PERSPECTIVE OF MENTAL HEALTH CARE IN INDIA
Suboth1, Chadha R
K2, Yadav J S3,
Senior Resident1, Professor2,
of Psychiatry AIIMS New Delhi1, 2, 3,
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
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
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
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
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
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.
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.
Increase awareness & reduce stigma related to
Mental Health problems.
Provide service for early detection & treatment of
mental illness in the community (OPD/ Indoor & follow up).
Provide valuable data & experience at the level of
community at the state & centre for future planning & improvement in
service & research
Government of India has approved the Manpower
Development Components of NMHP for XIth Five Year
Plan to improve the training infrastructure in mental health.
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
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
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
(a) electro-convulsive therapy without the use of muscle relaxants and
(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.
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
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
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
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
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
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).
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.
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
(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
(d)35–50% of those discharged from mental
hospitals are re-admitted within one year of discharge and 65–75% within
(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.
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
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.
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
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.
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