INDIAN PSYCHOSOCIAL FOUNDATION
 
   INDIAN PSYCHOSOCIAL FOUNDATION
         
IJPS >
IJPS April 2011
IJPS October 2011
IJPS April 2012
IJPS October 2012
IJPS April 2013
IJPS October 2013
IJPS Apirl 2014
IJPS October 2014
IJPS Apirl 2015
IJPS Apirl 2016
IJPS October 2016
IJPS Apirl 2017
 
 
 
MODERN PERSPECTIVE OF MENTAL HEALTH CARE IN INDIA

MODERN PERSPECTIVE OF MENTAL HEALTH CARE IN INDIA

Suboth1, Chadha R K2, Yadav J S3,

Senior Resident1, Professor2, Assistant professor3,

Department of Psychiatry AIIMS New Delhi1, 2, 3,

Abstract

The early establishment of Asylum in the Indian subcontinent reflected the needs of separate environment, food and shelters for European psychiatric patients in India during British period.1 The primarily aim of, those mental asylums were, segregating of insane who were considered troublesome and dangerous to the society, thus the overriding concern was to protect the citizens without regard for appropriate care and cure of the patients, Such asylums were constructed away from cities with high enclosures area or dilapidated buildings such as barracks left by the military men 2,3.

In 1946 the Bhore committee report stress for revision of existence of all 17 mental hospitals with 10289 patients and given addition needs for training for medical, paramedical and ancillary nurses, but unfortunately up to independence no satisfactory improvement were found4.

Keyword;modern perspective of mental health

Mental Hospitals in Independent India: During early years Custodial institutions traditionally evoke images of gross overcrowding, poor sanitary conditions, and loss of individual freedom. Then mental health administrators began to develop out-patient services in mental institutions. Thus the gross overcrowding in hospitals began to reduce. By the 1960s, traditional institutions like CIP (Ranchi) and Madras mental hospital offered a range of specialized services, like child and adolescent clinics, geriatric, epileptic and neuropsychiatric services, CIP also started a Child Guidance Clinic in 1950 followed by an independent 50-bed child and adolescent psychiatry unit in 1975.5 Another important innovation in the 1960s was the concept of a day hospital; CIP took initiatives in community mental health services. Keeping with the reforms in community psychiatry, the first psychiatric mental health camp in India was organized in 1972, at Bagalkot, a taluka of Mysore6. The occupational therapy and recreational facilities were introduced in a phased manner in many of the large institutions. Dr Vidya Sagar at the Amritsar Mental Hospital in1960 used comprehensive involvement of families in the after care, facilitation of acceptance and return patient to their own homes in the community 7.

During early phase of management less effective therapeutic options included like paraldehyde, bromide and insulin-coma induction therapy were available, however later these therapeutic options changed with the advent of chlorpromazine. CIP was the first centre in India that used lithium and chlorpromazine in the 1950, this centre also began to set up radiology, laboratory, EEG facilities within their campus 8. The Government of India established the All India Institute of Mental Health in 1954 at Bangalore (later known as NIMHANS). This became the first Indian training centre for postgraduate in psychiatry, clinical psychology and psychiatric nursing. Later the postgraduate training, diploma in Psychological Medicine (DPM) and Diploma in Medical and Social Psychology, courses started at CIP in 1962 9.

The Indian psychiatric society started publication of the “Indian Journal of Neurology and Psychiatry” in 1949 and the name of this journal later changed to Indian Journal of Psychiatry in 195810. The major epidemiological studies of those days included work of Surya, Sethi, Ganguli and Gopinath, which helped to establish the magnitude of mental health care in the community. The year 1980 Indian psychiatry shows a fresh surge in mental health research as during the time many projects were started in various parts of the country in collaboration with Indian Council of Medical Research and World Health Organization WHO11.

After implementation of the Mental Health Act, 1987, government focus upon mental hospital reform and paved way for a more specific and futuristic role for mental hospitals and in planning of psychiatric services, especially for severe mental illnesses. Thus that stage was set for a contemporary, holistic approach towards the management of mental illness12.

Relevance of mental hospitals

Bhaskaran in his 1971 Presidential address of the Indian Psychiatric Society, at Hyderabad, addressed the issue of mental health services extensively under the title ‘unwanted patient’. He has given more stress on need of interventions in psychiatric patients. He further address that traditional large mental hospitals have outlived their usefulness and may actually serve as breeding grounds for secondary problems like hospitalism13-14.

In a study of mental hospital Varanasi found that 32% patients stayed between 6 to 40 years and 2% more than 45 years. Those patients were not stayed only for their psychiatric problems but major problems were assessment before keeping them in fitness board and send back to their respective place even after declaring them fit15.

Therefore the questions arises that such institutions should ever be built in future? So there is enough convincing evidence to show that patients with schizophrenia of all types and stages of illness can be successfully treated in smaller open institutions, those situated more centrally in the community”. But there are still controversies that whether mental health services should be provided in community or hospital settings. There is no worldwide consensus that which mental health service models are appropriate for low, medium and high- resource areas? Cochrane systematic reviews and other reviews were summarised by Thornicroft & Tansella (2004) makes clear that there is no compelling argument and no scientific evidence favouring the use of hospital services alone or community services alone can provide satisfactory and comprehensive care16. The evidence available so far of clinical experience support that the approach incorporating elements of both hospital and community care are good approach.

Since independence, the numbers of mental hospitals in India have increased from 31 to 59 (NHRC Report), out of them like 43 mental hospitals are in the public sector in the country, with a total of around 30,000 beds. The ratio of psychiatric bed per 10000 populations in mental hospitals is 0.2 compared to 0.05 beds per 10000 populations in general hospitals 17-18. These have to serve an estimated one crore people with severe mental illness. It has been noticed that several times few numbers of patients do not need for hospitalisation with subset of mentally ill persons. The patients having more severe forms of illness, poor social supports, significant family and societal burden constitute nearly 1% of the population at any point of time. Mental hospitals have drawbacks that no Consultation-liaison psychiatry hospital situated to Proximity of premises. Being a part of psychiatry unit in general hospital there are number of benefits like community interaction, easy accessibility and approachability, opportunity for interaction with other clinical departments, enhancement of research, and reduction of the stigma associated with psychiatric illness or going to a psychiatrist (Kuruvilla, 1993)19.

A decade after the NHRC quality assurance initiative: A status of government psychiatric hospitals in India

After PIL in 1980 Supreme Court became active and turned to the plight of the mentally ill patient and their treatment in psychiatry hospitals. With the help of NIMHANS, the NHRC initiated a project to evaluate the status of mental health in the country. A detailed questionnaire sent and visits to 33 of the 37 hospitals was made. The NHRC Quality Report was largely based on conditions during 1996-1997 and this report find that ‘the deficiencies of mental health care in many areas are enough indicators that the rights of the mentally ill are grossly violated in those hospitals. (National Human Rights Commission. Quality assurance in mental health. New Delhi: NHRC; 1999)20-21.

NMHP and Humanizing Mental Hospital for its role in mental health care

The NMHP was re-strategized in the year 2003 (in X Five Year Plan) with the following components 22.

1. Extension of DMHP to 100 districts

2. Up gradation of Psychiatry wings of Government Medical Colleges/ General Hospitals

3. Modernization of State Mental hospitals

4. Information, education and communication (IEC)

5. Monitoring & Evaluation

To modernizing, streamlining and transform them from the present custodial mode to tertiary care centres of excellence, dynamic social orientation, providing leadership in research and development in the field of community mental health (In the XI Five Year Plan) the NMHP has given additional emphasis on Manpower Development Schemes - Centres of Excellence and Setting up Strengthening of PG training in departments of mental health specialities along with other components of five year plan.

The DMHP (District mental health programme) envisages a community based approach with integration of mental health with General health services through decentralization of treatment from Specialized Mental Hospital based care to primary health care services 22-23.

a.       Training of mental health team at identified nodal institutions. They act as a nodal centres to co-ordinate all the mental health services like DMHP, rehabilitation programs in a defined geographical area.

b.      Increase awareness & reduce stigma related to Mental Health problems.

c.       Provide service for early detection & treatment of mental illness in the community (OPD/ Indoor & follow up).

d.      Provide valuable data & experience at the level of community at the state & centre for future planning & improvement in service & research

e.       Government of India has approved the Manpower Development Components of NMHP for XIth Five Year Plan to improve the training infrastructure in mental health.

f.       Manpower development scheme has two sub schemes.

A. Development of centres of excellence in mental Health (scheme A)

B. Scheme for manpower development in mental health popularly known as (Scheme B) 23.

Centres of Excellence (Scheme A) Under Scheme-A, 11 Centres chosen for centre of Excellence status by upgrading existing mental health institutions/hospitals and a provision of grant of up to Rs.30 crore was approved 23.

Scheme for Manpower Development in Mental Health (Scheme B).

Under scheme B the target was to develop manpower in the field of mental health by establishing/strengthening: 30 departments of Psychiatry , 30 departments of Clinical Psychology , 30 departments of Psychiatric Social Work and 30 departments of Psychiatric Nursing in the country and 10 more mental hospitals with the aim of constructing modern buildings as well as strengthening staff planed. 20 more mental hospitals taken up for reconstruction and Non-viable mental hospitals planned to close down or merged within general hospitals22-23.

The mental health care bill, 2013

The Mental Health Care Bill, 2013 which seeks to provide for mental health care and services for persons with mental illness was introduced in the Rajya Sabha on 19 August 2013, this Bill repeals the Mental Health Act, 1987 with aims, that no person or organisation shall establish or run a mental health hospital unless it has been registered with the authority under the provisions of Act. Each mental hospital establishment shall fulfil the minimum standards of facilities, services and the minimum qualifications of the personnel engaged. The Authority may issue a show cause notice for the cancellation of the registration on ground of not maintaining the minimum standards as specified by the Authority. Every mental health hospital shall display establishment place (including on its website), the contact details including address and telephone numbers of the concerned Board 24.

For voluntary patient or an independent admission” refers to the admission of person with mental illness, to a mental hospital, who has the capacity to make valid will for treatment decisions or requires minimal support in making decisions.

For Admission of the Minor if the two medical officer or psychiatrists in charge of the mental health independently conclude about his/her mental illness and found necessity of admission in the best interests of the minor.

For admission and treatment of persons with mental illness, who not able to give valid will or needs high support, in mental health establishment, may be kept under treatment up to thirty days.

The physical restraint or seclusion may be used when; it is the only means available to prevent immediate harm to person concerned or to others.

The following treatments shall not be performed on any person with mental illness–

(a) electro-convulsive therapy without the use of muscle relaxants and anaesthesia

(b) electro-convulsive therapy for minors

(c)Sterilisation of men or women, when such sterilisation is intended as a treatment for mental illness

(d)Chained in any manner or form whatever

(e)Psychosurgery shall not be performed as a treatment for mental illness unless the informed consent of the person and approval from the concerned Board to perform the surgery has been obtained24.

Current Scenario

Supreme Court directed that if that State /Union Territories do not have full-fledged mental hospital, then the Chief Secretary of the State/ Union Territory must file an Affidavit within one month from the date of this order indicating for establishment of such State government mental hospital in that State/Union Territory. The Erwady tragedy in 2001 not only evoked a sense of horror, but also compel to human rights for close supervisor of mentally ill patients in all its aspects 25-26. After tragedy Parliament, the state legislatures, the Supreme Court and the high court’s took up the matter actively in reforms of mental health services. The result that many hospitals in the states of Bihar, Himachal Pradesh, Haryana and Tripura started running regular outpatient services catering to large catchment areas and most of the hospitals those were affiliated to Universities started post graduate training courses (MD and DPM), clinical psychology, social work and psychiatric nursing, Special clinics like Sex Clinic, Headache Clinic, OCD Clinic, epilepsy clinic, lithium clinics, Clinic for homeless persons, mental retardation clinic, child guidance clinic, tobacco cessation clinic, drug addiction treatment and rehabilitation clinic, marital and psycho sexual clinic, movement disorder clinic and neuro-behaviour clinic, separate clinic for group therapy, family counselling, occupational and industrial therapy.

Nowadays many hospitals also running their community psychiatry programs and satellite clinics in nearby districts. The Mental hospitals actively involved in organizing workshops for developing linkage and networking with NGOs working in the field of mental health. Other major contribution of mental hospitals has been in mental health research and developing models for schools, primary healthcare and general practitioners. The research projects undertaken with the help of international and national funding agencies like WHO, ICMR, IEA and CSIR has been started. In many hospitals established independent unit to promote research projects, substance abuse, stressful life events, psychopathology, rehabilitation, personality, gender differences, paid work activities, geriatric psychiatry, and stigma and insight management clinics 26.

Forensic mental health services

A separate out-patient service in forensic mental health offered at IMH Hyderabad, LGBRIMH Tezpur, IHBAS, RINPAS, MHC Kozhikode, MHC Thrissur, VGMH Amritsar and PC Rajasthan and the separate wards for the criminally mentally ill are available at LGBRI, Tezpur, IHBAS, IPHB Goa, PDH Jammu, MHC Thrissur, RMH Thane, VGMH Amritsar, PC Jaipur, MHC Thiruvanathapuram, MHC Kozhikode and IMH Chennai 27.

Application of modern equipment

The many centres like AIIMS, CIP and NIMHANS has substantial growth in clinical and research applications in the field of cognitive neurosciences and giving the facilities of quantitative EEG , event related potential (ERP), Polysomnography (40 channels), and a repetitive transcranial magnetic stimulation (rTMS). Electromyogram (EMG), nerve conduction velocity (NCV), visual evoked potentials (VEP), somatosensory evoked potentials (SSEP), brainstem auditory evoked response (BAER) and the galvanic skin response (GSR).

Training of judicial officers

RINPAS, Ahmedabad and KIMH Dharwad report conducting regular sensitisation programmes for the judicial magistrates and other officers about the nature of mental illness, needs of patients, treatments availability, laws pertaining to mental health and family reconciliation services for couples at court 28.

Disability Certification

Under the Persons with Disability (PWD) Act, the mentally ill person can receive benefits of disability therefore Nineteen (53%) MH of the 36 hospitals presently carry out disability assessment and certification 29.

Free Drugs

Most of the mental hospitals providing psychotropic drugs, free of cast.

Some patients those having problems of the long stay due attribution of wrong addresses furnished by family members during admission or their family/relatives not interested to take back cured patients or chronic ailments which required prolonged treatment or patients not responding to treatment despite best possible measures, to solve the problem of these patients, following steps were taken :

(a) Full particulars of immediate family members, close relatives and one or two prominent members of the community.

(b) To encourage patients to address letters.

(c) The hospital had sent many long stay patients to their homes or to State managed NGO homes.

(d) Such patients are rehabilitated within the hospital.

Natural death or the suicide in hospital premises documented with information to local Police and a detailed post mortem report to be prepared in the prescribed format and sent to NHRC.

New Steps and New Facilities in Mental Hospitals- Hope reborn

Addition of new specialities in mental hospital like ENT, Ophthalmology, radiology and dentistry were done, as in NIMHANS, PGI, RINPAS, Ranchi and Agra, the Physiotherapy Unit for physically and orthopedically handicapped also included as in RINPAS, Ranchi. The provision of soft and subdued music (as in GMA, Gwalior) from selected educational Hindi films in the dining hall which will have a salutary effect on inmates and sooth their ruffled nerves. Every fortnight, educative and entertaining movies are shown to the patients through an LCD projector and provision of picnics which provide patients good outing and relaxation and to rejuvenate their dampened spirits of inmates (RINPAS, CIP and IHBAS).

The Vocational training for patients as well as economically poor relatives/family members of patients were started at many centres. The agricultural work has been introduced for occupational engagements of the patients and sheltered workshop for both male and female patients separately were arranged.

The products made in OT are marketed and displayed in fairs/ exhibitions. A system of remuneration to the patients has been introduced in the hospitals which are credited in the personal account of the patients as an incentive for their rehabilitation/work activities, In GMA, Gwalior cooking skills in culinary varieties started. The introduction of yoga, pranayam and meditation (as in GMA, RINPAS) which is having a salutary effect on the body and mind of the inmates, were initiated in IMHH Agra, GMA Gwalior and RINPAS Ranchi and provides BPL patients for free or concessional travel by train, this recommendation are sent to railway authorities with full details of the patient/family members/relatives for necessary action. The providing the night stay for those who reach hospital after OPD hours and Dharamsala for relatives and family members of the patient (IHBAS, Shahadra, RINPAS, Ranchi, GMHC Thrissur). The patient staff group meetings on monthly basis to resolve issues related to day to day problems through coordinated efforts; to explain treatment related issues to the patients and their family members; and to discuss the opportunities in the making after discharge of the patient and follow up.

The Institute of Psychiatry at Jaipur has developed excellent IEC materials in Hindi and Marathi. A School mental health programme started which include designing curriculum, course content and textual materials for sensitization of parents, teachers and students separately through a workshop, teachers training, and motivation of parents and students. The promotion of cultural and recreational activities (IMHH Agra, RINPAS, CIP) and the recreation Unit has been augmented with many indoor and outdoor games and basic gym equipment. The promotion of both indoor and outdoor games; annual sports for the patients along with employees and staff members of the hospital and celebration of various other awareness programmes like World Mental Health Week through role plays, nukkad nataks, street theatres, skits, simulation exercises etc.

In literacy Programme for patients a separate well lighted and ventilated library with well-furnished reading rooms for the patients (RINPAS, CIP and other hospitals) started mmainly in attached day care centres and halfway homes and the concept of a Family Ward has been introduced in mental hospital, Kerala and addition of new tools and equipment to the existing pathological and psychological laboratories to take up new tests. The Computerized systems have been installed for a modified ECT and Psycho diagnostic Unit started or renovated 30.

The Need for a Balanced Approach

De-institutionalisation has several disadvantages:

a) It poses a great strain on the relatives of patients who have to look after them, especially if there has been no previous special training

(b) De-institutionalisation often results in trans-institutionalisation; the patient gets transferred from one institution to another which is equally unsatisfactory

(c)If there are no adequate community-based supportive services, there is every chance of the patients slipping through the gaps in the mental health service network.

(d)35–50% of those discharged from mental hospitals are re-admitted within one year of discharge and 65–75% within five years;

(e) The four clearly identifiable groups who together constitute 6–10% of the population cannot be treated in the community-based mental health centres for want of specialised treatment facilities. These groups are: (i) mentally retarded patients with concomitant psychiatric illness and assaultive behaviour; (ii) patients with a serious loss of impulse control due to brain damage from head injury and degenerative diseases; (iii) schizophrenics who are unremittingly assaultive, suicidal and uncooperative despite the use of available treatment modalities over a period of years; and (iv) chronic schizophrenics who exhibit socially unacceptable behaviour. While hospital psychiatry units and community based mental health initiative are effective in identification and treatment of most minor & less severe forms of illnesses, there still exist a large number of patients who require long term inpatient care (sometimes in restrained settings) in mental hospitals. In India, we are not in a position to close down our mental hospitals, on accounts of alternative community-based services as these services are not adequately developed, so there are balanced approach is the need of making the future management plan31.

Future

Sreenivasa Murthy (2001) has estimated that in India inpatient care is available only to about 10% of the very ill mental patients but remaining 90% needs network care through community or institutional OPD settings. The future probabilities in improving the structural and functional aspects of mental hospitals in India needs, the greater administrative autonomy, budgetary provisions, reducing bureaucratic and procedural delays. The public private partnership needs to be improved and enhanced, they must share the information on their clinical work so that the state/country statistics reflect the total picture not only public sector alone.

Mental hospitals need to take a more expanded role in the community - not only as treatment centres, but also as facilitators of social awareness and training of personnel to meet community mental health needs. The last two decades have seen an explosion in the knowledge base neurosciences, epidemiology, management and growth in interdisciplinary linkages. These progresses support integrated socially and culturally appropriate approaches to mental health interventions 32.

Further it also needs that mental hospitals should not be lag behind new evolving strategies to offer diagnostic and therapeutic facilities of all corners of India and utilization of advances technology. It also need establish training facilities and impart knowledge in the field of mental health and Neurosciences to all the developing countries by institutional and distance Learning. The nodal centre in the country also needs research development centre to develop strategies for disaster management, psychological rehabilitation, and integration of physical and metaphysical aspects of Neuroscience Research.

Conclusion

The amalgamation of mental health and primary health care has led to a major shift from the concept of custodial care to community and hospital Indoor/OPD care. Although a huge gap between the rhetoric of this new policy and its implementation still awaited. The mental Hospitals are powerful institution for proper care of those who having severe forms of illness and poor familial/social supports. These hospitals also having tremendous potential to meet expectations in fields of specialist care at tertiary level with links to peripheral areas. Though there are certain deficits in functioning of these hospitals those need to rectify as it fit into newer role. In India, the traditional approach for the care of mentally ill patients during the last 200 years has been modelled after contemporary Britain and being custodial in nature, nowadays, institutionalization an deinstitutionalization both seem to be alternating with each other in attempt to provide 'proper' care for the mentally ill patients.

Reference

1.      Varma LP. History of psychiatry in India and Pakistan. Indian J Neurol Psychiatry 1953; 4(3/4):138-64.

2.      Sharma S, Varma LP. History of mental hospitals in Indian subcontinent. Indian J Psychiatry1984; 26:295–300.

3.      Sharma S. Mental hospitals in IndiaNew Delhi: Directorate General of Health Services, Government of India 1990.

4.      Bhore Committee. Report of the Health Survey and Development Committee, Vol. III. Simla:Government of India Press; 1946. Extracts pertaining to mental health reproduced as Appendix ‘A’ In: Agarwal SP, Goel DS, Salhan RN, Ichhpujani RL, Shrivastava S (eds). Mental health: An Indian perspective (1946–2003).

5.      Wig NN, Awasthi AK. Origin and Growth of general hospital psychiatry. In: Mental Health: An Indian Perspective 1946-2003.

6.      Parkar SR, Dawani VS, Apte JS. History of psychiatry in India. J Postgrad Med 2001; 47:73-76. 

7.      Kapur R L. Community Involvement in mental health care. Nat. Med J India 1994; 7(6):292-294.

8.      Haque N, Nishant G, Mohammad Z H, Sayeed A. Central Institute of Psychiatry: A tradition in excellence. Indian J Psychiatry 2008; 50(2): 144–148.

9.      Parkar SR, Dawani VS, Apte JS. History of psychiatry in India. J Postgrad Med 2001; 47:73-6.

10.  Sharma S, Nizamie HS, Goyal N. History of the Indian Journal of Psychiatry. Indian J Psychiatry 2007; 49:48–59.

11.  .Wig NN, Akhtar S. Twenty five years of psychiatric research in India. Indian J Psychiatry 1974; 16:48–64.

12.  Ganju V. The Mental Health System in India History, current system, and prospects. Int J Law Psychiatry 2000; 23:393–402.

13.  Bhaskaran K. The unwanted patient. Indian J Psychiatry 1971; 13:1–12.

14.  Bhaskaran K. Planning for mental health services for India for the next two decades. J Indian Med Assoc. 1973; 60:385–9.

15.  Yadav J S, Kaur S, Tripathi M N, Kumar p. Problems of disposal of long staying criminal psychiatric patients from mental hospital Varansi. Delhi Journal of Psychiatry 2010; 13(1):53-57.

16.  Thornicroft, G., Tansella, M., Becker, T., Knapp M. et al. Schizophrenia Research 2004; 69: 125 -231.

17.  WHO-AIMS Report on Mental Health System in Uttarkhand, India, WHO and Ministry of Health, Dehradun, Uttarkhand, India, 2006.

18.  Ministry of Health and Family Welfare, Government of India (2007) Bulletin on rural health statistics. http://mohfw.nic.in/Bulletin%20on%20RHS%20%20March,%202007%20%20PDF%20Version/Title%20Page.htm.

19.  Kuruvilla K. Challenges in general hospital psychiatry. Indian Journal of Psychiatry 1993; 35(4): 191-19.

20.  Venketasubramanian G.Human right initiation in mental health care in India: Historical perspectives. NHRC 2008; 1:37-48.

21.   National Mental Health Programme for IndiaNew Delhi: Ministry of Health and Family Welfare, Government of India; 1982. Directorate General of Health Services (DGHS)

22.  Salhan RN, Sinha SK, Kaur J. Asia Australia Community Mental Health Development Project, Asia Australia Mental Health. Melbourne: 2008. Country Report-India.

23.  Planning Commission. Towards a faster and more inclusive growth - an approach to the 11 Five Year Plan. New Delhi: Government of India, Yojana Bhavan; November 2006 p. 72.

24.  Mental health care bill2013. Bill No. L IV chapter V Rajya Sabha.

25.   Asha K K. "Deliverance in Erwadi". Frontline Retrieved 2001. 24 August 2011.

26.  Indian mental homes face closure". BBC News. August 8, 2001. Retrieved 24 August 2011

27.  Asokan TV. Forensic psychiatry in India: The road ahead. Indian J Psychiatry 2014; 56 (2):121-127.

28.  National Legal services authority. Available at:http://causelists.nic.in/nalsa.N.

29.  Nagaraja D, Murthy P. Mental Health Care and Human Rights. National Human Rights Commission, New Delhi and National Institute of Mental Health and Neuro Sciences, Bangalore. First Edition: 2008.

30.  Nizami S P. Contribution of Rachi to psychiatry of India; paper presented in 38th ANCIPS Vishakhapattanum 1985.

31.  Topor, A. (2001). Managing the contradictions: recovery from severe mental disorders. Stockholm Studies of Social Work. Stockholm University. United Nations. (1991). Principles for the protection of persons with mental illness and the improvement of mental health care, General Assembly resolution 46/119.

32.  Sreenivasa Murthy, R.(2001) Lessons from the Erwadi Tragedy for Mental Health Care in India. Indian Journal of Psychiatry, 43,362-366.