Early this year, the Ministry of Health and Family Welfare, Government of India, invited “research proposals for funding as part of the ongoing National Mental Health Programme (NMHP) which aims at providing community based mental Healthcare using the existing public health infrastructure. The proposed research should be relevant and transnational in nature, i.e., it should conform to the aims/objectives of the NMHP and should translate into more effective/cost-effective Self-Development interventions/service delivery”1.
Mental Health In the New Millennium
This Rs 10 crore(US$22.2 million) is an unprecedented research support to the NMHP for “phased implementation of the District Mental Health Programme, strengthening of medical college departments of psychiatry, modernisation of mental hospitals, focused IEC initiatives, research and training”.
Commencing with the first epidemiological studies at Bangalore in the 1950s and at Agra in the early 1960s, the Indian Council of Medical Research (ICMR) has been in the forefront of mental health research 2. The other major studies include the multi centered research cum intervention project titled “Severe Mental Morbidity” in four centres 3. The “Strategies for Mental Health Research”, based on six task forces that identified research priorities in mental health in 1980 was a major milestone.
Two of these task force projects focused on acute psychosis and course and outcome of schizophrenia4,6. Findings of the studies have not only influenced mental health care in India, but contributed to the inclusion of acute psychosis as a separate diagnostic category in International Classification of Diseases (ICD) 10th Edition, of the World Health Organisation. Other studies were mental health care of the aged and child psychiatric problems. Many of the trainees who participated in the community mental health training programmes initiated their own community mental health projects.
These initiatives demonstrated both the need for research support to the developing NMHP (formulated in 1982) as well as the willingness of professionals to work as teams. The 1980s also saw the Council set up Advanced Centers for Research on Community Mental Health at Bangalore, Mental Health of Aged at Madurai, and Biological Psychiatry at Lucknow – all of which demonstrated how research support can help develop mental health services.
The ICMR also supported research into the mental health aspects of disasters like the Bhopal Disaster in the 198Os, the Marathwada earthquake in the 1990s and the most recently Gujarat earthquake and the fire tragedy in Delhi. It is largely the result of these efforts.that following any disaster in India, psychosocial support is readily provided to the survivors along with other services7.
Mental health care in India over the last 25 yr has been an intense period of growth and innovation. Prior to the formulation of the NMHP in 1982, the major initiatives included setting up of mental hospitals during 1950s and early 1960s and general hospital psychiatric units in the 1960s and 1970s8. Simultaneously, involvement of the families in care of the mentally ill was also initiated in a number of centres.
Another major step in mental health care was to integrate mental health care with general health services. Followed by the initial demonstration projects at Chandigarh and Bangalore9-11, in the last two decades, the pilot programmes of integration of mental health with primary health care were initiated at several centres. The district model of mental health (DMHP) care was developed by National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore during the latter part of 1980s12.
The next big step was extending of DMHP to 25 centres around the country with central funding during the 9th Five Year Plan13. Currently, during the 10th Plan period, the goal is to cover 100 districts with about 150 million population14,15.
India enters the new millennium with many changes in the social, political, and economic fields with an urgent need for reorganization of policies and programmes. The mental health scene in India, in recent times, reflects the complexity of developing mental health policy in a developing country.
There has been a critical examination of the existing mental hospitals in the country by the National Human Rights Commission of India16. The Supreme Court of India is continuously examining the wide variety of issues relating to mental health care, following the Erwadi Tragedy in which 28 mentally ill persons were burned to death while chained to pillars. The National Health Policy17 clearly spells out the place of mental health in the overall planning of health care.
These developments have occurred against the over 25 yr of efforts to integrate mental health care with primary health care (from 1975), replacement of the Indian Lunacy Act 1912 by the Mental Health Act 1987, and the enactment of The Persons with Disabilities Act 1995 focusing on the equal opportunities, protection of rights and full participation of disabled persons’8.
The growth of voluntary action for mental health care in the areas of suicide prevention, disaster mental health care, setting up of community mentalhealth care facilities, movement of family members (care givers) of mentally ill individuals, drug dependence, public interest litigation to address the human rights of the mentally ill; research in depression, schizophrenia and child psychiatric problems are other major developments19.
The rapid growth of private psychiatry with associated spread of services to peripheral cities and small towns and challenges of regulation is an another significant development of the last 10 yr.
Against the above positive developments, the main challenges are the extremely limited number of mental health professionals (about 10,000 professionals of all categories for one billion population) and the very limited mental health service infrastructure (about 30,000 psychiatric beds for over a billion population); limited investment in health by the government (estimated public sector expenditure on health is only 17 % of total health expenditure) and problems of poverty (about 30% of population live below poverty line) and low literacy with associated stigma and discrimination for persons with mental disorders.
At the International level, the World Health Report 2001 on Mental Health has been a landmark in the development of policies and programmes relating to mental health in the world and specifically in developing countries20. The Report provides a framework for countries with different development levels to initiate actions appropriate to their resources. Already there is evidence of change in many countries.
Another important document Neurological, psychiatric, and developmental disorders: meeting the challenges in the developing world, published by the Institute of Medicine in 2001 also focusses on the research needed to support mental health programmes in developing countries21.
The scope of mental health in the new millennium should include care of the mentally ill persons, prevention of mental disorders and promotion of mental health as outlined by Dr Govindaswamy, the first Director of All India Institute of Mental Health (now NIMHANS), Bangalore22 over 50 yr back: “Mental health in India has three objectives. One of these has to do with mentally ill persons. For them the objective is the restoration of health.
A second has to do with these people who are mentally healthy but who may become ill if they are not protected from conditions that are conducive to mental illness which however are not the same for every individual. The third objective has to do with the promotion of mental health with normal persons, quite apart from any question of disease or infirmity. This is positive mental health. It consists of the protection and development of all levels of human society of secure, affectionate and satisfying human relationships and in the reduction of hostile tensions in the community.”
The challenge for professionals working in India is the competing demand to provide services to large numbers of persons with mental disorders and generation of new knowledge through research. The research agenda for the Council could have the goals of (i) reduction of the incidence, prevalence and burden of mental and behavioural disorders; (ii) develop and evaluate the mental health services so that they become available and accessible to the total population; (iii) enhance the positive mental health of the population; and (iv) create structures to promote long-term mental health research and dissemination of mentalhealth information.
The following four strategies can be used by the ICMR to achieve the above goals: (i) provide research and evaluative foundation to the expanding national level mental health services, both as part of NMHP and in the private sector psychiatry; (ii) help generate new knowledge about the nature, course and outcome of mental disorders; (iii) develop measures for monitoring of the mental health of the community; and (iv) build capacity for mentalhealth research and dissemination of mental health information among the public, policy makers and professionals.
Research in service development should focus as a priority, on areas like integration of mental health in primary care, early intervention in psychosis, use of family support, models of community long-term care, evaluation of suicide prevention initiatives and mental health in schools.
The topics for generation of new knowledge could focus on course and outcome of different mental disorders; treatment by pharmacological and non-pharmacological methods of common mental disorders; mental health of women; .mental health of adolescents; disaster mental health; health and behaviour, development of culturally appropriate assessment tools; health system research; spirituality and health; and basic biological studies of mental disorders.
The development of mental health indicators is an important strategy to give greater acceptance of mental health programmes. These indicators could be at the community level relating to services, studies of burden of mental disorders and the impact of alcohol and substance abuse.
Capacity building through setting up of centres of excellence or advanced centres to support young professionals; regular compilation of psychiatric research data and periodic publications; greater use of information technology for dissemination of information is essential.
The last two decades of research efforts of the Council allow for focused national level workshops in the areas of disaster mental health, schizophrenia and organization of mental health care. Such workshops can not only allow consolidation of knowledge but greater dissemination of information.
India is thus entering the new millennium with many challenges like promoting mentalhealth of the population and developing mental services involving different social institutions. Professionals have been in the forefront to find solutions appropriate to the country and towards developing an Indian system of mental health care.
There is need for a vision for the development of mental health that is broad-based, inclusive of all the needs of all the people, which is community based and community intensive. The ICMR and the mental healthprofessionals in India have their roles clearly cut out.
I am thankful to Drs Somnath Chatterji and Shekhar Saxena of WHO, Geneva for the technical inputs towards the development of the goals, strategies and priority research areas during the year 2001 and Prof. N.K. Ganguly for initiating these discussions during one of his visits to Geneva.