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Mental disorders: Strengthening the district mental health programme

Apr 14, 2015

Depression alone accounts for around 3% of the total burden of disease in India, writes Rahul Shidhaye.

New Delhi: Mental disorders affect a large number of people across all age groups in India, and hence constitute a significant public health burden. These disorders are the result of an interaction between genetic, biological, psychological, and adverse social and environmental factors that shape an individual’s personal make-up and lead to poor quality of life, disability and even death.

Mental disorders can be broadly categorised into common mental disorders (depression, anxiety and somatoform disorders), severe mental disorders (schizophrenia, bipolar disorder, dementia), substance use disorders (alcohol use disorders, opioid dependence, cannabis dependence) and childhood mental disorders. Various studies in India have reported widely varying prevalence rates of mental health problems from 9.54 to 370 per 1,000 population.

A meta-analyses of these studies have estimated that the prevalence of any mental health problem ranges from 5.8 to 7.3 per cent of the population. This translatesto 70.2 to 88.3 million people in India based on the Census 2011 population.

Depression alone accounts for around 3% of the total burden of disease in India. Most importantly, there has been a 50% increase in the burden contributed by depression in last two decades and is projected to increase further during the next 25 years as a consequence of the epidemiological and demographic transitions in India.Mental disorders are also an important proximal risk factor for suicide.

The findings of the Million Death Study observed that 3 per cent of the surveyed deaths in individuals aged 15 years or older were due tosuicide, corresponding to about 187,000 suicide deaths in India in 2010. Suicide mostly kills individuals in their youth, 40 per cent of suicide deaths in men and 56 per cent of suicide deaths in women occurredat ages 15–29 years, thus making suicide a leading cause of death in this age group.

There are a wide range of drug, psychological and social interventions which have been shown to be cost-effective and which can transform the lives of people affected by depression. Despite this evidence, very few people with depression (around 5%) seek services for same and amongst them very few actually receive evidence-based interventions.

The New National Mental Health Policy released in October 2014, the rejuvenated and re-designed implementation plan for the District Mental Health Program (DMHP) prepared by the Mental Health Policy Group and the draft Mental Health Care Bill provide a very conducive policy environment for strengthening the mental health system in India and improving the delivery of mental health services.

In the twelfth Five Year Plan period (2012-2017), the Ministry of Health and Family Welfare plans to role-out the DMHP in 565 districts across the country in a phased manner. However, recent evaluations of the DMHP indicate that it is, to a large extent, ineffective in practice and has not been able to improve coverage of evidence-based services for mental disorders.

Public Health Foundation of India and Sangath are two premier national level organizations working in the field of public mental health in India for last few years. We are currently implementing a major community based programme for Improving Mental Health Care (PRIME) and the findings from this programme can be utilized to strengthen the existing DMHP which can ultimately improve effective coverage for mental disorders at the district level.

PRIME is currently implemented in Sehore district of Madhya Pradesh covering three sub-district hospitals and a population of approximately 350000. In the last three and half years we have developed and pilot tested a comprehensive mental healthcare plan aimed at integrating the delivery of evidence based interventions for three priority mental disorders (depression, psychosis and Alcohol Use Disorders) in primary healthcare and community setting. This work is in close collaboration with the existing DMHP in Sehore district and the Department of Health Services.

The key lessons from the implementation of PRIME project are: (a) mental health service delivery as part of the DMHP can be strengthened with strong facilitation by an external resource team such as PRIME team; (b) an additional human resource in the form of a case manager is essential to establish true collaborative models of care and integrate mental health in primary care; and (c) enabling packages such as programme monitoring, quality improvement and community mobilization need to be installed as a foundation prior to the implementation of service delivery packages.

There is a scope to further strengthen the partnership between the DMHP and the PRIME programme in the state of Madhya Pradesh to provide collaborative, coordinated and continued care which is patient-centric and integrated with general health care. This partnership will provide the much required technical support to the Department of Health Services and the DMHP in the state and can ultimately lead to the improvement in the coverage of evidence based treatments for priority mental disorders.

(The Author is Associate Professor at PHFI, and Heads the Madhya Pradesh based PRIME Project)

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