Let me start with some exciting stories of Community Oriented Mental Health Interventions (COMHIs) in Kerala, initiated by Psychiatrists, that have taken our services from beyond the clinic to our community.
Margadeepthi, at Palakkad, is one such initiative by Drs. Sivathanu Pillai and Bindu Menon. It started functioning in full scale by 2007. Initially they used to cover all the Panchayaths and Municipalities in the district once a month, and more than 4000 clients used to get benefitted. Margadeepthi was started much before the implementation of government’s Community Mental Health Program (CMHP) in Palakkad, and they are now withdrawing from places where CMHP has started its function. Dr. Sivathanu Pillai still visits 36 centers once in two months and covers about 1000 clients. Margadeepthi has been able to persuade some Panchayats to fund medicines, and medicines thus purchased by the Panchayaths are distributed through PHC pharmacies.
Can such COMHIs be linked with palliative care movement? The Mental Health Action Trust, a team led by Dr. Manoj Kumar, says yes! Most of its centers in the districts of Malappuram, Wayanad and Kozhikode are a part of successful community palliative care initiatives and benefit over 1800 patients with chronic mental disorders.
Efforts of Mehac team led by Dr. Chitra Venkateswaran too are worth mentioning. Mehac too incorporates a mental health component into already existing palliative care units, and has now expanded its partnership to other interested groups, NGOs, individuals, and local self governments. Mehac has presence in four districts — nine units in Alappuzha, four in Ernakulam, two in Palakkad and one in Kannur. It has initiated a program for children with learning disorders and behavioral problems, with a focus on life skills education, at South Mararikkulam Panchyath in Alappuzha. These projects draw strength from people who volunteer in various capacities like identifying persons with mental illness, monitoring their care, and coordinating with their families. Mehac has the support of five doctors to facilitate this process. Home-care services is one of their major approaches. Currently 750 patients and a couple of rehabilitation homes receive their care. Involving the Panchayath as a main stakeholder has helped the sustainability of Mehac’s program.
Government of Kerala has community mental health initiatives in all our districts. National Rural Health Mission (NRHM) supports District Mental Health Program (DMHP) and Community Mental Health Program (CMHP). Institute of Mental Health and Neurosciences (IMHANS), Kozhikode leads the programs in the Malabar area. They have CMHP clinics in various districts — 20 in Kozhikode, 42 in Malappuram, 13 in Wayanad and 15 in Kasargode. In Kannur, DMHP is run by Department of Psychiatry, Govt. Medical College, Kozhikode. Regular follow-ups and free medicines available at these clinics ensure good drug compliance, and there are indications that DMHP has reduced the number of hospitalizations and revolving door phenomena in Mental Health Center, Kozhikode. Community-based awareness programs and training programs organized by DMHP have helped early identification of patients, rehabilitation of chronic cases, and stigma reduction.
DMHP Thiruvanathapuram was started in 1999, and hence has a long history. In 2013 they started “Sampoorna Manasikarogyam - Mental Health for All” - an ambitious targeted intervention project that aims to extend mental health coverage to all households in the district. Undetected cases in the community are identified through door to door visits and then integrated into the primary care health system. Various community-level workers, like ASHA workers, were trained to detect cases and ensure follow-ups in their respective communities, and this helped create mental health awareness in each household. Till date they have completed the project in five Panchayaths, and have been able to detect 481 new patients (including 218 cases of psychosis). Such attempts are excellent ways to tackle the treatment gap. Their School Mental Health Program (Thaliru) too has been successful, and was recently chosen for implementation in other districts too.
DMHP has taken up the task of conducting the Epidemiological Survey of Mental Health Morbidity in the state, and is also in the process of starting day care centers in all districts. First such center was started in Pullazhi under DMHP Thrissur. With all its glowing stories of success, however, DMHP is facing serious manpower constraints in districts like Idukki.
Dr. KR Anandan has been successful in integrating components of mental health in the Mulamkunnathukavu Arogya Gramam — a people’s voluntary health and education concept. This program has been going on for thirteen years now.
Dr. Pfizer and his team have been providing free treatment and rehabilitation services for people with chronic mental illness through Thanal, a day care center of Rajah Rehabilitation Trust, Chavakkadu, since 2001. Thanal helps the patients find meaningful jobs in the community through supported employment, and currently caters to 32 patients. Shreyas, a carers’ support group associated with Thanal, organizes monthly family meetings. Dr. Pfizer has been organizing the New Life Alcoholic Anonymous group at the rehabilitation center since 2001, and the group now has 60 members.
Enthusiastic school-based projects, which target child mental health, by Drs. Anil Kumar TV and Arun B Nair at Thiruvananthapuram, and by Dr. Varghese Punnose while he was in Alappuzha are worth mentioning. Our members also support various school-level projects by government departments. There is a need for projects that enhance positive parenting skills too — a component that is crucial to ensure the success of child mental health interventions.
Works in the area of dementia care by Drs. KS Shaji and S Shaji too are significant.
Maithri, a voluntary organization in Kochi, has been leading the suicide prevention initiatives in Kerala for the past nineteen years. It is a model COMHI that combines people’s participation, volunteer leadership, and expert guidance. It runs a helpline, and has tested out many outreach innovations like child guidance camp, elder’s well-being camp, student-to-family campaign for alcohol and domestic violence-free homes, and community outreach for those bereaved by suicide. Maithri’s positive mental health project conducted a participatory rural appraisal in all wards of Kizhakkambalam Grama Panchayath, and this inspired the local self government to address the identified mental health issues in its budget. (This project was also supported by Ernakulam Psychiatric Society).
This is by no means a complete list of such initiatives in Kerala. My attempt was just to showcase some sample initiatives to stimulate thoughts and create sparks of inspiration that shall fuel many more such projects.
Deficiency of funds has slowed many projects. There have been great difficulties in getting Corporate Social Responsibility funding for mental health initiatives. Questions are raised about documentable results as in detection and treatment of cataracts. A corporate organization once asked us to commit on quantifiable results at the planning stage of a school-based life skills project. It is important to remove these reservations so that more funds are available for community projects on mental health. Branch of Indian Psychiatric Society (Kerala) has to take the leadership, and offer a platform for those interested in COMHI to explore the possibility of evolving innovative proposals that suit Kerala's needs. Opportunities for intersectorial partnerships should be encouraged and actively pursued. It is also important to lobby for due share and deployment of manpower as mental health is going to be under general planning for Non Communicable Diseases. Attempts at marginalization must be resisted. There is a need to lobby for the presence of Psychiatrists at all Taluk Hospitals. There is also a need to provide more encouragement to those who pursue an interest in community mental health. And let us not hesitate to encourage Dr. Ramkumar’s online scribbling and compilations in www.communitypsyindia.wordpress.com that often stimulate such thoughts and debates.
Many Psychiatrists in Kerala are actively engaged in mental health education campaigns through media and awareness classes for various target groups. Television visibility for mental health topics is significant too. Kerala IPS has its own mental health education website for public - www.manasikarogyam.com - designed and executed by Dr. Shahul Ameen. We still hear stories of quackery in spite of all these, and stigma about mental illnesses prevail. IPS needs to take the leadership to bring together everyone interested in mental health education campaigns to make these efforts more focused, meaningful and effective.
I bring this particular work to your attention to stimulate innovative thoughts about developing similar COMHIs in Kerala. There is a need to design intervention models that target specific areas and include a built-in research dimension. We may get results that can be showcased internationally. WHO indicates that four out of 10 health concerns with highest Disability Adjusted Life Years lost are mental health related. Major depression is the highest contributor. Depression is well known to increase the risk of developing physical illnesses like diabetes mellitus, hypertension, cardiovascular disorders, and even cancer. Depression can also adversely impact the prognosis of many physical illnesses. Depression in the community is an unrecognized, untreated, and under-treated condition that needs to be brought up as a public health concern in Kerala as we have high rates of suicide. Such works with implications in both emotional and physical well-being will surely take mental health to the mainstream and help stigma reduction. Interventions that focus on early detection and treatment of alcoholism at the community health care level itself is another important area. A Kerala Alliance Against Depression and Alcoholism can devise COMHIs that can be taken up by all active community mental health teams of our state. The state government too should take these areas as state health initiatives.
Lao Tsu, in 700 B.C, had penned: “Go to the people. Live with them. Learn from them. Love them. Start with what they know. Build with what they have. But with the best leaders, when the work is done, the task accomplished, the people will say ‘We have done this ourselves.’” Yes — ideal community work is born in an empowered community, one that is inspired to be the driving force that creates meaningful progress. Together, let us groom leaders who will make this a reality.