2. TABLE OF CONTENTS
• Introduction and background information
• Aims and objectives of this programme
• Development
• Organizing Body
• XIIth Plan: DMHP Clinical Team
• DMHP – Clinical Services
• Operational Guideline for the FY 2018-19 of NMHP & DMHP
• Evaluation Of District Mental Health Programme
• Timelines
• Future Directions and Possible Solutions
• References
3. BACKGROUND
• “Mental health has been defined as a state of balance between the
individual and the surrounding world, a state of harmony between
oneself and others, a coexistence between the realities of the self and
that of other people and that of the environment-” World Health
Organization (WHO).
• All kinds of mental and behavioral disorders are widely prevalent in Indian
population.
• Review of the situation of psychiatric disorders in India highlighted the
gross neglect of mental disorders (Neki and Carstairs, 1975) due to:
• Pervasive stigma, widespread misconceptions
• Grossly inadequate budgets for mental healthcare
• Acute shortage of trained mental health personnel
4. CONT..
Recommendations by an expert committee on “organization of mental health services
in developing countries” ( World Health Organization. 1975): Basic mental health care
should be integrated with general health services and be provided by non-specialized
health workers at all levels.
• Starting of “Community Mental Health Unit” by NIMHANS , Bangalore – 1975
SAKALWARA PROJECT :Focus on developing services and model.
• WHO Multi-country project: “Strategies for extending mental health services into the
community” (1976-1981)
• RAIPUR RANI PROJECT- Focus on testing and evaluating models.
• Indian Council of Medical Research – Department of Science and Technology (ICMR-
DST) Collaborative project (1980):
• To evaluate the feasibility of training of PHC staff to provide mental health care as
part of their routine work.
5. CONT..
• In 1980 the Government of India felt the necessity of evolving a plan of action
aimed at the mental health component of the National Health Programme.
• In February 1981, a drafting committee met in Lucknow and prepared the first draft
of the NMHP. This was presented at a workshop at New Delhi on 20–21 July 1981.
• In August 1982, the highest policy making body in the field of health in the country,
the Central Council of Health and Family Welfare (CCHFW) adopted and
recommended for implementation of National Mental Health Programme (NMHP).
• The Government of India launched the National Mental Health Programme (NMHP)
in 1982, keeping in view the heavy burden of mental illness in the community, and
the absolute inadequacy of mental health care infrastructure in the country to deal
with it.
• The district Mental Health Program was added to the Program in 1996.
6. Development of the pilot district mental health
Programme at Bellary district in Karnataka:
population of about 20 lakhs
located about 350 kms away from Bangalore
chosen for the pilot development of a (DMHP).
Components of the DMHP at Bellary were:
training for all primary care staff,
provision of 6 essential psychotropic and anti epileptic drugs
(chlorpromazine, amitryptaline, trihexyphenidyl, injection fluphenazine
deaconate, phenobarbitone and diphenyl hydantoin) at all PHCs and sub centres,
a system of simple mental heath case records,
a system of monthly reporting,
regular monitoring and feed back from the district level mental health
team
7. • The psychiatrist - mental health clinic at the district hospital to review patients referred from
the PHCs.
• admit up to 10 patients at the district hospital for brief in patient
• The mental health programme was reviewed every month at the district level by the district
health officer during the monthly meeting of primary health centre medical officers.
• The Ministry of Health and Family Welfare, Govt. of India formulated District Mental Health
Programme (under National Mental Health Programme)
• . The District Mental Health Programme (DMHP) is the flagship mental health intervention
programme of the Government of India as part of the National Mental Health Programme.
• The programme was to be implemented in two phases,
• Phase I taken up during 1996-97,
• Phase II be a continuation of the programme during the IX Five Year Plan
• period (1997-2002).
• Budget line for implementation of the DMHP as a major component of the NMHP was
created in 1996; 14 years after CCHFW approved the NMHP.
• DMHP was to be implemented as a fully “centrally supported” project.
8. • Launched in 1996–97 in four districts, one each in Andhra Pradesh, Assam,
Rajasthan, and Tamil Nadu.
• 1Xth 5-year Plan (1997-2002) - 27 districts.
• Xth 5-year Plan (2002-2007)- 110 districts.
• X1th 5-year Plan (2007-2012)- 123 districts
• XIIth 5-year Plan (2012-2017)- DMHP is also being started in 325 new districts
• The central grant for implementation of DMHP per district with avg population of
20 lakh for five years will be Rs. 2.5 crore
• National Health Policy: specified the inclusion of mental health in general health
services, in 2002.
9. NMHP
• Objectives -
• To ensure the availability and accessibility of
minimum mental healthcare for all in the
foreseeable future;
• To encourage the application of mental health
knowledge in general healthcare and in social
development
• To promote community participation in the
mental health service development
• To enhance human resource in mental health
sub-specialties.
DMHP
• Objective: -
• To provide sustainable basic mental health services
to the community and to integrate these services
with other health services
• Early detection and treatment of patients within the
community itself
• To reduce the stigma of mental illness through
public awareness.
• To treat and rehabilitate mental patients within the
community.
10. KEY PRINCIPLES UNDERLYING THE PROGRAMME COMPONENTS
i) A life course perspective with attention to the unique needs of children,
adolescents
and adults.
ii) A recovery perspective, through provision of services across the continuum of
care
and empowerment of persons with mental illness and their care-givers.
iii) An equity perspective through specific attention to vulnerable groups and to
ensure
geographical access to mental health services
iv) An evidence based perspective by following established guidelines and
experiences
on treatments and delivery models.
v) A health systems perspective with clearly defined roles and responsibilities for
each
sector from community to district hospital and including a cascading model of
11. IMPLEMENTATION OF DMHP
• The DISTRICT MENTAL HEALTH PROGRAMME was started
as " a community based approach’’ , which includes:
Provide services for early detection and treatment of mental illness in
the community itself with both OPD and indoor treatment and follow-
up of discharged cases.
Increase awareness in the care necessity about mental health
problems.
Training of the mental health team at the identified nodal institutes
within the State.
Provide valuable data and experience at the level of community in the
state and Centre for future planning, improvement in service and research.
12. • Based on the evaluation conducted by Indian Council of Marketing Research
(ICMR) in 2008 and feedback received from a series of consultations DMHP has
now incorporated promotive and preventive activities for positive mental health
which includes:
• School mental health services: life skill education in schools, counselling.
• College counselling services: Through trained teachers/ counsellors.
• Work place stress management: Formal and informal sector, including
farmers, women etc.
• Suicide prevention services: Counselling center at district level, sensitization
workshops, IEC, helpline
13. ORGANIZING BODY
• 1. At the Central Level: Central Implementation Team
• 2. At the State Level: State Implementation Team
• 3. At the District Level: A full-time District Programme Manager with a
background in public health management will have overall administrative
responsibility for implementation of the DMHP in that district.
14. (XIITH 5-YEAR PLAN (DISTRICT MENTAL HEALTH PROGRAMME)
DMHP CLINICAL TEAM
• District Hospital Level
• a) Psychiatrists : All DMHP districts shall appoint two full-time psychiatrists to the
DMHP Programme.
• b) Nurses –7 Nurses shall be appointed for in-patient and outpatient care.
• c) Clinical Psychologist: Two clinical psychologists will be appointed.
• d) Psychiatric Social Worker : Four psychiatric social workers will be appointed.
• e) Programme Assistant (1 Nos)
• g) M&E Officer (1 Nos)
• h) Ward Assistants/Orderlies (4 Nos)
15. DMHP – CLINICAL SERVICES
• District Hospital
• Outpatient services & Inpatient services,
• Child mental health services,
• Collaboration with RCH services to address post partum mental disorders,
• Specialist Counselling and Therapy services, Availability and Provision of psychotropic
medications
• Clinical support to continuing care services
• Disability Certification
• Laboratory Services
• Interventions for persons attempting suicide
• Support and supervision to PHC staff
• Outreach outpatients at CHC/Taluk Hospitals
• Capacity building and Training Activities
• Emergencies
• Administrative and Managerial support to all clinical services
16. CHC/Taluk Hospitals:
• Outpatients services
• Inpatient services
• Specialist counselling services
• Social support
PHCs
• Management of common mental disorders, Management of mental health
emergencies, Referrals to District Hospitals, Follow up of patients with SMD
with a treatment plan drawn up by District DMHP Team
• Identification of persons with SMD in community and mobilizing them for
assessment to PHC Community based rehabilitation for persons with severe
mental disorders Assist in accessing services in the community (eg day care
centres).
• Assist in accessing social benefits Availability and Provision of psychotropic
medications
DMHP – Continuing Care Services
17.
18.
19. 12TH 5 YEAR PLAN FOR NMHP & DMHP
• April 2012-2017 Strategy:
• Manpower development scheme
centre for excellence
Strengthening PG departments in mental health specialities
• Upgrading central mental health institutes to provide basic neurological and
neurosurgical facilities on the pattern of NIMHANS, Bangalore.
• Support for central and state health authorities
• Central mental health team for NMHP
• Training and research activities
• IEC activities
• Monitoring and evaluation of mental health information management system
20. KEY LESSONS ON THE FUNCTIONING OF THE DMHP IN THE XI
&XIIth 5-YEAR PLAN
• Large gaps exist in the coverage of the DMHP within the country.
• Although the DMHP is supposed to be active in 123 (X1th) districts, it was barely
functional in most districts.
• Performance of the Programme was not entirely satisfactory in most districts, there
was an emerging pattern of the Programme functioning better in some states while
in others there were no districts where the DMHP was implemented.
• The method of selection of the 123 districts itself resulted in a skewed distribution of
DMHP districts with certain parts of the country (south and west) enjoying many
DMHP districts while the north, central having comparatively fewer districts.
21.
22. DISTRICT MENTAL HEALTH PROGRAM - NEED TO LOOK INTO
STRATEGIES IN THE ERA OF MENTAL HEALTH CARE ACT, 2017
AND MOVING BEYOND BELLARY MODEL
• Medical officers trained under the program have better awareness of mental illness but still lack
of confidence in treating mental disorders.
• There is also lack of confidence on the part of beneficiaries from taking treatment from
nonmental health professionals even after so many years.
• The Mental Healthcare Act (MHCA), 2017 allows only emergency treatment for 72 h by a
physician before referral to higher center, and there is no provision for treatment by a
nonmental health professional during follow-up.
• Even there will be serious limitation in treating drug abuse cases in primary care. MHCA requires
diagnosis by internationally recognized classificatory systems like International Classification of
Diseases 10th Revision. It will be an uphill task for primary care physicians to become familiar
with such systems.
24. OPERATIONAL GUIDELINE FOR THE FY 2018-19 OF
NMHP & DMHP
Activity No. 1
• Targeted interventions at community level Activities & interventions targeted at
schools, colleges, workplaces, out of schools, colleges, workplaces, out of school
adolescents, urban slums and suicide prevention
• Aim: To sensitize the whole community by the trained community health workers about
mental health, features of mental disorders, screening of mental health disorders
among whole population, availability of their management in the PHCs/CHCs/District
Hospitals and benefits of treatment.
25. Activity No. 2
• District Counseling Centre (DCC) and crisis helpline outsourced to psychology
department/NGO per year.
• Guideline: This activity will be started under the supervision of State Programme
Officer for Counseling Centre and Crisis Helpline in collaboration with “The
SARATHI 104”- Health information helpline service for answering all health
26. Activity No. 3
• District DMHP centre, Counseling centre under psychology
department in a selected college including crisis helpline
Activity No. 4
• Equipment
• Aim: For providing all equipments along with the assessment
tools in District Hospitals.
27. • Activity No. 5
Name of the Activity: Drugs and supplies under NMHP
Aim: For providing all needed psychotic drugs to the District Hospitals.
• Activity No. 6:
Name of the Activity: Ambulatory Services
About the activity: Ambulatory services for the mobility of the patients
28. • Activity No. 7
Name of the Activity: Training of PHC Medical Officers, Nurses,
Paramedical Workers & Other Health Staff working under NMHP.
About the activity:Training of MOs, Staff Nurses, Paramedical
workers, drivers, police personals, Jail Doctor, Personal from Social
Welfare deptt., Govt. officials, Magistrates and NGO workers for
mentally ill patient.
29. Activity No. 8
Name of the Activity: Others (Training)
Aim: For providing training to the Non- Psychiatric Medical Officers along
with Clinical Psychologist and Psychiatric Social Worker at Lokpriya
Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH), Tezpur
under National Mental Health Programme (NMHP).
Activity No. 9
Name of the Activity: Translation of IEC materials and distribution
Aim: For providing the IEC materials and training modules to the districts
30. • Activity No. 10
Name of the Activity: Awareness generation activities in the
community, schools, workplaces with community involvement.
• Activity No. 11
Name of the Activity: NGO based activities
Aim: To develop 3 (Three) Day Care Centre in the existing registered
NGOs in 3 (Three) different districts in the state.
31. • Activity No. 12
Name of the Activity: Operational expenses of the district center: rent,
telephone expenses, website etc.
About the activity: Operational expenses of the district center: rent,
telephone expenses, website will be formulated accordingly.
• Activity No. 13:
Name of the Activity: Contingency under NMHP
About the activity: Contingency costs including Miscellaneous costs,
Travel costs and Contingency costs
32. REGIONAL WORKSHOPS ON NMHP & DMHP
• In order to disseminate the guidelines of revised National Mental Health Program, Mental Health
Program Division of Ministry of Health and Family Welfare organized five regional workshops of 2
days each, across the country. (2011-12).
The agenda items for discussion in the regional workshops were following:
1. To discuss and disseminate revised DMHP guidelines and other added
components of NMHP.
2. Role and responsibilities of the various stakeholders of NMHP in the states.
3. Issues of concerns and bottlenecks for the implementation of NMHP in the
respective states.
4. To discuss the action plan for implementing the revised DMHP.
5. NMHP strategy for the 12th FYP.
33. EVALUATION OF DISTRICT MENTAL HEALTH
PROGRAMME
• MENTAL HEALTH SERVICE UTILIZATION:
• Site of contact of beneficiaries under DMHP
• 61%-district hospital
• 12.7%-CHCs
• 11.5%-PHCs
• 18% of the total respondents were referred to district level for treatment.
• “So mental health services have been decentralized at least to the district level
if not to the level of PHCs, from mental hospitals and medical college hospitals
with partial integration of these services with the general health services”.
34. • DRUG SUPPLY UNDER DMHP
25% of the districts under DMHP have regular inflow of
drugs.
80% beneficiaries received at least some medicines from the
health centers.
“This is because of lack of dedicated drug procuring mechanism for DMHP”
35. • FUND UTILIZATION:
One third of the districts utilized over 99%, one third has utilized 63-91%, and rests
have utilized 37-47% of the total amount they have received.
Only 10% of the districts, utilized funds allocated for IEC activities. 20% of the
districts did not utilize funds under IEC and rest 70% district had partially utilized.
“This is mainly due to administrative delay, difficulty in recruiting and retaining qualified
mental health professional, low utilization in training and IEC components”
55% of the health personnel confirmed that they had received training.
More than half of the health personnel (54.7%) trained were satisfied with the
programme.
“Training and IEC components which require a lot of ground work, coordination and
networking in the community is below par in most of the districts”
• The ICMR review reported that over half of the patients had to travel more than 5 kms
to access treatment services; 40% had to travel over 10 kms. patients spend Rs 43.5
Rs 10 – max Rs 250) on travel to the hospital to access services provided under the
DMHP.
36. National Mental Health Survey of India 2015–2016 by R. Srinivasa Murthy
Professor of Psychiatry (Retd), Formery of NIMHANS, Bangalore, Karnataka, India
• Treatment gap for mental disorders ranged between 70% and 92% for different disorders:
• common mental disorder - 85.0%
• severe mental disorder - 73.6%; psychosis - 75.5%;
• BPAD - 70.4%; alcohol use disorder - 86.3%;
• and tobacco use - 91.8%.
• The median duration for seeking care from the time
of the onset of symptoms varied from 2.5 months for
depressive disorder.
•
37. NATIONAL MENTAL HEALTH SURVEY (NMHS) – ASSAM (2015-
16)
• As of 2015 -16, the treatment gap for mental disorders in Assam was 82.58%
.
• Homeless Mentally Ill: Despite advances in treatment modalities and
available facilities, almost every day, 1-2 homeless mentally ill persons are
found on the streets.
• The state did not have any written dedicated mental health policy, defining
the, values, vision, mission, principles, objectives and mechanisms for
improving mental health care.
• Mental health activities are carried out in the state, but were fragmented and
dis-organized.
• The DMHP program was implemented in 5 districts (Nagaon, Tinsukia,
Nalbari, Goalpara & Morigaon) of the state, prior to 12th five-year plan
period.
38. • Later, 7 more districts were identified for DMHP supported by state
government.
• However, apart from appointing a few psychiatrists in district hospitals
during the early part of 2012, under implementation of the scheme “State
Support for Mental Health Programme”, DMHP has not been implemented
during the 12th five-year plan from 2012 -2016.
• DMHP covered only 14.29% of the districts of Assam and less than a quarter
(22.08%) of the total population.
• There was no reliable information on the functioning of DMHP in these
districts.
• Some of the barriers in successful implementation of DMHP in the state are
non-regularization of post for DMHP staff, irregular salary of contractual
staff, medicines and lack of co-ordination between state officials and district
hospital.
• Failure to utilize the granted amount and submit utilization certificates as
39. TIMELINE
• 1969- Mudaliar Committee recommendations on Mental Health
• 1974- Srivastava Committee recommendation of Communiy Health Volunteer (CHV)
includes Mental health in scope of work
• 1975- Training of General practitioners in psychiatry started at NIMHANS
• 1976- Program of Community Psychiatry launched at NIMHANS
• 1975-80- Needs of rural population studied by NIMHANS in one primary health centre
• 1976-81- Raipur Rani project as part of WHO multi centric project on strategies for
extending mental health care
• 1980-86 Pilot experiment to integrate Mental health into primary health care at one
Primary health centre of population of 1 lac at select talukas of Bellary district.
• 1982-84- Indian Council of Medical Research (ICMR) project at three sites tests out the
NIMHANS material for training of GP in psychiatry
• 1984- Bellary model upscaled to entire Bellary district
• 1985-90- DMHP Pilot test in Bellary district
40. • 1985-87 ICMR Project – Mental Health in PHC – Solur, Karnataka
• 1987 ICMR-DST project at four locations in the country (Collaborative study on severe mental morbidity)
• 1995 Meeting of Central Council of Health
• 1996 Recommendation on starting mental health program at a workshop of all health administrators in
Bangalore
• 1996-97 DMHP launched in 4 districts of the country
• 1997 Quality Assurance in Mental health care services report by National Human Rights Commission
• 1997-2000 Phased expansion of DMHP districts
• 1999 Mental Health agenda of World Health Organisation set; MH identified as priority for WHO’s work
• 2001 World Health Day theme based on Mental Health
• 2001 World Health Report with focus on Mental Health
• 2003 World Health Survey involving 5 states
• 2007-08 DMHP in 123 districts
• 2008-09 Evaluation of DMHP by Indian Council of Marketing Research (ICMR) in 20 of 127 districts
• 2011 A review of 23 districts of four southern state DMHP conducted by NIMHANS
• 2012 WHO Executive Board adopts a Resolution (proposed by India, US and Switzerland) on co-ordinated
health and social sector response to mental health problems
• 2012-2017 (XIIth 5-year plan)
41. FUTURE DIRECTIONS AND POSSIBLE SOLUTIONS
• Human resource development:
Undergraduate training to be strengthened
Departments of psychiatry to be strengthened
Filling of lacunae like scarcity in numbers of PSW, psychologists and
psychiatric nurses
• Involvement of private health care services
• Support to voluntary organizations active in mental health
• Better administrative support and responsibility.
42. REFERENCES
• National health portal; MoHFW, Govt. of India.
• XIIth Plan District Mental Health Programme (DMHP) prepared by
Policy Group 29th June 2012.
• OPERATIONAL GUIDELINES 2018-19 NATIONAL MENTAL HEALTH PROGRAMME (National Health Mission,
Assam, Saikia Commercial Complex, Christian Basti, Guwahati-05).
• DIRECTORATE GENERAL OF HEALTH SERVICES Ministry of Health & Family Welfare ,Government of India.
• Mental health care act, 2017
• National health programs of India: J Kishore 11th ed
• Regional Workshops on National Mental Health Programme (2011-12).
• National Mental Health Survey India, 2015-16 ASSAM State Report (Conducted by Lokopriya Gopinath
Bordoloi Regional Institute of Mental Health).
• National mental health program of India: a review of the history and the current scenario
Sarbjeet Khurana1*, Shweta Sharma (Institute of Human Behaviour and Allied Sciences, 2016)
