LOK SABHA SECRETARIAT PARLIAMENT LIBRARY AND REFERENCE, RESEARCH, DOCUMENTATION AND INFORMATION SERVICE (LARRDIS) MEMBERS REFERENCE SERVICE

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1 LOK SABHA SECRETARIAT PARLIAMENT LIBRARY AND REFERENCE, RESEARCH, DOCUMENTATION AND INFORMATION SERVICE (LARRDIS) MEMBERS REFERENCE SERVICE REFERENCE NOTE. No. 33/RN/Ref./December/2013 For the use of Members of Parliament Not for Publication MENTAL HEALTH CARE The reference material is for personal use of the Members in the discharge of their Parliamentary duties, and is not for publication. This Service is not to be quoted as the source of the information as it is based on the sources indicated at the end/in the text. This Service does not accept any responsibility for the accuracy or veracity of the information or views contained in the note/collection.

2 MENTAL HEALTH CARE INTRODUCTION Mental health is an integral and essential component of health. The World Health Organization (WHO) defines mental health as a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community 1. Mental and behavior problems are increasing part of the health problems the world over. The burden of illness resulting from psychiatric and behavioural disorders is enormous. Psychiatric symptoms are common in general population in both sides of the globe. These symptoms viz. worry, tiredness, and sleepless nights affect more than half of the adults at some time, while as many as one person in seven experiences some form of diagnosable neurotic disorder. INTERNATIONAL SCENARIO Prevalence of mental disorders as per World Health Report (2001) is around 10% and it is predicted that burden of disorders is likely to increase by 15% by At the international level, mental health is receiving increasing importance as reflected by the WHO focus on mental health as the theme for the World Health Day (4 th October 2001), World Health Assembly (15 th May 2001) and the World Health Report 2001 with Mental Health as the focus 22. In 2008, the WHO Mental Health Gap Action Programme (mhgap) was launched which aims at scaling up services for mental, neurological and substance use disorders for countries especially with low and middle income. 1 WHO, Mental Health: Strengthening our Response, February Indian Council of Medical Research, Mental Health Research in India 2005.

3 -2- Taken together, mental, neurological and substance use disorders accounting for 13% of the total global burden of disease in the year Depression alone accounts for 4.3% of the global burden of disease and is among the largest single causes of disability worldwide (11% of all years lived with disability globally), particularly for women. The gap between the need for treatment and its provision is large all over the world. WHO s Mental Health Atlas 2011 provides data that demonstrate the scarcity of resources within countries to meet mental health needs 3. The Director General, World Health Organization launched the Mental Health Action Plan on 7 October The action plan recognizes the essential role of mental health in achieving health for all people. It aims to achieve equity through universal health coverage and stresses the importance of prevention. The four major objectives of the Action Plan are to: Strengthen effective leadership and governance for mental health. Provide comprehensive, integrated and responsive mental health and social care services in community-based settings. Implement strategies for promotion and prevention in mental health. Strengthen information systems, evidence and research for mental health. Every year on 10 October, the World Health Organization joins in celebrating the World Mental Health Day. The day is celebrated at the initiative of the World Federation of Mental Health and WHO supports this initiative through raising awareness on mental health issues. The theme of the day in 2013 was Mental Health and Older Adults. On 10 December 2013 the Human Rights Day, WHO launched the MiNDbank. It is a new online platform which brings together key international resources and national policies, strategies, laws and service standards for mental health, substance abuse, general health, disability, human rights and development. MiNDbank will facilitate 3 Sixty-sixth World Health Assembly, Comprehensive Mental Health Action Plan

4 -3- debate, dialogue, advocacy and research in order to promote national reform in line with international human rights and best practice standards. INDIAN SCENARIO According to various community based surveys, prevalence of mental disorders in India is 6-7% for common mental disorders and 1-2% for severe mental disorders. In India the rate of psychiatric disorders in children aged between 4 to 16 years is about 12% and nearly one-third of the population is less than 14 years of age. With such a magnitude of mental disorders it becomes necessary to promote mental health services for the well being of general population, in addition to provide treatment for mental illnesses. Treatment gap for severe mental disorders is approximately 50% and in case of Common Mental Disorders it is over 90% 4. As per the National Survey of Mental Health Resources carried out by the Directorate General of Health Services, Ministry of Health and Family Welfare during May and July, 2002, the details of number of patients with mental disorders and proportionate availability of psychiatrist, psychiatric nurses and social workers, clinical psychologist and mental hospitals and beds in the Country, State/UT wise is given in Annexure-I. As per the same survey, the ideal required number of mental health professionals has been calculated and the details of present requirement and availability of mental health professionals in the country are given in Annexure-II 5. In India the Government has been implementing several programmes to address mental disorder as explained below: NATIONAL MENTAL HEALTH PROGRAMME The National Mental Health Programme (NMHP) was started in 1982 with the objectives to ensure availability and accessibility of minimum mental health care for all, 4 Ministry of Health and Family Welfare, Annual Report , p Rajya Sabha Unstarred Question No. 4439, dated 7 May 2013

5 -4- to encourage mental health knowledge and skills and to promote community participation in mental health service development and to stimulate self-help in the community. The strategies of National Mental Health Programme were - integration of mental health with primary health care through the NMHP; provision of tertiary care institutions for treatment of mental disorders; to eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority, and State Mental Health Authority. Gradually the approach of mental health care services has shifted from hospital based care (institutional) to community based mental healthcare, as majority of mental disorders do not require hospitalization and can be managed at community level. The National Mental Health Programme Division conducts nationwide mass media campaign through audio-video and print media 6. DISTRICT MENTAL HEALTH PROGRAMME The District Mental Health Programme (DMHP) was initiated in 1996 during the Ninth Five Year Plan based on Bellary Model developed by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangaluru. During the plan period, 27 districts were covered under DMHP. At present DMHP is covering 123 districts in 30 States and Union Territories. In addition to early identification and treatment of mentally ill, District Mental Health Programme has now incorporated promotive and preventive activities for positive mental health which include School Mental Health Services, College Counselling Services, Work place Stress Management and Suicide Prevention Services. The issues of awareness regarding mental illness and availability of treatment are addressed through Information, Education and Communication (IEC) activities at District level by the DMHP 7. 6 Op.cit,. Annual Report , pp Ibid

6 -5- The components of District Mental Health Programme include- training programmes of all workers in the mental health team at the identified Nodal Institute in the State; public education in the mental health to increase awareness and reduce stigma; for early detection and treatment, the OPD and indoor services are provided ; providing valuable data and experience at the level of community to the state and Centre for future planning, improvement in service and research. Agencies like World Bank and WHO have been contacted to support various components of the programme. Funds are provided by the Government of India to the State Governments and the nodal institutes to meet the expenditure on staff, equipments, vehicles, medicine, stationary, contingencies, training, etc. for initial 5 years and thereafter they should manage themselves. As per the Mental Health Act, 1987, there is provision for constitution of Central Mental Health Authority (CMHA) at central level and State Mental Health Authority (SMHA) at State Level. These statutory bodies are entrusted with the task of development, regulation and coordination of mental health services in a State/Union Territory, etc. The National Human Rights Commission also monitors the conditions in the mental hospitals along with the Government of India and the states are acting to ensure quality in delivery of mental care. MANPOWER DEVELOPMENT SCHEMES Establishment of Centre of Excellence in Mental Health Centres of Excellence in the field of mental health are being established by upgrading and strengthening identified existing mental health hospitals/institutes for addressing acute manpower gap and provision of state of the art mental health care facilities in the long run. Eleven such Centres of Excellence were envisaged. Total budgetary support of up to Rs 338 crore (Rs 30 crore per center) was provided for undertaking capital work, equipment, library, faculty induction and retention for the plan

7 -6- period. 11 Mental Health Institutes have been funded for developing as Centres of Excellence in Mental Health. Establishment/up-gradation of Post Graduate Training Departments To provide an impetus to development of Manpower in Mental Health Training Centers, Government Medical Colleges/Government General Hospitals/ State run Mental Health Institutes were also to be supported for starting Post Graduate (PG) courses or increasing the intake capacity for PG training in Mental Health. Support was to be provided for setting up/strengthening 30 units of Psychiatry, 30 Departments of Clinical Psychology, 30 Departments of Psychiatric Social Work (PSW) and 30 Departments of Psychiatric Nursing. Total budget allocated for this scheme was Rs 70 crores during Eleventh Plan period with a limit of Rs 51 lacs to Rs 1 crore per PG Department. As of now, 23 PG Departments in 11 Institutes have been taken up during the Eleventh Plan period. MAINSTREAMING NMHP INTO NATIONAL RURAL HEALTH MISSION Efforts are being made to mainstream the components of NMHP under the overall umbrella of National Rural Health Mission so that the States are able to plan requirements concerning mental health services as part of their respective Programme Implementation Plans (PIPs) 8. FIVE YEAR PLANS AND MENTAL HEALTH CARE Tenth Five Year Plan The thrust areas of Mental Health Programme in the Tenth Five Year Plan were: District Mental Health Programme in an enlarged and more effective form covering the entire country. Streamlining/ modernisation of mental hospitals in order to modify their custodial role. 8 Ibid

8 -7- Upgrading department of psychiatry in Government medical colleges and enhancing the psychiatry content of the medical curriculum at the undergraduate as well as postgraduate level. Strengthening the Central and State Mental Health Authorities with a permanent secretariat. Appointment of medical officers at state headquarters in order to make their monitoring role more effective; Research and training in the field of community mental health, substance abuse and child/ adolescent psychiatric clinics 9. Eleventh Five Year Plan Under the Eleventh Five Year Plan, the National Mental Health Programme has been restructured to include the following components: Manpower Development Scheme: i) Establishment of Centres of Excellence (Scheme - A); ii) Scheme for manpower development in Mental Health (Scheme - B); and District Mental Health Programme with added components of Life Skills Education and Counseling in Schools and Colleges, Suicide Prevention Services etc. Up-gradation of Psychiatric Wings of Government Medical Colleges. Modernization of Government Mental Hospitals 10. (The List of Government Mental Hospitals and Grants-in-aid provided for their modernisation are given at Annexure-III and IV) Rs crore was approved as Eleventh Plan outlay for the National Mental Health Programme. Year wise financial allocation for the NMHP and expenditure incurred is as given in the table below Financial Year Allocation ( Rs. crore) Expenditure(Rs. Crore) Source: MHFW, Annual Report, Services/National Health Programme 10 Lok Sabha Unstarred Question No dated 8 March 2013.

9 -8- Twelfth Five Year Plan The Government has accorded high priority particularly to child and adolescent mental health care during the Twelfth Five Year Plan. The Government is integrating different components of National Mental Health Programme with the components of National Rural Health Mission namely School Health, Reproductive Child Health and Adolescent Friendly Clinics during the Twelfth Five Year Plan to reach out to the community in a more effective manner 11. OTHER INITIATIVES The Ministry of Social Justice and Empowerment, under its Central Sector Deendayal Disabled Rehabilitation Scheme (DDRS) has provided financial assistance to Non-Governmental Organizations (NGOs), for providing various services to persons with disabilities including special schools, half way homes etc. for mentally retarded persons. The National Trust for the Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities implements various other schemes for the rehabilitation of such persons. The State-wise details of funds released under DDRS by the Ministry of Social Justice and Empowerment for the rehabilitation of the mentally retarded persons during the last three years is given at Annexure-V. 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 and to protect, promote and fulfil the rights of such persons during delivery of mental health care and services and for matters connected therewith or incidental thereto, was introduced in the Rajya Sabha on 19 August The Bill was referred to the Departmentally Related Standing Committee on Health and Family Welfare. The Bill repeals the Mental Health Act, The key features of the Bill are: The Central and State Mental Health Authorities will continue as regulatory agencies. 11 Ibid

10 -9- All persons have the right to access mental health care and treatment from mental health services run or funded by the Government. Such services should be affordable, of good quality and available without discrimination. Any person with or without mental illness can make an Advance Directive stating how he/she wishes to be treated for a future mental illness and also how he does not wish to be treated. A person with mental illness had the right to live in, be part of and not segregated from society.the Government has an obligation to provide for half way homes, community caring centres etc. Provision for Mental Health Review Commission (MHRC). The MHRC is a quasijudicial body to provide an independent oversight to the functioning of mental health facilities and protect the rights of persons with mental illness in these facilities. It thus meets the need for an independent review mechanism as required under the Convention on the Rights of Persons with Disabilities (CRPD) 12. CONCLUSION Problems relating to mental health would be managed with sensitivity at the community level, through better training of community workers and primary care teams, and through education of care givers. However, to address the huge burden of mental disorders and shortage of qualified professionals in the field of mental health, the Government is implementing the National Mental Health Programme since Further there are 3 centrally run mental health institutes, 43 Government run mental hospitals and institutions and 381 medical colleges both Government and Private across the country equipped to treat the patients suffering from mental illness. The Mental Health Care Bill 2013 would bring about a paradigm shift in the area of mental health. The National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore which has become an institution of national importance would mentor and support child and adolescent mental health services Departmentally Related Parliamentary Standing Committee on Health & Family Welfare, Seventy- Fourth Report on The Mental Health Care Bill, 2013, pp Press Information Bureau, Ministry of Health and Family Welfare, 25 September, 2013.

11 Density/ Sq Km (3) Available Ideal req. Deficit Available Ideal req. Deficit Available Ideal req. Deficit Available Ideal req. Deficit -10- ANNEXURE - 1 Number of Patients with mental disorder and proportionate availability of Psychiatrist, Psychiatric Nurses and Social Workers etc. S.No State (1) Population (2) Estimated case load (4) Major mental disorders Minor mental disorders Existing facilities Hospital beds (5) Govt. sector Pvt. secto r Manpower resources (6) Psychiatrists Clinical psychologists Psy. social workers Psychiatric nurses i ii iii iv v vi vii viii ix x xi xii xiii xiv xv xvi xvii xviii xix xx 1 A & N Andhra Pradesh Nil Arunachal Pradesh 4 Assam Bihar NA 1656 ** NA ** ** 6 Chandigarh Chhattisgarh Daman & Diu, Dadra & Nagar Haveli , , Delhi ** 10 Goa Gujarat Haryana Himachal Pradesh Jharkhand NA 135 ** 15 J & K Karnataka Kerala Lakshadweep MP NA Maharashtra

12 Manipur Meghalaya Mizoram Nagaland Odisha Pondicherry (+13) 27 Punjab Rajasthan Sikkim Tamil Nadu NA Tripura Uttaranchal Uttar Pradesh West Bengal * Grand Total ** 4036 ** (6527) Note *figures unreliable: Nurses with some psychiatric training but without a Diploma in Psychiatric Nursing (DPN) appear to have been included. ** Figures unreliable Column 2.The population figures have been taken from the Census of India-2001 as published in Provisional Population Totals (Registrar General Census Commissioner, India). Column 3.Population density per square kilometre together with geographical terrain is a useful input in planning deployment of mental health resources. Column 4.Case-load in respect to major mental disorders has been calculated at the rate of 1% of the population and that of minor mental disorders at the rate of 5% of population. SOURCE: National Survey of Mental Health Resources carried out by the Directorate General of Health Services, Ministry of Health & Family Welfare during May and July, 2002 Source: Rajya Sabha Unstarred Question No dated 7 May 2013

13 -12- ANNEXURE-II Ideal required number of mental health professionals. i. Psychiatrists : 1.0 per 1,00,000 population ii. Clinical Psychologist : 1.5 per 1,00,000 population iii. Psychiatric Social Workers : 2.0 per 1,00,000 population iv. Psychiatric Nurses : 1.0 per 10 psychiatric beds. The details of requirement and availability of mental health professionals in the country is as under: Manpower Requirement Availability Psychiatrist Clinical Psychologist Psychiatric Social Workers Psychiatric Nurses Total Source: Ibid.

14 -13- ANNEXURE - III List of Govt. Mental Hospitals/Institutes S. No. State Name of the Mental Hospital 1. Institute of Mental Health, Govt. Hospital for Mental Care, S.R. Nagar, Andhra Hyderabad Pradesh 2. Government Hospital for Mental Care, Chinnawaltair, Vishakapatnam. 3. Assam Lokopriya Gopinath Bordoloi Institute of Mental Health, P.O. Tezpur, Dist. Sonitpur, Assam * 4. Bihar Institute of Mental Health, Koelwar, Bhojpur, BIHAR 5. Central Institute of Psychiatry, Kanke P.O. Ranchi. * 6. Jharkhand Ranchi Institute of Neuropsychiaty and Allied Science (RINPAS), Kanke, Ranchi. 7. Delhi Institute of Human Behavior & Allied Sciences, G.T. Road, Jhilmil, Delhi 8. Goa Institute of Psychiatry & Human Behavior, Altinho, Panaji. 9. Hospital for Mental Health, Bhuj. 10. Hospital for Mental Health, Vikasgruh Road, Jamnagar. 11. Gujarat Hospital for Mental Health, Behind Kapadia High School, Outside Delhi Gate, Shahibaug Road, Ahamedabad 12. Hospital for Mental Health, Karelibag, Baroda. 13. Himachal Pradesh Himachal Hospital of Mental Health & Rehabilitation, Boileauganj, Shimla 14. Govt. Hospital for Psychiatric Diseases, Rainawari, Khatidarwaze, Jammu & SRINAGAR 15. Kashmir The Medical Superintendent, Psychiatric Diseases hospital GMC, Jammu, Ambphalla B.C. Road, Jammu. 16. Karnataka Karnataka Institute of Mental Health, Belgaum Road, Dharwad, Karnataka. 17. National Institute of Mental Health and Neuro Sciences, Bangalore * 18. Mental Health Centre, Oolampara, Thiruvanathapuram. 19. Kerala Govt. Mental Health Centre, Kuthiravattom, Kozhikode. 20. Govt. Mental Health Centre, Poothole, Thrissur.

15 -14- S. No. State Name of the Mental Hospital 21. Madhya Gwalior Manasik Arogyasala, Central jail Road, Gwalior 22. Pradesh Mental Hospital, Banganga Sawer Road, Indore. 23. Regional Mental Hospital, Nagpur. 24. Regional Mental Hospital, Yeravda, Pune. Maharashtra 25. Regional Mental Hospital, Wagle Estate, Thane (W) 26. Regional Mental Hospital, Ratnagiri 27. Meghalaya Institute of Mental Health & Neurosciences, Shillong, Meghalaya 28. Modern Psychiatric Hospital, Narsingarh, Agartala, West Tripura. 29. Nagaland Mental Hospital, Kohima, Nagaland. 30. Orissa Mental Health Institute, S.C.B. Medical College, Cuttack. 31. Punjab Dr. Vidyasagar Punjab Mental Hospital. Circular Road, Amritsar. 32. Mental Hospital (Psychiatric Centre), Janta Colony, Jaipur. Rajasthan 33. Mental Hospital, (Psychiatric Center), Shastri Nagar, Jodhpur. 34. Tamil Nadu Institute of Mental Health, Medavakkam Tank Road,Kilpauk, Chennai. 35. Institute of Mental Health & Hospital, Billochpura, Mathura Road, Agra 36. Uttar Pradesh Mental Hospital Bareilly, Civil Lines, Bareilly. 37. Mental Hospital, S2/1 Pandeypur, Varanasi. 38. Lumbini Park Mental Hospital, 115, G.S, Bose Road, Calcutta. 39. Institute for Mental Care, Purulia P.O., Purulia. 40. Mental Hospital Berhampore, Berhampore Mental Hospital, 41. West Bengal Berhampore, Murshidabad, The Mental Hospital (Calcutta & Mankundu), 133, Vivekananda Road, Calcutta, 42. Institute of Psychiatry, 7, D.L. Khan Road, Calcutta 43. Calcutta Pavlov Hospital, 18, Gobra Road, Calcutta Source: Lok Sabha Unstarred Question No dated 16 August 2013

16 -15- ANNEXURE - IV Grant-in-aid provided to Govt. Mental Hospitals under National Mental Health Programme for their Modernisation Sl. No. States Year Institute Amount (in Rs.) 1. Andhra Pradesh Institution of Mental Health, Hyderabad 2,71,00,000/- 2. Andhra Pradesh Government Hospital for Mental Care, Vishakhapatnam. 3,00,00,000/- 3. Assam Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur (Central Govt. 3,00,00,000/- Institute) 4. Gujarat Hospital for Mental Health, Ahmedabad 76,64,000/- 5. Gujarat Hospital for Mental Health, Vadodara 2,99,50,000/- 6. Gujarat Hospital for Mental Health, Jamnagar 82,28,000/- 7. Jammu & Kashmir Govt. Psychiatric Diseases Hospital, Srinagar. 2,50,00,000/- 8. Jharkhand Ranchi Institute of Neuro Psychiatry & allied sciences, Ranchi 2,45,00,000/- 9. Karnataka Karnataka Institute of Mental Health, Dharwad. 3,00,00,000/- 10. Kerala Mental Health Centre, Kozhikode 2,85,00,000/- 11. Kerala Mental Health Centre, Thrissur 1,10,00,000/- 12. Kerala Mental Health Centre, Trivandrum 2,50,00,000/- 13. Madhya Pradesh Gwalior Mansik Arogyasala, Gwalior 2,13,00,000/- 14. Madhya Pradesh Mental Hospital, Indore 2,99,75,000/- 15. Maharashtra Regional Mental Hospital, Yervada/ Pune 2,71,00,000/- 16. Maharashtra Regional Mental Hospital, Thane 2,49,50,000/- 17. Maharashtra Regional Mental Hospital, Nagpur 2,89,00,000/- 18. Maharashtra Regional Mental Hospital, Ratnagiri, 2,84,00,000/- 19. Meghalaya Meghalaya Institute of Mental Health & Neurological, Shillong 3,00,00,000/- 20. Nagaland Mental Hospital, Kohima 1,60,00,000/- 21. Orissa Mental Health Institute, Cuttack 1,51,00,000/- 22. Rajasthan Psychiatric Centre, Jaipur 2,60,50,000/- 23. Tamil Nadu Mental Health Institution, Kilpauk 2,69,00,000/- 24. Uttar Pradesh Mental Hospital Bareily 2,33,32,000/- 25. Uttar Pradesh Institute of Mental Health and Hospital, Agra. 3,00,00,000/- 26. Uttar Pradesh Mental Hospital, Varanasi 3,00,00,000/- 27. West Bengal Pavlov Mental Hospital, Kolkata 94,40,000/- 28. West Bengal Behrampore Mental Hospital, Murshidabad 2,94,80,000/- 29. West Bengal Institute of Mental Health Care, Purulia 1,00,00,000/- Source: Ibid

17 -16- Annexure-V Statement Indicating State-wise details of funds released under DDRS to the various NGOs for the rehabilitation of MR persons. S. No Amount Released (Rs in lakh) State Andhra Pradesh Assam Bihar Chhattisgarh Delhi Gujarat Haryana Himachal Pradesh Jammu & Kashmir Karnataka Kerala Madhya Pradesh Maharshtra Manipur Meghalya Mizoram Odisha Punjab Rajsthan Tamil Nadu Tripura Uttar Pradesh Utrakhand West Bengal Total Source: Lok Sabha Unstarred Question No.5156 dated 26 April 2013.