The Relevance of Community Psychiatry in India1

Community psychiatry in India is nearly six decades old. (Agarwaal et al., 2004; Srinivasa Murthy, 2008). Starting as an effort to involve families of mentally ill persons in the care of persons admitted to the Amritsar Mental Hospital in 1950s and isolated extension psychiatric clinics in primary health clinics, today the integration of mental health care in general services covers over 120 districts or about 20 percent of the country, along with a wide variety of community level facilities and initiatives to address a broad spectrum of mental health initiatives in the areas of care, prevention of mental disorders and promotion of mental health. From a situation of almost no community based services for persons with mental disorders, the country today has a framework for mental healthcare in the public, private and voluntary sectors. In moving forward India has been influenced by local challenges as well as by medical developments abroad.

However, in recent times the movement of community psychiatry has come under criticism and termed variously as ‘ineffective’ (Kapur, 2004); ‘not based on cultural aspects of India’ (Jadhav and Jain, 2009); ‘bandwagon’ and ‘a failure’(Thara et al., 2008).

This chapter is an attempt to present the development process and the progress of community psychiatry in India, its relevance to the development of mental healthcare and to identify the forces and factors driving the movement. The chapter concludes with the future directions for the community psychiatry movement. Each of the initiatives, reviewed here, have been addressed in detail in separate chapters in the book.

The key questions that will be addressed in this overview are given in Box 1.

Though the prevalence rates of depression are higher than psychosis, the rates treated are far lower in the former, pointing to the limited awareness about depression in the community. The rates of treatment were even lower among the rural population. Treated cases were higher in the urban areas (61.7 percent as compared to 47.5 percent). Treated cases were also higher in the higher income quartiles (p.62-66). Indirect evidence of the large proportion of the ‘untreated’ patients come from another field study conducted in Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. Basic Needs (India), as part of the caregivers in the community mental health study examined 201 persons with severe mental illness, of which nearly 50 percent were found to be suffering with schizophrenia. The duration of illness at contact was more than two years in 90 percent of the subjects, over five years in 70 percent of the subjects and in over 25 percent of the subjects the duration was over ten years (Janardhan & Raghunandan, 2009).

India is home to pluralistic approaches to all types of care. There are not only other systems of health care, apart from Allopathy, such as Ayurveda, Unani, Naturopathy, Homeopathy (AYUSH), but also there are a large number of places where people go to seek help; especially religious places (Sebastia, 2009). The current approach of most professionals is one of ‘live and let live’. However, this approach leaves the situation unclear to the general public. It would be in the interest of professionals of all systems of care to initiate a dialogue and communicate the relative suitability and effectiveness of the varied interventions on the different aspects of mental health (prevention, promotion and treatment). There is no need for each of the systems and interventions to be equally suitable and effective in all the areas of mental health. There is also greater need for linkage of services on a need based approach.

‘Thirty eight percent of the hospitals still retain the jail like structure that they had at the time of inception … nine of the hospitals constructed before 1900 have a custodial type of architecture, compared to 4 built during pre-independence and one post-independence … 57 percent have high walls … patients are referred to as “inmates” and persons in whose care the patients remain through most of the day are referred to as “warders” and their supervisors as “overseers” and the different wards are referred to as “enclosures” (p.32) … overcrowding in large hospitals was evident … (p.34) … the overall ratio of cots:patient is 1:1.4 indicating that floor beds are a common occurrence in many hospitals (p.37) … in hospitals at Varanasi, Indore, Murshadabad and Ahmedabad patients are expected to urinate and defecate into open drains in public view (p.38) … many hospitals have problems with running water … storage facilities are also poor in 70 percent of hospitals … lighting is inadequate in 38 percent of the hospitals …89 percent had closed wards while 51 percent had exclusively closed wards … 43 percent have cells for isolation of patients (p.39) …leaking roofs, overflowing toilets, eroded floors, broken doors and windows are common sights (p.44) … privacy for patients was present in less than half the hospitals … seclusion rooms were present in 76 percent hospitals and used in majority of these hospitals … only 14 percent of the staff felt that their hospital inpatient facility was adequate (p.47) in most hospitals case file recording was extremely inadequate … less than half of the hospitals have clinical psychologists and psychiatric social workers … trained psychiatric nurses were present in less than 25 percent of the hospitals …(p.48) … even routine blood and urine tests were not available in more than 20 percent of hospitals … 81 percent of the hospital in-charge reported that their staff position was inadequate (p.54)6.

The poor conditions of these institutions have negatively projected the mentally ill as violent, mental illnesses as chronic, and mental illness as untreatable. Though the second evaluation showed significant improvements in many of the institutions, there are still many unmet needs (National Human Rights Commission, 2008).

The WHO Atlas (WHO, 2005) and recent statewise analysis of psychiatrists (Thiruvanakarasu & Thiruvanakarasu, 2010) highlight the low numbers of mental health professionals in India. The figures are worrisome, especially given the pandemic proportions of the figures of the mentally ill. The average national deficit of psychiatrists is estimated to be 77 percent. The deficit of psychiatrists exceeds 90 percent among more than one third of the population. Only Chandigarh, Delhi, Goa and Pondicherry can claim to have surplus psychiatrists. Kerala and Maharastra have less than a 50 percent deficit while the rest of the states have more than 50 percent deficit in psychiatrists. What is striking is the vast variation of the distribution of psychiatrists across the country. The figures for psychologists working in mental health care are not too different, and there is also a paucity of social workers and psychiatric nurses.

The continuing constraints in availability of trained professionals in medical colleges and district hospitals need to be addressed by creatively bringing professionals from the private sector into the state mental health care program. This can be at many levels, ranging from training programs, treatment of specific conditions, follow-up care, certification, rehabilitation, etc. An active dialogue needs to be initiated to create a system of integrated and coordinated care across public and private facilities in the states. This requires cooperation among professionals and institutionalized methods of carrying out such collaboration. The current system of training of ‘counsellors’ with varying duration and content of training, also needs review and reorganization.

The decentralisation of services by the reorganization of the District Mental Health Program (DMHP) is a priority (discussed in detail in Chapter 5). The DMHP should be strengthened in the following manner:

‘Over the past half century, the model for mental health care has changed from the institutionalisation of individuals suffering from mental disorders to a community care approach backed by the availability of beds in general hospitals for acute cases. This change is based both on respect for the human rights of individuals with mental disorders, and on the use of updated interventions and techniques. The care of people with mental and behavioral disorders has always reflected prevailing social values related to the social perception of mental illness. Through the ages, people with mental and behavioral disorders have been treated in different ways. They have been given a high status in societies which believe them to intermediate with gods and the dead. In medieval Europe and elsewhere they were beaten and burnt at the stake. They have been locked up in large institutions. They have been explored as scientific objects. And they have been cared for and integrated into the communities to which they belong. In Europe, the 19th century witnessed diverging trends. On one hand, mental illness was seen as a legitimate topic for scientific enquiry; psychiatry burgeoned as a medical discipline, and people with mental disorders were considered medical patients. On the other hand, people with mental disorders, like those with many other diseases and undesirable social behavior, were isolated from society in large custodial institutions, the state mental hospitals, formerly known as lunatic asylums. These trends were later exported to Africa, the Americas and Asia. During the second half of the 20th century, a shift in the mental health care paradigm took place, largely owing to three independent factors, namely (i) psychopharmacology made significant progress, with the discovery of new classes of drugs, particularly neuroleptics and antidepressants, as well as the development of new forms of psychosocial interventions; (ii) the human rights movement became a truly international phenomenon under the sponsorship of the newly created United Nations, and democracy advanced on a global basis, albeit at different speeds in different places and (iii) social and mental components were firmly incorporated in the definition of health of the newly established WHO in 1948. These technical and sociopolitical events contributed to a change in emphasis: from care in large custodial institutions to more open and flexible care in the community. Community care is about the empowerment of people with mental and behavioral disorders. In practice, community care implies the development of a wide range of services within local settings. This process, which has not yet begun in many regions and countries, aims to ensure that some of the protective functions of the asylum are fully provided in the community, and the negative aspects of the institutions are not perpetuated. The accumulating evidence of the inadequacies of the psychiatric hospital, coupled with the appearance of “institutionalism”—the development of disabilities as a consequence of social isolation and institutional care in remote asylums—led to the de-institutionalization movement. Deinstitutionalization is a complex process leading to the implementation of a solid network of community alternatives. Closing mental hospitals without community alternatives is as dangerous as creating community alternatives without closing mental hospitals. Deinstitutionalization has not been an unqualified success, and community care still faces some operational problems. Among the reasons for the lack of better results are that governments have not allocated resources saved by closing hospitals to community care; professionals have not been adequately prepared to accept their changing roles; and the stigma attached to mental disorders remains strong, resulting in negative public attitudes towards people with mental disorders. In some countries, many people with severe mental disorders are shifted to prisons or become homeless. In most developing countries, there is no psychiatric care for the majority of the population; the only services available are in mental hospitals. These 8mental hospitals are usually centralised and not easily accessible, so people often seek help there only as a last resort. The hospitals are large in size, built for economy of function rather than treatment. In a way, the asylum becomes a community of its own with very little contact with society at large. The hospitals operate under legislation which is more penal than therapeutic. In many countries, laws that are more than 40 years old place barriers to admission and discharge. Furthermore, most developing countries do not have adequate training programs at national level to train psychiatrists, psychiatric nurses, clinical psychologists, psychiatric social workers and occupational therapists. Since there are few specialized professionals, the community turns to the available traditional healers’.

The changes in mental health services in economically affluent countries, during the second half of the last century and particularly in the last ten years have been largely driven by the movement towards ensuring human rights of persons with mental disorders, which have been reflected in deinstitutionalization, care received in the community and greater voice to users and the carers (UNCRPD, 2006). This is summarised as follows:

‘The practice of psychiatry in the second half of the 20th century, and especially in its last decade, has changed fundamentally. Mentally ill people have been moved out of the relative ‘simplicity’ of the large institution, with its clear structures and hierarchies and into the community. This necessitated new types of relationships between ‘health’ and ‘social’ care. A range of new facilities has been required for the treatment, care and support for people with mental health problems in the community, replacing many of the functions previously provided in hospitals. More agencies and staff (professional and non-professional) have declared an interest and entered the scene, often bringing new and quite different perspectives on the needs of those with mental disorders. Among these new voices in the community have been those of service users themselves. Increasing cultural diversity and respect for social difference have added to the range of value systems to be taken into account. At the same time, governments are taking an increasing direct interest in mental health issues, formulating more specific strategies, guidance, directives and legislation. (Thornicroft & Smuzkler, 2001).

The shift has been the outcome of many forces as seen by the following quote:

‘Our problem in the West is, that somehow or other WE HAVE TO MAKE UP FOR THE FAMILIES who have disappeared and create a supportive structure—not for the patients but for the single relatives who are often desperately trying to cope with schizophrenia. It is, of course, very expensive to create a network of professionals who act as a SURROGATE FAMILY, but we have to provide that form of support, because it is even more expensive to keep hospitalising patients’. (Leff, 1996).

Reflective of the shift in focus are the large number of initiatives undertaken, to understand disabilities of mentally ill persons, the impact of the ill person on the family, the coping by the family, user movement and the recently accepted UN Convention on the Rights of Persons with Disabilities (UNCRPD, 2006).

Szmukler and Thornicroft (2001) define community psychiatry as follows:

‘Community psychiatry comprises the principles and practices needed to provide mental health services for a local population by: (i) Establishing population-based needs for treatment and care; (ii) Providing a service system linking a wide range of resources of adequate capacity, operating in accessible locations; (iii) Delivering evidence based treatments to people with mental disorders’.

In the above definition, it is important to note that the significant parts are- ‘needs of the population, wide range of services and accessibility of services’.

Community psychiatry in affluent countries has come to represent a wide range of initiatives beyond what is provided by mental health professionals. For example, a recent book ‘Empowering People with Severe Mental Illness’ (Linhorst, 2006) encompasses empowerment in terms of treatment planning, housing, organisational decision making, policy making, employment, research and service provision.

Similarly, the ‘Textbook of Community Psychiatry’ (Thornicroft & Smuzkler, 2001), covers a wide variety of subjects. For example, under the service system, the areas included are integration of components into the systems of care (multidisciplinary teams, sectorization and generic versus specialist teams, training for competence). Under the service components, the areas include—case management and assertive community treatments, emergency psychiatric services, partial hospitalization, day care and occupation, residential care, outpatient and inpatient treatment. Under the interfaces between mental health services and the wider community, the areas include—primary care, integrated health and welfare services, community alliances; and users and carers as partners.

In a way, community psychiatry has developed in these countries as ‘the service’ and not as an ‘alternative’ to institutionalised care. This distinction of the development of community psychiatry is important to understand developments in the LAMI countries (Srinivasa Murthy 2008, 2011).

A striking aspect of the development of mental health services in India, is as much the location of the care in the community where most of the ill persons were already living as well as the utilization of a wide variety of community resources for the community. For instance, in the initial phase, family members were the focus, which was followed by the utilization of the existing general health care infrastructure through integration of mental health services with general health services. Subsequently, the increased use of school teachers, volunteers, counsellors, mentally ill persons, survivors of disasters, parents of children with mental disorders, took place (Srinivasa Murthy, 2006). In this manner, the three principles of community psychiatry, meeting population based needs, use of range of resources, and accessibility were partially addressed.

In India, most persons with mental disorders live with their families. Care is taken by the family who ensure services and plan and provide for their future. Thus, in India the family care model is very important. The role of the family, therefore, becomes crucial when one takes cognizance of the acute shortage of affordable professionals rehabilitation services and residential facilities, whether in the private or government sector. We should also take note of absence of welfare facilities or benefits for persons with mental disorders.

In India, family involvement started in the 1950s (Carstairs, 1974; Srinivasa Murthy, 2007; Vidya Sagar, 1973). Indian initiatives relating to families and mental health care have depended on family support for the mentally ill persons. Since the 1950s, families have been formally included to supplement and support psychiatric care by professionals. During this period, family members were actually admitted along with the mentally ill to be part of the care for the patients. This has largely been the pattern in most of the LAMI countries. During the 1970s and 1980s, efforts were made to understand the functioning of families with an ill person in the family and their needs (Bhatti, 1980; Bhatti et al., 1980, 1982; Bhatti & Verghese, 1995).10

Two centers namely, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh and National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore systematically studied the needs of the families, the role of non-medical professional to provide support to the families (Suman et al., 1980). At NIMHANS, Bangalore (Pai & Kapur, 1982, 1983; Pai, et al., 1983, 1985), two similar groups of schizophrenic patients, undergoing two treatment modalities, namely, hospital admission and home treatment through a nurse were compared for the outcome in terms of symptoms, social dysfunction, burden on the family, cost of treatment and outcome at the end of six months. A nurse trained in patient follow-up and counseling visited the home regularly for the purpose of patient assessment and treatment. The findings revealed that home treatment through a visiting nurse had a better clinical outcome, better social functioning of the patient and greatly reduced the burden on the patients‵ families. Further, the treatment modality was also more economical. In a follow-up study, it was observed that the home care group of patients had maintained significantly better clinical status than the controls and this group had been admitted less often). In a further study, where the focus of family care by visiting nurses was chronic patients with a diagnosis of chronic schizophrenia, it was found that only two of the home care group were admitted to hospital over two years in comparison to eight patients in routine care. Together with this, was a study of factors contributing positively or negatively to the course and outcome of schizophrenia. Research into the special needs of mentally retarded and their families had also been studied (Russell et al., 1999, 2004).

During the last ten years, a more active role for families is emerging in the form of formation of self-help groups and professionals accepting to work in partnership with families (Srinivasan, 2008; Srinivasa Murthy, 2006). However, many of the leads provided by pilot studies and successes of family care programs have not received the support of professionals and planners to the extent it could become a routine part of psychiatric care in the 21st century. It is interesting to note that in the last decade there is recognition of the value of family involvement in mental health care in developed countries (Selis, 2007; Shimazu et al., 2011).

The value of the availability of family as a resource for professionals in LAMI countries can be understood by the challenges faced when families cannot be depended on for mental healthcare as pointed out by Leff (1996).

We have to recognize that there are large unfinished tasks to make families a part of the community mental health movement. Reviewing the scene, Rao (1997), opined that ‘professional inputs have not kept pace’ and concluded that the family movement in India is one of ‘unfulfilled promises or great expectations for the future’. He says as follows:

However, many of the leads provided by pilot studies and successes of family care programs have not received the support of professionals and planners to the extent it could become a part of routine psychiatric care. In coming years, moving from passive utilization of the families to partnership and true empowerment of the families has the greatest potential in organizing mental healthcare in LAMI countries. The advances in communication technology (mobile phones) and the growing availability of information technology (internet) should be used creatively to share caring skills with families and to bridge the gap in professional resources. This will be building of mental health care from the ‘bottom of the pyramid’ as it has happened in the other developmental and commercial areas in developing countries (Prahlad, 2006). This area should receive the highest importance in future efforts.

It is relevant to note that the generation of psychiatrists in the 1960s and 1970s faced the challenge of moving mental healthcare beyond the isolated mental hospitals and bringing mental healthcare to the general medical care setting (liaison psychiatry). It was these two forces that led to the development of General Hospital Psychiatric Unit (GHPU). Another striking aspect of the Indian GHP units is their function as 11primary centers for mental healthcare. It has been a slow and quiet change but in many ways a major revolution in the entire approach to psychiatric treatment. The general hospitals psychiatric unit offered numerous advantages over the traditional mental hospital. They are more accessible, easily approachable and above all less stigamatised. They are situated in the community, hence more accessible and easily approachable. Families can frequently visit and relatives can even stay with disturbed patients. The stigma of a mental hospital is absent. There are limited legal restrictions to admission or treatment. Ambulatory treatment on an outpatient basis is available with the use of drugs, ECT and psychotherapy. Proximity of other medical facilities ensure thorough physical investigations and early detection of physical problems. It is important to note that the GHPUs have contributed richly to the development of liaison psychiatry (Garg et al., 1976, 1978), the training of psychiatrists and research. For instance, at the Chandigarh and Delhi centers it was seen that it is feasible to provide mental healthcare in a general hospital setting and the characteristics of the patients seeking care and their treatment utilization patterns. These centers also demonstrated the importance of psychiatry to medicine and surgery through research in matters of body and mind. An illustration of this was the collaboration with cardiology, examining the psychiatric symptoms following mitral surgery, measures of neuroticism and prediction of psychiatric disturbances in patients awaiting cardiac surgery, disturbance of body image in patients awaiting surgery, and problems of rehabilitation in patients undergoing cardiac surgery (Wahi et al., 1970, 1976). Also an illustration of this was the collaboration with nephrology to understand the psychiatric aspects of hemodialysis and psychiatric aspects of chronic uremia (Garg et al., 1976, 1978) and with neurology to study cerebral cysticercosis presenting in a psychiatric clinic (Kala & Wig, 1977) and other departments. In Delhi, studies demonstrated the prevalence of psychiatric problems in general medical wards and the different aspects of psychiatric problems of emergency room (Deshpande et al., 1989). Monthly joint case conferences with the departments of medicine and neurology were an excellent demonstration of the importance of the collaborative effort and recognition of the integrated approach to health issues.

In the last decade, psychiatric units in all major hospitals have become a reality. This shifting of the place of care to the general hospital setting has contributed significantly to the process of destigmatization of psychiatric illnesses and psychiatric care.

The initial stimulus to this approach came from the recommendations of WHO in 1975, in the Expert Committee report ‘Organisation of Mental Health Services in Developing Countries’ (WHO, 1975). The chief recommendations were to:

India was the first developing country to formulate a National Mental Health Program (NMHP) in 1982 (DGHS, 1982). Twenty-five years later, WHO again re-emphasized the approach through the recommendation in the World Health Report, 2001 (WHO, 2001) to ‘provide treatment in primary care’.

The integration of mental health care into general health services, particularly at the primary healthcare level has many advantages. These include, less stigmatization of patients and staff, as mental and behavioral disorders are being seen and managed alongside physical health problems; improved screening and treatment, in particular improved detection rates for patients presenting vague somatic complaints which are related to mental and behavioral disorders; the potential for improved treatment of the physical problems of those suffering from mental illness, and vice versa; and better treatment of mental aspects associated with ‘physical’ problems. For the administrator, advantages include a shared infrastructure leading to cost-efficiency, the potential to provide universal coverage of mental healthcare, and the use of community resources which can partly offset the limited availability of mental health personnel.

In India, training primary healthcare workers for mental health was started in 1975 at the Bangalore and Chandigarh centers and integrating mental health with general health care (Chandrasekar et al., 1981; Issac et al., 1982, 1986; Parthasarathy et al., 1981; Sartorius & Harding, 1983; Srinivasa Murthy et al., 1978; Srinivasa Murthy & Wig, 1983; 12Wig & Srinivasa Murthy, 1980; Wig et al., 1981;). These experiences formed the basis of the National Mental Health Program (NMHP) formulated in 1982. Currently, the government supports over 125 district level programs in 22 states, covering a population of over 200 million (GOI, 2007). Following initial studies, other efforts to understand the integration of mental health with primary healthcare have occurred (Chisholm et al., 2000; Gautam, 1985; James et al., 2002) and has been extensively reviewed in the book in a separate chapter.

During the first 10 years of the NMHP, the initial small scale models of care (1975-84) by integrating mental health care with general healthcare were systematically evaluated (ICMR-DST, 1987). Realising the limited mental health resources in the country, from 1985-90, the district level model in Bellary district of Karnataka was developed and evaluated (Issac et al., 1986; Naik et al., 1996). These efforts dominated the first decade of community mental health movement in the country, and it is often confused as the only community psychiatry model in the country. During the next 15 years, (1993-2008), the district model called the district mental health program (DMHP) initially launched in 27 districts was later extended to 127 districts. Thus, within a relatively short period of time the basic approach to integrate mental health with general health care was adopted to cover a larger segment of the population (GOI, 2007).

Developments between 1946-2003 have been critically and comprehensively covered by different professionals (Agarwaal et al., 2004). Though NMHP was introduced in 1982, the subsequent three Five-year plans did not make adequate fund allocations (Reddy et al., 1986). Furthermore, even the funds allotted were not fully utilised. It was only in the 9th Five-year Plan that a substantial amount of Rs 28 crore was made available and was increased in the 10th Five-year Plan to around Rs 140 crore. The availability of funds in 1995 for the DMHP has shown that once funds are available, states are willing to undertake intervention programs and professionals are willing to be a part of the process of integrating mental health with primary healthcare and also take up a wide variety of initiatives for mental health care. The projected funding for mental health program during the 11th Five-year Plan (2008-12), is approximately ₹ 1,000 crore. (GOI, 2007, Planning Commission, 2006).

Given below are some of the limitations of the development efforts in the last twenty-five years, since the formulation of the NMHP (Agarwaal et al., 2004; Reddy et al., 1986; Srinivasa Murthy, 2004; Wig & Srinivasa Murthy 1980, reprinted 1993).

The other recent criticism of community psychiatry in India (Jadhav & Jain, 2009; Kapur, 1997; Thara et al., 2008) is that:

This criticism is not valid as can be seen from the review of the developments in the last four decades. Community psychiatry in India has been driven by the realities of the country (eg. involvement of families from 1950s, when the rest of the world was viewing the family as ‘toxic’). Development of the models of care were based on one decade of fieldwork to understand and meet the needs of the community by two academic centers (Wig & Srinivasa Murthy, 1980) and not in response to the WHO. These two centers based their interventions on the ‘community voices’ and these have been well documented. The development of policies of WHO were as much influenced by the Indian professionals as was the Indian movement driven by WHO. It is relevant to note that throughout the last twenty-five years, Indian professionals have played important roles in the WHO as regular staff at the Geneva office and at regional offices. At present, the Mental Health division of WHO is headed by an Indian psychiatrist.

Recently, Issac & Guruje (2009) have reviewed the primary health care approach to mental healthcare and point out that,

“the large unmet need for mental health services in many LAMI countries, despite the availability of effective and relatively affordable interventions, calls for an urgent effort to scale up primary care service in those countries. Efforts to scale up services must include a comprehensive review of the training provided for primary care providers in the recognition and treatment of mental health problems and a reorganization of the primary healthcare system. Assumptions made about the relative autonomy of the primary healthcare system have led to an unsupported and unmotivated health workforce. A reorganization of primary healthcare system in the LAMI countries must recognize the need for an effective secondary care level., with a sufficient number of specialist mental health workers to provide training and support for primary care providers and back up for difficult cases requiring specialist interventions. Adequate resources are also needed. However, it has been estimated that the investment needed to scale up mental health care is not large in absolute terms, when considered at the population level and in comparison with other health sector investments (efforts to integrate mental health efficiently into primary care services are unlikely to work until public funded health systems are better resourced and made more effective)” (p83-84).

‘community based initiatives in the management of mental disorders however well intentioned will not be sustainable 14unless the family and the community are involved in the intervention program with support being provided regularly by mental health professionals’.

If the belief is that chronicity of schizophrenia can be reduced and every person with schizophrenia can improve is coupled with an enthusiastic and aggressive management comprising both medical and social interventions, then it is possible that many patients can improve or recover and have meaningful and productive lives.

However, this initiative raises crucial questions (Srinivasa Murthy, 2007; Srinivasa Murthy & Wig, 1983). The involvement of ‘non-specialist mental health personnel’ require clarity about:

Furthermore, regarding the involvement of non-specialist personnel, the following safeguards are essential:

In view of the wide variations in the specialist human resources available in the country (Thirunavukkarasu, 2010), there will be a need to examine the human resources in each state and identify tasks in the seven areas outlined above, and allocate responsibilities to the different categories of personnel. In addition, these programs need to be periodically reviewed and the experience used for upgrading and modifying educational training programs for different categories of personnel.

As indicated in recent books ‘Mental Health by the People’ (Srinivasa Murthy, 2006) and ‘NGO Innovations in India’ (Patel & Thara, 2003), the community psychiatry movement in India is not a ‘single model’ program but a wide array of initiatives involving a variety of community resources.

‘India is an ancient and great cultural, spiritual and an anthropological laboratory. She has been the nursery of saints and sages, scientists and founders of the world's major religions and promulgators of profound philosophy. Nevertheless, to be satisfied with the glory of the past is to turn into a fossil; but to interpret the old from a new point of view is to revitalise the past and bring in a current of fresh air into the monotonous present’ (Rao, 1997).

‘… one has to admit that there is little firm evidence that either meditation or religious observance significantly modifies… tens of thousands of Indians, young and old, have become disciples of teachers who support them in their twofold ambition to practice right conduct in accordance with Hindu dharma and to enhance their personalities by following a particular technique of meditation. If it could be established, with appropriate controls, that changes in symptoms and in personality traits do come about, and in the desired direction, then the possibility of collaborating between psychiatrists and gurus could be worth exploring,’ (Carstairs, 1980).

The above efforts had laid greater emphasis on the care of persons with mental disorders, though there have been attempts on a smaller scale on the promotion of mental health and prevention of mental disorders. There is also growing recognition of the impact of social changes on the mental health of the population (e.g. growing suicide rates, domestic violence, violence in children, elderly mental health, migrant populations, displaced populations, etc.) which makes it necessary that future mental health programs should include promotion of mental health, prevention of mental disorders and care and rehabilitation of persons with mental disorders.

One striking aspect is the innovativeness of the professionals and voluntary agencies to address the multiple needs using the available community resources. This has occurred in a number of areas. This, I consider is the strength of the Indian mental health movement. However, the negative aspect of these developments is the lack of depth in most of the initiatives. Even when initial results have been quite positive (e.g. nurse involvement in community care), the innovations have not received the kind of amplification and in depth understanding that should have happened. The lack of evaluation is seen uniformly in all the programs and I have considered the need for this aspect in each of the sections. The other aspect of significance is the largely person and center specific nature of the initiatives. There has been limited teamwork in carrying forward the effort beyond the initial initiators. A result of all of these factors has been the lack of theory building and influencing of policies at the national level. It is important that the next phase of development should address some of these in a more focussed manner.

Recognizing the special value of the community mental health initiatives for India, there are two ways at looking at the developments. The positive aspects have been the story recounted so far. However, the reverse is the limitations of the most of the initiatives that have been outlined in the earlier sections. What could be the reasons for this? One possibility is that the initiatives that are non-institutional in their care setting were more difficult and will need more time to develop fully. Another possibility is that these were ideologically driven and not fully rooted to the realities of the country. The third possibility is that professionals have not fully accepted the processes of deinstitutional care, decentralization of care and de-professionalization of care, as it could affect their own identity and income. However, it can be clearly said that if the community mental health programs are to fully blossom and reach the needs of the population, this will be an important contribution from India to the rest of the world (Wig, 1989).

There should be both a willingness to share mental health caring responsibilities with non-specialists, and overcome the fear by some professionals of losing their work, identity and income. The method should be not to convert the non-specialist into a mini-psychiatrist but to identify what is relevant, feasible and possible for the specific non-specialist to undertake.

There is a need to decrease the amount of time devoted by specialist mental health professionals to individual clinical care and increase the time for training, support and supervision of other personnel. This is a huge challenge for clinicians who value directly caring for ill people by themselves. This change in role becomes meaningful when it is recognized that training of other personnel has a multiplier effect in providing mental health services to the population.18

There is a need to devote significant time to periodic support and supervision of the non-specialists. Reports of mental healthcare in developing countries have repeatedly shown the importance of support and supervision by psychiatrists to the non-specialist personnel. Fortunately, the easy and inexpensive availability of mobile phones, internet and satellite communication for telepsychiatry, allows for distant support to the non-specialists on a continuous and interactive basis.

There is a need for professionals to acquire the skills to work with the community, education sector personnel, welfare sector personnel, voluntary organizations, and policy makers. This includes understanding the planning process, fighting for priority for mental health in health programs, becoming familiar with legislations and budget procedures, and developing skills to negotiate with different stakeholders.

In addressing these needs to cover the total population and in a manner that requires limited travel, there is a need to take advantage of available modern technology such as the world wide web, mobile phones, telemedicine, community radio to reach and continuously support the persons and families with mental disorders. Already some small scale initiatives have been made but these have to be widened to cover the entire population of the country. The use of information technology in spreading the agricultural information should give hope for similar success in the area of mental health.

The mental health professionals have emphasized the need for public mental health and its challenges in the last decade (Desai 2005, 2006; Reddy, 2007; Singh, 2007). It is significant that on 15 April 2011, the Government of India set in motion a broad-based task force for mental health to develop the mental health policy of the country. This is timely and should give new life and momentum to the movement.

In conclusion, development of mental health services all over the world, countries rich and poor alike, have been the product of the larger social situations (political, social, economic and human rights), specifically the importance that society gives to the rights of disadvantaged and marginalised groups (Wig, 1989). Economically rich countries have addressed the community psychiatry movement from the institutionalized care to community care building on the strength of their social institutions. India, though began this process more recently has made significant progress utilising the strengths of the community. There is a need to continue the process by widening the scope of the mental health interventions, increasing the involvement of all available community resources and anchoring the interventions in the historical, social and cultural roots of India. This is a continuing challenge for professionals and people in the coming years.