Advances In Psychiatry Rehabilitation: Government - NGO Collaboration In South India: The

Unique Navajeen-Mariasadan Experience

Roy Abraham Kallivayalil MD, DPMGen. Secretary, Indian Psychiatric Society &

Secretary General, SAARC Psych. FederationAssociate Professor of Psychiatry

Medical College, Kottayam, Kerala, India.

WHO STATEMENT ON MENTAL HEALTH

“Mental health – neglected for too long in crucial to the over all well-bring of

individuals, societies and countries and must be universally regarded in a new light”.

“Mental illness is not a personal failure. It doesn’t happen only to other people”.

- Gro Harlem Brundtland

D.G., WHO-2001

THE WORLD HEALTH REPORT - 2001

“Mental Health – New Understanding, New Hope”

World Health Day Theme (2001)“Stop Exclusion – Dare to Care”

MENTAL HEALTH ISSUES- FAILURE OF ASYLUMS

1. Illtreatment of patients

2. Geographical and professional isolation

3. Weak reporting and accounting

4. Bad management

5. Poorly targeted financial resources

6. Lack of staff training

7. Inadequate quality assurance procedure

AIM OF DE-INSTITUTIONALISATION

1. No inappropriate admissions in

mental hospitals

2. Discharge to community - after

preparation

3. Community support systems.

DELIVERY OF IDEAL MENTAL HEALTH SERVICES

• High quality, affordable medical care for all citizens

• Promoting medical research

• Encouraging new technologies

“Social and economic factors, however significantly affect a nation’s health status and the delivery of health services”

DELIVERY OF MENTAL HEALTH SERVICES (CONTD…)

1. Not different from general health services.

2. Protection from catastrophic financial risk.

3. Minimise out-of-pocket payments.

4. Prepayment methods options:

a. Mandatory social insurance

b. Voluntary private insurance

c. General taxation

5. The healthy/well off to subside the sick/poor.

SHIFT IN MENTAL HEALTH CARE PARADIGM

1. Due to progress in psychopharmacology

2. New forms of psycho-social intervention

3. Human rights movements

4. A mental health component was firmly

incorporated into the concept of health

IDEAL MENTAL HEALTH POLICY

1. Identify major issues and objectives

2. Define the role of public and pvt. sector

3. Identify requirements in public sector

4. Prompting action for capacity building

5. Guidance for prioritising expenditure

6. Link analysis of problems to decisions about resource allocation

MENTAL HEALTH POLICY (CONTD…)

7. Highlight vulnerable groups with special

mental health needs. (Eg: children, the

elderly, the women, refugees/displaced

persons)

8. Include suicide prevention. (Reduce access

to poisons /fire-arms etc.)

9. Care for individuals at risk (with depression,

schizophrenia, alcohol dependence)

10.Control of alcohol & illicit drugs

MENTAL HEALTH POLICY (CONTD…)

11. Coherent alcohol and drug policies.

12. Involve all stake holders.

13. Ensure respect of human rights.

14. Mass media and public

awareness.

15. NGOs and consumer groups are

involved.

POLICY FORMULATION

1. Up-to-date and reliable information about:

a. Community

b. Mental health indicators

c. Effective treatments

d. Prevention and promotion strategies

e. Mental health resources

2. Review the Policy periodically

SCENARIO IN INDIA1. Mental health policy formulated in 1982.2. Substance abuse policy – absent.3. National Mental Health Programme – 1982.4. Essential list of drugs – Yes 5. Mental Health Legislation – MHA 1987.6. 0.83% of Health Budget on Mental Health.7. Disability benefits – Yes8. NGOs involved in advocacy, promotion,

prevention, treatment and rehabilitation.

SCENARIO – INDIA (WHO Atlas 2001)

1. Beds (per 10,000) 0.252. Beds in Mental Hospitals 0.23. Beds in General Hospitals 0.054. Beds (Others) 0.015. Psychiatrists (per 100,000)

0.046. Neurosurgeons 0.067. Psychiatric nurse 0.048. Neurologists 0.059. Psychologists 0.0210.Social workers 0.02

India – some general issues

• Mental health is not a priority area

• Only <1% of health budget for mental health

• Escalating health care costs

• High cost of drugs

• Some Indian states are ahead of others in health care delivery.

The Success Story of Kerala

• Kerala is model for developing world.

• High quality health care at low cost.

• 100% literacy

• High female literacy

• Only state where females out number males

• Highly developed social sector

Health scenario in Kerala

• Lowest Infant Mortality Rate (11%)

• Lowest Maternal Mortality Rate (<1%)

• Highest Life Expectancy

• Life Expectancy Males – 72 yrs

• Life Expectancy Females – 74.5 yrs

• Health statistics comparable to the

developed nations of the World

Mental Health scenario in Kerala

• One of the best – but still a long way to go

• Number of psychiatrists – 300

• 1 for 100,000 population

• Inadequate but 2.5 times the national average.

• Large number of General Hospital Psychiatry Units.

• Three Mental Health Centres

Mental Health Inadequacies

• Rehabilitation centres – Few and Far between

• Inadequate half way homes

• Less than adequate facilities at the Govt. sector

• Private sector growing but costs are high

A Unique Experience in Kerala

• Government – NGO Collaboration in

rehabilitation

• The Navajeevan Centre – 3kms from

the Psychiatry Department

• The Mariasadan Centre – Out reach

rehabilitation centre – 30 kms away.

Services from Med. College, Kottayam

• 20-30 patients are seen per week

• Follow up and new cases

• No consultation fees, no charges

• Available medications are supplied free

• Post graduate residents are posted

• Community Psychiatry Training

Services from Med. College (Contd…)

• Psycho education for the volunteers

• Various types of rehabilitation measurers

• Training facilities

• Out reach community services

Features of these NGO centres

• These are not mental health hospitals

• No qualified psychiatrists

• Patients are looked after by volunteers

• No human rights violation

• Individual rights are protected

• Provides dignified living

Features of these NGO centres (contd…)

• Transparency in functioning • Equity of services • Patients are not chained up or tied up • Functions in an open setting• Continuous supervision by psychiatrist • Support of the teaching faculty• Approval by Mahatma Gandhi University

as centres for community psych. Training.

SOCIO-DEMOGRAPHIC DATA FROM SOCIO-DEMOGRAPHIC DATA FROM REHABILITATION CENTRE- REHABILITATION CENTRE-

NAVAJEEVAN (1-1-2004 – 31-12-2004)NAVAJEEVAN (1-1-2004 – 31-12-2004)

• Total No. of mentally patients – 182Total No. of mentally patients – 182

• Total No. of medically ill patients – 10Total No. of medically ill patients – 10

– Males-106 Males-106

– Females-76Females-76

Table 1: Age and sex groupsTable 1: Age and sex groups

Age Males Females Total %

15-25 1 3 4 2.2

26-35 25 17 42 23.08

36-45 37 24 61 33.52

46-55 18 21 39 21.43

56-65 12 6 18 9.89

66-75 11 3 14 7.69

>75 2 2 4 .2

Table 2: Educational StatusTable 2: Educational Status

Education Males Females Total %

Barely literate 15 10 35 13.7

Primary 30 24 54 29.67

Secondary 15 17 32 17 .58

Intermediate 10 4 14 7.69

Gr. 1 1 2 1.1

Unknown 35 20 55 30.22

Table 3: Marital statusTable 3: Marital status

Marital status Males Females Total %

Unmarried 41 25 66 36.26

Married 35 23 58 31.87

Sep./divorced 1 0 1 0.55

Widowed 1 0 1 0.55

Unknown 28 28 56 30.77

Table 4: Source of referralTable 4: Source of referral

Source of referral Males Females Total %

Wandering 68 55 123 67.58

Relatives 10 8 18 9.89

Self 2 5 7 3.85

Other institution 26 8 34 18.68

Table 5: Native placeTable 5: Native place

Place Males Females Total %

Kerala 100 67 167 91.76

Other states 6 9 15 8.24

Table 6: Prevalence of psychiatric disordersTable 6: Prevalence of psychiatric disorders

Psychiatric Diagnosis Males Females Total %

Schizophrenia 82 56 138 75.82

Mood disorder 17 15 32 17.58

Remission 12 10 22 12.09

Substance abuse 21 0 21 19.8

Dementia 3 2 5 2.75

Mental retardation 4 3 7 3.85

Table 7: Comorbid medical disordersTable 7: Comorbid medical disorders

Medical disorders Males Females Total %

Diabetes mellitus 3 6 9 4.95

Skin lesions 10 12 22 12.09

Seizure disorders 5 7 12 6.59

Tuberculosis 4 5 9 4.95

Leprosy 1 0 1 0.55

Anaemia& Nutritional deficiency

20 30 50 27.47

Cardiac disease 3 1 4 2.20

Total 58.79

Table 8: Mental status examinationTable 8: Mental status examination

Males Females Total %

Suicidal ideas 8 6 14 7.69

+ve symptoms 52 32 84 60.84

-ve symptoms 30 24 54 39.14

SOCIO-DEMOGRAPHIC DATA FROM SOCIO-DEMOGRAPHIC DATA FROM REHABILITATION CENTRE REHABILITATION CENTRE

-MARIA SADANAM (1-1-2004 – 31-12-2004)-MARIA SADANAM (1-1-2004 – 31-12-2004)

•Total No. of mentally ill patients – 233Total No. of mentally ill patients – 233

•Total No. of medically ill patients – 5Total No. of medically ill patients – 5

– Males-146Males-146

– Females-87Females-87

Table 1: Age and sex groupsTable 1: Age and sex groups

Age Males Females Total %

15-25 9 7 16 6.87

26-35 45 24 69 29.61

36-45 51 25 76 32.62

46-55 26 17 43 18.45

56-65 10 5 15 6.44

66-75 3 7 10 4.29

>75 2 2 4 1.72

Table 2: Educational StatusTable 2: Educational Status

Education Males Females Total %

Barely literate 12 10 22 9.44

Primary 48 31 79 33.91

Secondary 36 12 48 21.03

Intermediate 12 4 16 6.87

Gr. 4 2 6 2.58

Unknown 34 28 62 26.61

Table 3: Marital statusTable 3: Marital status

Marital status Males Females Total %

Unmarried 73 25 98 42.06

Married 37 28 65 27.89

Sep./divorced 3 7 10 4.29

Widowed 2 4 6 2.58

Unknown 31 23 54 23.17

Table 4: Source of referralTable 4: Source of referral

Source of referral Males Females Total %

Wandering 55 34 89 38.20

Relatives 81 45 126 54.08

Self 0 2 2 0.86

Other institution 10 6 16 6.87

Table 5: Native placeTable 5: Native place

Place Males Females Total %

Kerala 142 84 226 97

Other states 4 3 7 3

Table 6: Prevalence of psychiatric disordersTable 6: Prevalence of psychiatric disorders

Psychiatric Diagnosis Males Females Total %

Schizophrenia 93 60 153 65.66

Mood disorder 38 20 58 24.89

Remission 24 16 40 17.17

Substance abuse 23 0 23 9.87

Dementia 5 4 9 3.86

Mental retardation 7 3 10 4.29

Table 7: Comorbid medical disordersTable 7: Comorbid medical disorders

Medical disorders Males Females Total %

Diabetes mellitus 4 7 11 4.72

Skin lesions 10 12 22 9.44

Seizure disorders 4 7 11 4.72

Tuberculosis 5 7 12 5.15

Leprosy 0 1 1 0.43

Anaemia & Nutritional deficiency

14 18 32 13.73

Cardiac disease 2 0 2 0.86

Total 39.06

Table 8: Mental status examinationTable 8: Mental status examination

Males Females Total %

Suicidal ideas 5 7 11 4.72

+ve symptoms 53 38 91 59.48

-ve symptoms 14 22 62 40.52

THE MESSAGE• Treatment of mental disorders – do

exist and are available• Most individuals and families can be

helped • Treatment, rehabilitation and

preventive strategies• Adopt suitable Mental Health Policy • Progressive Legislation

“ There is New Understanding, New Hope”

“Nature has provided everything to satisfy the

need of everyone, but not enough to satisfy the greed

of anyone”

- Mahatma Gandhi