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Scaling up mental health services; Making it happen through mann-kaksh

Oct 20, 2016

Mental health of a population is very closely linked with the overall development of the society, writes Rahul Shidhaye.

New Delhi: World Mental Health Day is celebrated every year on 10 October. The theme of the World Mental Health Day this year covers “psychological first aid”. According to the World Health Organization (WHO) it is important to ensure that anyone in acute distress due to a crisis is able to receive basic support, and that those who need more than psychological first aid will receive additional advanced support from health, mental health and social services. In India, unfortunately very few people with mental health condition receive any care from formal health service providers leading to what is termed as a big treatment gap. Mental health of a population is very closely linked with the overall development of the society and it is imperative to improve access to evidence-based mental health services as part of the broader agenda of Universal Health Coverage. This article describes establishment of Mann-Kaksh, a recent innovation undertaken by the Government of Madhya Pradesh to scale up mental health services across the state.

What is a Mann-Kaksh?

Mann’ is a Sanskrit word for mind while ‘Kaksh’ another Sanskrit word which literally means room. So, Mann-Kaksh is a room dedicated for mental health. If one visits any of the busy District Hospitals in 51 districts of Madhya Pradesh, he/she is quite unlikely to miss a small nicely decorated room in the OPD (Out-Patient Department) complex which offers services to patients with mental health conditions. During the OPD hours a nurse is present in these Mann-Kakshs and attains to common mental health conditions such as depression, alcohol use disorder and other priority mental health conditions included in the mhGAP (mental health Gap Action Program) initiative of the World Health Organization. Almost every fourth person attending OPD in a District Hospital suffers from co-morbid depression or drinking problem. In the past, almost all of them were missed by the health care providers and they never received any treatment for their mental ailments. This is not the case anymore as some of these patients are now detected by a medical officer who receives a month long training in diagnosis and treatment of common conditions. In addition to this other doctors/specialists in the hospital are also regularly sensitized about the importance of mental health and receive a short training (one day) which enables them to understand the overlap between mental health conditions and the physical disorders in which they specialize. Patients who are detected by the doctors are sent to Mann-Kaksh for a detailed evaluation and for the psycho-education sessions delivered by the nurse. Mann-Kakshprovides a secluded, safe and secure space to the patients to share their problems with the nurse who is specially trained to provide psycho-social counseling.

Why do we need Mann-Kaksh?

Mental health conditions contribute significantly to the overall burden of disease in any population. A population based survey from Sehore district in Madhya Pradesh, the findings of which were recently published in two reputed international journals has estimated that 17.7% adults in the community setting had depression while 10% adult males were diagnosed to have alcohol use disorders. If these numbers are extrapolated for the entire state of Madhya Pradesh then it results in a huge number of individuals who are in need of mental health services. As per the survey, a small proportion of these individuals (12.8% in case of depression and 2.8% for alcohol use disorders) seek any care for these conditions. The problem is further compounded by the fact there are very few Psychiatrists and Psychologists in the state and almost all of them are in urban settings. People across vast stretches of rural hinterland do not have access to any mental health services. With this back-drop, the Department of Health Services, Government of Madhya Pradesh decided to scale up mental health services by establishing Mann-Kaksh in each of the District Hospitals as a part of the bigger initiativeSOHAM (Scaling Up Opportunities for Healthy and Active Minds).

How did the concept of Man-Kaksha developed?

In 2011 an innovative implementation research initiative,PRIME (Programme for Improving Mental Health Care) was launched in Sehore district of Madhya Pradesh as a three-way collaboration between the Public Health Foundation of India, Sangath and Ministry of Health and Family Welfare, Government of Madhya Pradesh. The work of PRIME over last five years demonstrated that it is feasible to integrate mental health services in primary care based on collaborative care model in which the initial screening and treatment of patients is led by the primary care staff, referral services are provided by the specialist and technical support and program monitoring is done by an academic organization (the Public Health Foundation and Sangath in this case). In this model, one room was specifically allocated for provision of psycho-social interventions and the members of the Community Advisory Board of PRIME (comprising of service user representatives, civil society leaders, media professionals and community volunteers) had suggested that this room be named Mann-Kakshas they thought that this label was not stigmatizing, rather conveyed a positive notion of mental health. In April 2015, the Department of Health Services decided to adopt PRIME model with certain modifications and scale up mental health services across the state.

What is the way forward?

It must be stated in very clear terms here that this is just the beginning and still a lot needs to be achieved in the forthcoming years. In last one year what we have been able to achieve is the establishment of Mann-Kaksh, training of at least two nurses and one medical officer from each of the 51 districts, sensitization of specialist doctors in most of these hospitals, regular reporting from each of the units to the program office at the state level which enables effective monitoring of the program and most importantly a dedicated allocation of financial resources through National Health Mission in order to achieve the program objectives. In the near future we would like to ensure that similar Mann-Kaksh are established at the sub-district hospital level in each district to improve the reach and coverage of services and the quality of care delivered is measured and continuously improved.

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