1. MENTAL HEALTH

2. Framework Definition Why to focus on Mental Health?
Burden of Mental Disorders
Indicators of Mental Health
Characteristics of Mental Health
Determinants of Mental Health
Mental Health – Programmes & Strategies

3. Definition
Mental health is not mere absence of mental illness, but is 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 fruitfully and is able to make a contribution to his or her community. (WHO)
Mental illness is the term that refers collectively to all diagnosable mental disorders.

4. Definition ....
Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behaviour (or sometimes combination thereof) associated with distress and/or impaired functioning.” ( CDC)
- It includes mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation
Knowledge and beliefs about the recognition, management and prevention of mental disorders is known as Mental Health Literacy (MHL).

5. Historical background
In Ayurveda
Psychiatry is called a s- Bhoot Vidhya
1222 A. D
Najabuddin Unhammad , an indian physician, described seven types of mental disorders
During Buddha and Mahavira
the focus on mind was done –as mental disorders were said to be mind disorders due to immortal thought processes
Emperor Ashoka
built mental hospitals for human treatment
1745
England psychiatry developed as a scientific and medical discipline

6. Mental Health: The Pre-independence Scenario
17th century
Mental hospitals were entirely a British concept.
Modern medicine and hospitals were first brought to India by the Portuguese in Goa, but impact was limited.
Mental asylums were built to protect the community from the insane and not to treat them as normal individuals
(1784–1857
Development of lunatic asylums in Calcutta (Kolkata), Madras (Chennai) and Bombay (Mumbai)
1858
First Lunacy Act, known as Act No. 36, was enacted by the British Parliament
Set up guidelines for the establishment of mental asylums, and procedures for admitting mental pt.
1905
The control of mental hospitals was transferred from the Inspector General of Prisons to the Directorate of Health Services and at the local level to the Civil Surgeons
1912
Indian Lunacy Act was enacted
1933
The first psychiatric OPD, was set up at the R.G. Kar Medical College, Calcutta by Dr G.S. Bose.

7. Mental Health: The Post-independence Scenario
1954
All India Institute of Mental Health in 1954 at Bangalore (later known as NIMHANS) was formed.
As very less research data was available on mental health ,ICMR has initiated projects on mental health research .
1982
National mental health programme was launched
1987
THE MENTAL HEALTH ACT came into force
2001
WHO chose the World Health Day Theme as ‘ Mental Health: Stop Exclusion- Dare To Care”
2013
National mental health care bill was launched
65th World Health Assembly-approved and adopted resolution on global burden of mental health
2014
National Mental Health Policy Of India was formed

8. Classification of Mental Disorders

9. The international Classification of mental disease (ICD-10) Version:2016
Mental illness
Organic including symptomatic, mental disorders-
. Dementia in Alzheimer’s disease, delirium
Mental and behavioral disorders due to psychoactive substance use
Harmful use of alcohol, opioid dependence syndrome.
Schizophrenia, schizotypal and delusional disorder
Paranoid schizophrenia, delusional disorders, acute and transient psychotic disorders
Neurotic, stress-related and somatoform disorders
generalized anxiety disorders, obsessive compulsive disorders
Behavioural syndromes associated with psychological disturbances and physical factors
eating disorder, non organic sleeping disorder

10. The international Classification of mental disease (ICD-10)
Mental illness
Disorders of psychological development-
specific reading disorders, childhood autism
Behavioural and emotional disorders with onset usually in childhood and adolescence
hyperkinetic disorders, conduct disorders, tic disorders
Unspecified disorde
Dementia in Alzheimer disease and dementia in other diseases
Disorders of adult personality and behaviour
paranoid personality disorder, trans- sexualism
Mood (affective) disorder
bipolar affective disorder, depressive disorder.
Mental retardation

11. Why to focus on Mental Health ?
Mental health problems -
are contributors to the burden of disease and the loss of quality of life, and have huge economic and social costs
Are always neglected and leads to social stigma, widespread misconceptions
(in population at special risk )– if left untreated , has impact not only on individuals but also families and society
includes neurological and substance-use disorders – so requires a coordinated response from health and social sectors
Prevent affected persons from accessing heath services
especially (depressive disorders) are strongly related to many chronic diseases
their occurrence, successful treatment, and course.
lead to risk behaviours for chronic disease;
Mental health studies Indicate -
the need and provision of effective programmes and health-care intervention.
Grossly inadequate budgets for mental healthcare
Acute shortage of trained mental health personnel

12. Burden of Mental Disorders
WORLD
Global Prevalence is 10% i.e. 450 million people affected
> 25% of all people at some time during their lives are affected i.e. One person in every four affected
DALYs loss – 11.5%
Major depression –
leading cause of disability- share of 13% of GBD and15% by 2020
Ranks third in the ten leading of GBD
8 Lack suicidal deaths every year-
- 90% associated with mental disorder
- 75% are in low and middle income countries
second  leading cause of death in year
INDIA
6-7 % i.e. 13 crores suffers with Mental disorders
out of which - 1% to 2% (10 to 20 million) have major & 5% (50 million) have minor mental disorders
1.2 lakhs – suicide/year – main cause is mental disorders
The prevalence of child mental health problem is 0.7 to 17.2%
The prevalence of geriatric mental health problem is 3.1% MH
7.3% have mental disorders

13. Burden of Mental Disorders
Depression
eighth place in low-income countries, but at first place in middle- and high-income countries.
Lifetime prevalence among women (11.7%) than men (5.6%).
350 million people suffer from depression
India- 34%
Anxiety
include panic disorder, generalized anxiety disorder, post-traumatic stress disorder, phobias, and separation anxiety disorder,
lifetime prevalence is - 15%
India – 30%
Bipolar Disorders
lifetime prevalence is - 4% / common in women , with a ratio of 3:2
INDIA- Ganguli (2000) - the rural and urban rates to be 3.4% and 3.7%,
schizophrenia
Worldwide prevalence - 0.5% and 1%
1/3rd will attempt suicide and 1:10 will take own life
India prevalence is 1.1 to 4.3 %
Alzheimer’s Disease
the fifth leading cause of death among persons > 65 years of age - 24 million are affected
Alcohol and substance abuse
Worldwide - 10 thousand million – regular alcohol users
13.5 million use opiods
India- 75 million –alcohol users/ 3 million opiod users-

14. Indicators of mental health
Emotional well-being
such as perceived life satisfaction, happiness, cheerfulness, peacefulness.
Psychological well-being
such as self-acceptance, personal growth including openness to new experiences, optimism, hopefulness, purpose in life, control of one’s environment, spirituality, self-direction, and positive relationships.
Social well-being
social acceptance, beliefs in the potential of people and society as a whole, personal self-worth and usefulness to society, sense of community.

15. Determinants of Mental Health
Heredity- familiy history of mental ilness
Risk of mental disorders to children
Organic conditions - neoplasm's, endocrine diseases, metabolic diseases ,Chronic diseases – TB, Leprosy, epilepsy
Psycosocial –worries, anxiety, emotional stress, tension, frustration, unhappy marriages, broken homes, poverty, economic insecurity, neglect, history of abuse ,Job ,family, acess to health care,domestic violence ,negative thinking, poor self esteem
Biological Factors-
Age ,sex, genetic factors and imbalances in chemicals in the brain.
Other –toxic substances,
Nutritional factors ,infection in pre/peri/post natal period,
trauma- accident, radiation

16. Characteristics of Mentally Healthy person
There are 3 main Characteristics:-
The mentally healthy person-
feels comfortable about himself- feels secure , accepts shortcomings, has self respect , doesn't under/over estimate himself
feels right towards others- interested in others, loves them, makes friendship, feels part of a group, he likes & trusts others ,takes responsibility of others
Is able to meet the demands of life- tackles problems, takes own decision, sets goal for himself, he has control over his own emotions,

17. Warning signs of mental disorders
Always worrying
Unable to concentrate
Continually unhappy
Lose temper often
Regular insomnia
Mood fluctuations
Continually dislike to be with people
Upset if routine of life is disturbed
Your Children get consistently on your nerves
Browned off and constantly bitter
Afraid without real cause
Feel you are always right and others are wrong
Numerous aches and pains – not treatable

19. Impact of mental disorders
Individual- poor quality of life, stigma and discrimination, stress restriction of social activities ,suffering from physical illnesses ,are unable to participate in work and leisure
Impact of mental disorders
Family- stigma and discrimination, stress ,economic loss, restriction of social activities
Society-
Economic loss,
Voilence, crimes,

20. Mental health: Prevention strategies
Life cycle approach
Levels of prevention
Role of WHO in Mental Health
Mental health Initiatives in India:-
- National mental Programme
- DMHP and Five year plans
- Mental health Act
- National health policy and Mental health

22. Three levels of Prevention
Primary level -
Operates on Community basis
consists of improving the social environment
includes – working for better living conditions and improved health and welfare resources in community
Secondary level -
It consists of early diagnosis of mental illness and social and emotional disturbances through screening programmes in schools, industries, universities etc.
and provision of treatment facilities- “family based health services” are effective
case work or counselling is the method used by family service agencies
Family counselling is done and psychosocial diagnosis is made by counsellors
Tertiary level –
it seeks to reduce the duration of mental illness and thus to reduce family and community stress
This is to prevent the illness from worsening

23. Comprehensive mental health programmes
95% of psychiatric cases can be treated with or without hospitalisation , close to their homes
So full integration of psychiatric services with other health services is current trend
CMHP includes following essential elements:-
IPD/OPD
Partial hospitalisation
Emergency services
Diagnostic services
Pre and after care services including home placement and visiting
Education services
Training services
research and evaluation services

24. Mental health services
Mental health services- Includes :-
promotion of good mental health
Prevention of mental illness
Early diagnosis and treatment
It comprises of:-
Rehabilitation
Group and individual psycotherapy
Mental health education
Use of modern psycoactive drugs
After care services

25. WHO role in Mental Health
In WHO chose the World Health Day Theme as ‘ Mental Health: Stop Exclusion- Dare To Care
World Mental Health Day Dignity in mental health
The theme for World Mental Health Day, on 10 October 2015 is "Dignity in mental health".
WHO MIND - Mental Health in Development
Flagship projects of WHO MIND
WHO MiNDbank: More Inclusiveness Needed in Disability and Development MiNDbank is an online platform which brings together many countries and international resources, covering mental health, substance abuse, disability, general health, human rights and development.
The Quality Rights project: act, unite and empower for better mental health This project works to unite and empower people to improve service delivery and human rights conditions in mental health facilities and social care home

26. WHO role ....
WB/WHO meeting: - Making Mental Health a Global Development Priority - - In April 2016, the World Bank Group and the World Health Organization will co-host a high-level meeting on global mental health, with a focus on depression and anxiety.
WHO Mental Health Gap Action Programme (mhGAP)
aims at upgrading services for mental, neurological and substance use disorders especially for low- and middle-income countries.
The programme insists that with proper care, psychosocial assistance and medication, many can be treated for mental disorders & prevented from suicide -even where resources are scarce.

27. Mental health action plan 2013 - 2020
The 66th World Health Assembly, consisting of Ministers of Health of 194 Member States, adopted the WHO’s Comprehensive Mental Health Action Plan in May 2013
It recognizes the essential role of mental health in achieving health for all people.
It is based on a life-course approach, aims to achieve equity through universal health coverage and stresses the importance of prevention.
Four major objectives are set forth:
more effective leadership and governance;
the provision of comprehensive, integrated mental health and social care services in community-based settings;
implementation of strategies for promotion and prevention; and
strengthened information systems, evidence and research.

28. The National Institute of Mental Health And Neuro Sciences
On the recommendation of Bhore committee (in 1946), All India Institute Mental Health was set up in 1954
This later became the National Institute of Mental Health And Neuro Sciences
( NIMHANS) In 1974 at Bangalore.
An expert committee of WHO in 1974, made several important recommendations, urging its members to consider mental disorder as a high priority problem.
The recommendations included :
to undertake pilot projects to assess existing mental health care program in a defined populations and
training program for health workers and to devise a manual for the same
First community Mental Health unit (CMHU) was started with the Dept. of Psychiatry at NIMHANS in 1975 / In Bellary , Karnataka - Mental health programme was pilot tested.
It plays a major role in training in mental health and conducts projects in mental health

29. National Mental Health Programme
In August 1982,the Central Council of Health and Family Welfare (CCHFW) adopted and recommended for implementation of National Mental Health Programme (NMHP)
OBJECTIVES OF NMHP:-
(1) To ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population.
(2) To encourage the application of mental health knowledge in general healthcare and in social development.
(3) To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.

30. National Mental Health Programme ...
STRATEGY OF IMPLEMENTING NMHP :-
Integration of mental health with primary health care through the NMHP
Provision of tertiary care institutions for treatment of mental disorders
Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority, and State Mental health Authority
APPROACHES OF NMHP
Integration of the mental health care services with the existing general health services.
To utilize the existing infrastructure of health services and to deliver the minimum mental health care services.
To provide appropriate task oriented training to the existing health staff.
To link health services with the existing community development programme.

31. National Mental Health Programme ...
Service components of NMHP
Treatment
Rehabilitation
Prevention
Drawbacks in NMHP
lacks adequate guidance and leadership.
No mental health policy existed before the programme,
the 1987 Mental Health Act (which established the central and state mental health authorities) has been largely non-functional.
No budgetary estimates or provisions
No response from psychiatrists

32. Advantages of Integration of NMHP into NRHM
NRHM can help in better implementation of NMHP :-
By Using and involving existing infrastructure also for training purposes
for transfer & flow of funds
State/District level health authorities in monitoring & implementation
For procurement of drugs
Involvement of community & PRI to make, referral chains for management of cases.
For managing MIS (Management Information System)
For Sustaining DMHP after expiry of the period of central assistance in the district
For making improvements/ changes in on going programme

33. District Mental Health Programme (DMHP)
As NMHP was not likely to be implemented on a larger scale, in 1996 the Ministry Of Health and Family Welfare, GOI formulated District Mental Health Programme (under National Mental Health Programme) as a fully centrally funded programme
This was to provide community based mental health services at the Primary Health Centre with the help of the Trained Medical Officer and referrals to the Psychiatrist for severe mental disorders.
The major components of DMHP:-
Training of all manpower to be involved in programme
Public education in the mental health to increase awareness and reduce stigma
OPD and IPD services for early detection and treatment
Providing data and experience, at the community level to the State and Centre for future planning, improvement in service and research.

34. District Mental Health Programme (DMHP)
Objectives of DMHP
To provide sustainable mental health services and to integrate these services with other services.
Early detection and treatment of patients within the community itself.
To see that patient and their relatives do not have to travel long distances to go to hospitals or nursing homes in cities.
To take pressure off mental hospitals.
To reduce the stigma attached towards mental illness through change of attitude and public education.
To treat and rehabilitate mentally ill patients discharged from the mental hospital within the community

35. Implementation of DMHP
The District Mental Health Programme was launched during in four districts.
During 9th Five Year Plan - extended to 27 districts across the country.
10th Five Year Plan -extended to 108 districts
Five strategies of NMHP in the Tenth Five-Year Plan-
Expanded and made more effective
Strengthening medical colleges for better treatment , develop psychiatry general hospitals
Streamlining and modernizing mental hospitals
Strengthening central and state mental health authorities- to co ordinate and monitor programmes
Research and training in the field of community mental health. Promotional campaign through IEC materials.

36. MENTAL HEALTH in 11th Five year plan :2007-2013
1) FUNDING:- The total amount of funding allotted is Rs crores ( a three fold increase from the previous Five Year Plan)
2) MANPOWER DEVELOPMENT- establishment of centres , upgrading and strengthening existing mental health hospitals/institutes for manpower production
3) Spill over activities of the 10th Plan : Up gradation of the psychiatric wings of Government medical colleges/general hospitals
4) Modernizations of state run mental hospitals.
 5) To integrate NMHP with the National Rural Health Mission (NRHM).

37. MENTAL HEALTH in 11TH FIVE YEAR PLAN ….
6) Added components of DMHP i.e. Life Skills training and counseling in schools/ service in colleges, work place stress management and suicide prevention services.
7) Research-There is huge gap in research in mental health which needs to be addressed.
8) IEC-An intensive media campaign is planned for 11th Plan duration.
9) NGOs and Public Private Partnership for implementation of the Programme. This would increase the outreach of community mental health initiatives under DMHP.
10) Monitoring ,Implementation & Evaluation-Effective monitoring at Central/State/District level will facilitate implementation of various components of NMHP.

38. Mental health in 12th five year plan
Mental illnesses are classified as non-communicable diseases
Integration of mental health in primary care.
Why this integration ?
Burden of mental disorders is high and prevalent in all societies
Mental and physical health problems are interwoven
The treatment gap for mental disorders is huge .
Primary care for mental health enhances access
Mental health services delivered in primary care minimize stigma and discrimination
Primary care for mental health is affordable and cost effective and generates good health outcomes
New Initiative in the 12th Plan
Expansion of DMHP to all the District of the country in a phased manner
Strengthening District Hospitals for providing services
Participation of NGOs & private sector for providing extended treatment facility and rehabilitation through community outreach programme

39. District Mental Health Programme (DMHP)
Current status of DMHP in India
New 325 districts added
fund per district for 5 years is 2.5 crores/ 20 lakh population
Many centers have trained doctors, and staff
Programme officer is psychiatrist in most districts
Clinical services are strengtned
PHCs refer patients to higher centers and are not treated there
In Karnataka ther is deputy director Mental Health – not in other states
MHCP is progressing very slowly
Challenges for DMHP :-
Delays in efforts to increase manpower
Little partnership with other government organisation
Insufficient capacity to use available funds effectively
Collaboration with NGOs and private practitioners could help to achieve manpower needed

40. National mental health Act- 1987
The Act is related to the treatment and care of mentally ill persons, to make better provision for them and treat them with respect
There are 10 chapters and 98 clauses in the Act .
The components are -
Definition of mental illness
Rules and Licence for Psychiatric hospitals and Nursing homes,
Formation of Central and State Authority for Mental Health Services ,
Set up rules for Admission And Detection, Inspection, discharge, Leave of Absence and removal of cases in hospitals, penalties and prosecutions , custody of mentally ill patients

41. National mental health care bill:
Introduced in the Rajya Sabha on the 19th August, 2013.
It contains16 chapters and 136 clauses
It mentioned the following:-
Definition of mental illness
All persons Right to access of mental health
Establish Central and state mental authority
Change of terminology from psychiatric hospitals to mental health establishments
Set up Mental health review commission and board -a person with mental illness can directly approach this forum for protection of his/her rights.

42. National health policy 2015 and mental health
Mental health issues are neglected and the gap between service availability and needs is very high.
There are only 43 facilities in the nation with a 0.47 psychologists per million people.
The policy recommends :-
Need to increase specialists with public financing
Integration with the primary care approach - to identify mentally ill persons,refer , follow up with medication and tele-medicine linkages.
specially trained general medical officers and nurses for some referral support at the secondary care level
Supplementing primary level facilities with counsellors and psychologists.
Creating a network of community members to provide psycho-social support for such problems.

43. JANAMANAS Project
Anjali Mental Health Rights Organisation, a Kolkata based Non Governmental Organisation, launched a community based Janamanas programme in 2006 to target mental illness.
focuses on 2 main aspects:
first - to establish health kiosks to provide services and
second - to create a community of trained mental health workers to run the kiosks and awareness camps.

44. References
Planning Commission. Towards a faster and more inclusive growth- an approach to the 11 Five Year Plan, Government of India, Yojana Bhavan, November 2006, P.72
K. Park. Park Textbook of preventive and Social medicine.23rd ed. Jabalpur (India ): M/S Banarsidas Bhanot; 2015.p
mhGAP: Mental Health Gap Action Programme: Scaling up care for mental, neurological and substance use disorders. Geneva: World Health Organization; 2008. 
WHO , Mental health,
CDC, Mental health
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Christian Kieling, Helen Baker-Henningham, Myron Belfer, Gabriella Conti, Ilgi Ertem, Olayinka Omigbodun, etall.Global Mental Health 2,Child and adolescent mental health worldwide: evidence for action , The Lancet, Vol 378 October 22, 2011
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Janamanas: Building Community Mental Health Kiosks and Community Mental Health Workers.Anjali Mental Health and Human Rights Organisation. July 2011

45. References
Report of evaluation of district MENTAL HEALTH PROGRAMS,Tamil Nadu, Karnataha, Andhra Pradesh and Maharashtra.NIMHANS Bangalore
URL:
National mental health care bill 2011
URL:
?Mental Health Act, Bare act with short comments; Commercial Law Publishers,
Delhi, 2007.
Evaluation of District Mental Health Programme, Final Report Submitted to Ministry of Health and Family Welfare, ICMR
World health organization. Mental health Gap action programme
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon
General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and
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Health, National Institute of Mental Health, 1999.
WHO and WONCA. Integrating mental health in primary care: a global perspective. Geneva: World Health Organization
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Director General of Health Services (DGHS): National Mental Health Programme for India. New Delhi, Ministry of Health and Family Welfare; 1982