1. Role of primary care in addressing mental health issues Dr K.V.Kishore Kumar Director, The Banyan and BALM

2. Primary health care? Essential health care Universally accessible Continuously available Affordable Acceptable Based on the needs of the population WHO 1978- Alma Ata Declaration

3. Goal of primary care The ultimate goal of primary health care is better health for all. WHO has identified five key elements to achieving that goal: reducing exclusion and social disparities in health (universal coverage reforms); organizing health services around people's needs and expectations (service delivery reforms); integrating health into all sectors (public policy reforms); pursuing collaborative models of policy dialogue (leadership reforms); and increasing stakeholder participation.

4. Integration of mental health into primary health care Solution to shortages in human resource Access to mental health care Early diagnosis and treatment Comprehensive treatment and follow up Reduction in family burden and disability Increase in social participation and productivity Reduction in stigma and discrimination Social integration and rehabilitation Protection of human rights

5. Recent research in the community Thirthahalli taluk - Shimoga district Despite 6 psychiatrists being available, 25% psychotics were never treated. 55% of patients were not on treatment currently All the patients were initiated on treatment after training HW and Doctors 95% of patients treated improved with intervention QOL increased, disability and burden reduced significantly with continued care in the primary care settings

6. Burden of mental disorders Cardiovascular diseases Diabetes Malignant neoplasms Digestive diseases Neuropsychiatric disorders Other NCDs Injuries Other CD causes Maternal conditions Malaria Childhood diseases Tuberculosis Diarrhoeal diseases Perinatal conditions HIV/AIDS Respiratory infections Respiratory diseases Nutritional deficiencies Sense organ disorders Diseases of the genitourinary systemMusculoskeletal diseases Congenital abnormalities

7. Mental disorders – what do we know Mental disorders are common and universal One in four persons suffer from mental disorders in their life time. Mental disorders are disabling and burdensome Uniformly seen across rural/ urban and tribal locations with respect severe mental disorder Mental disorders are treatable Early treatment results in better recovery Caring families in India makes it eminently possible to treat persons with mental disorders in the community Community care is economical and effective

8. Magnitude of mental disorders Prevalence: 65/1000 population in all ages and both sexes Schizophrenia- 3/1000; mood disorders-16/1000; CMD’s: conservative estimate of 20% Alcohol-60/1000, cannabis-8/1000 and opiates- 2/1000 Estimated that a minimum of 6.7 crore persons would need immediate care for severe and moderate (easily recognizable) problems (Reddy and Chandrashekhar 1998; and Ganguli 2000)

9. Prevalence of schizophrenia in India Author and Year Location Sample size Rate /1000 population Reddy and Chandrashekar 1998 Rural and Urban 33,5722.7 R- 2.6 U-2.9 Ganguli 2000 Rural and Urban Not Known 2.5 R- 3.6 U- 2.5

10. Prevalence of Mood Disorders in India Author and Year Location Sample size Rate /1000 population Reddy and Chandrashek ar 1998 All India Not known 12.3 R- 11 U- 17.9 Ganguli 2000 All India Not Known 34 R- 34 U- 37

11. Common mental disorders Author and Year Findings Harding et al 1980 12.7% in primary care settings Bagadia et al 1985 57% in OPD attendees Shyamsunder et al 1986 36% in Private GP settings Sen et al 1987 50% in 3 PHC settings Bhatia et al 1989 49% in surgical OP patients Kishore et al 1996 42% in PHC settings in Haryana Patel et al 1998 47% 0f 97% with bodily complaints had CMD Nambi et al 2002 44% amongst persons with bodily symptoms Pothen et al 2003 34% in primary care settings Gururaj et al 2004 13% in a community sample 10,168

12. World Health Survey 2003 – Karnataka A national sample of 10,000 individuals were surveyed as part of WHS 2003 States selected were Assam, West Bengal, Rajasthan, Karnataka and Maharasthra. Sample size of Karnataka was 1300 9% of the sample were diagnosed as depression Psychosis was < 1%

13. Burden of mental and neurological disorders

14. Burden- Percentage of DALYS lost world wide 1990 10% 2002 13% 2020 15%

15. Disability Mental and neurological conditions account for 30.8% of all years lived with disability Depression accounts for nearly 12% disability. Of of the top 20 causes of disability 6 belong to neuro-psychitric conditions

16. Burden of mental disorders Cardiovascular diseases Diabetes Malignant neoplasms Digestive diseases Neuropsychiatric disorders Other NCDs Injuries Other CD causes Maternal conditions Malaria Childhood diseases Tuberculosis Diarrhoeal diseases Perinatal conditions HIV/AIDS Respiratory infections Respiratory diseases Nutritional deficiencies Sense organ disorders Diseases of the genitourinary systemMusculoskeletal diseases Congenital abnormalities

17. WHR- 2001 need of the ill

19. Cost of care

20. Advantages of mental health care in primary care settings PHC/SUB CENTRE is closest to where the patient lives. Early identification is possible since community needs assessment is done every year. Primary care personnel visit the field frequently making identification possible Fear of stigma is reduced since care occurs in general medical settings

21. 21 Community-based care benefits Services close to home Focus on disabilities as well as symptoms Focus on the individual Wide range of services Ambulatory rather than static services Partnership with carers Better quality of life for ill persons Prevents inappropriate admissions CHAPTER THREECHAPTER THREE © 2001

23. Challenges Primary care personnel have multiple tasks Not motivated to participate in MH Care Poor leadership to drive integrated care Inadequate logistics support to carry out work. Poor monitoring and supervision PHC personnel hesitate to use psychotropic drugs Poor hand holding on the part of specialists

24. IEC-Manual for Health workers

25. IEC-Manual for medical officers

26. Ten features of mental disorder- Flip charts and posters

27. Interactive computer-based video training modules (6 CDs)

28. Conclusions Mental Health Problems are common and universal There is no health care without mental health care Mental Disorders are disabling and burdensome Effective and safe interventions are available in the country Integrating mental health care with general health services is an important strategy

29. Conclusions- continued Strengthening medical colleges and development of regional institutes of mental health is crucial for increase in mental health manpower resource Considering and implementing innovative approaches to fill the void in manpower is an important short term measure. Development of telemedicine facilities to disseminate knowledge, skills is of parmount importance