substitution Therapy(OST) and Occupational rehabilitation for Opioid
dependence persons.
MENTAL HEALTHCARE ACT, 2017

■ The Mental Health Care Act 2017 (MHCA) is an act enacted on 07th April 2017 by
the the Ministry of Health and Family Welfare, Government of India.
■ “To provide mental health care and services for persons with mental illness, and
to protect, promote and fulfil the rights of such persons during delivery of mental
health care services. ”
■ Community psychiatry care in the act through right to access mental health care.
■ The components of this include
(a) Half-way homes, sheltered accommodation, supported accommodation,
(b)Mental health services to support family of persons with mental illness or home-
based rehabilitation and
(c) Community based rehabilitation establishments and services .
MENTAL HEALTHCARE ACT,
2017
■ Suicide - MHCA 2017 has decriminalized attempt to suicide and advice to
consult mental health specialist.
■ Promote Mental health -School mental health programs, life-skills
education, industrial mental health and positive mental health. Focus on the
prevention of attempted suicides.
■ Rehabilitation and disability - Disability can be due to lack of opportunity
secondary to discrimination.
• Half-way homes, sheltered accommodation, hospital and home or community-
based rehabilitation and supported accommodation.
• Disability benefits, reservations in education or jobs.
MENTAL HEALTHCARE ACT,
2017
■ Primary Health Care integration - Integration of mental health care into the
primary health care system by establishing general hospital psychiatry units
(GHPUs).
■ Stigma
• Enabling access to treatment.
• Preventing discrimination in work and employment policies .
• Organising programs to address alcohol abuse and other drug abuse.
• Mental hospitals renamed as mental health establishments.
MENTAL HEALTH LEGISLATIONS AND THE
HOMELESS PERSONS WITH MENTAL ILLNESS
Role of TELE-PSYCHIATRY in
Community Psychiatry
■ Plays a crucial role in reaching the unreached.
■ Services are provided on a custom-built bus that contains a consultation room
and a pharmacy.
■ The communication takes place between the patient/care-givers inside the bus
and the mental health professional elsewhere.
■ Largely been successful and has demonstrated the feasibility of service
delivery.
■ But service is largely under- utilized and has failed to deliver the promise.
NON-GOVERNMENTAL
ORGANISATIONS
■ Alzheimer and Related Disorders Society of India (ARDSI), which was started in Cochin and has
now spread to more than a dozen centers in India
■ Sangath Society (Goa) and Umeed and the Research Society (Mumbai) –Child mental health.
■ TTK Hospital in Chennai, the TRADA in Karalla and Karnataka, Parivarthan in Maharashtra,
Kripa Foundation, Alcoholics Anonymous ,National Addiction Research Center in Mumbai
focuses on substance abuse problems.
■ Sneha (Chennai), MPA (Bangalore) and Saarthak (Delhi) work on suicide prevention activities.
NON-GOVERNMENTAL
ORGANISATIONS
■ Banyan (Chennai) provides shelter and care for women living with mental disorders.
■ ACMI (Bangalore) and Aasha in Chennai are entirely run by families of those affected by severe
mental disorders.
■ SCARF, as part of vocational support activities, has distributed livestock, cows and helped
expansion of petty shops in rural areas to help persons with schizophrenia
IN THE FUTURE
■ Mental health will receive higher position in the hierarchy of needs of
individuals, families, communities, and the government.
■ Mental health care will be seen beyond clinical conditions and will include
promotion of mental health and prevention of mental disorders.
■ Most of the mental health care will occur in the community and not
“institutions”
■ Greater efforts will be made at empowering individuals, families, and
communities toward “self‐care” for mental health
■ Greater recognition of mental health implications of developmental processes
■ Greater leadership of mental health professionals to work with the sectors
beyond health, such as education, welfare, labour, law and justice,
environment, and human rights
■ Increased multidisciplinary and multidimensional initiatives for mental health
care.
REFERENCES
■ THE SEMINAR BOOKLET SERIES ON COMMUNITY PSYCHIATRY – NIMHANS
■ Swaminath, et al.: Homeless persons with mental illness in India
■ Hans, G., & Sharan, P. (2021). Community-Based Mental Health Services in India: Current status
and roadmap for the future. Consortium Psychiatricum/Consortium Psychiatricum, 2(3), 63–71.
https://doi.org/10.17816/cp92
■ Thara and Patel: Mental health- role of NGOs
■ Murthy, R. S. (2018). Rural and community psychiatry. Indian Journal of Social Psychiatry
(Online)/Indian Journal of Social Psychiatry, 34(4), 281. https://doi.org/10.4103/ijsp.ijsp_77_18
Thank
you