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  1. 1. Indian J Med Res 120, August 2004, pp 63-66Editorial Mental Health in the new millennium: Research strategies for India Early this year, the Ministry of Health and Family Community Mental Health at Bangalore, Mental HealthWelfare, Government of India, invited “research of Aged at Madurai, and Biological Psychiatry atproposals for funding as part of the ongoing National Lucknow – all of which demonstrated how researchMental Health Programme (NMHP) which aims at support can help develop mental health services. Theproviding community based mental healthcare using the ICMR also supported research into the mental healthexisting public health infrastructure. The proposed aspects of disasters like the Bhopal Disaster in the 1980s,research should be relevant and translational in nature, the Marathwada earthquake in the 1990s and the mosti.e., it should conform to the aims/objectives of the recently Gujarat earthquake and the fire tragedy in Delhi.NMHP and should translate into more effective/cost- It is largely the result of these efforts that following anyeffective mental health interventions/service delivery”1. disaster in India, psychosocial support is readily providedThis Rs 10 crore (US$ 22.2 million) is an unprecedented to the survivors along with other services7.research support to the NMHP for “phasedimplementation of the District Mental Health Mental health care in India over the last 25 yr hasProgramme, strengthening of medical college been an intense period of growth and innovation. Priordepartments of psychiatry, modernisation of mental to the formulation of the NMHP in 1982, the majorhospitals, focused IEC initiatives, research and training”. initiatives included setting up of mental hospitals during 1950s and early 1960s and general hospital psychiatric Commencing with the first epidemiological studies at units in the 1960s and 1970s 8. Simultaneously,Bangalore in the 1950s and at Agra in the early 1960s, involvement of the families in care of the mentally illthe Indian Council of Medical Research (ICMR) has was also initiated in a number of centres. Another majorbeen in the forefront of mental health research2. The step in mental health care was to integrate mental healthother major studies include the multicentered research care with general health services. Followed by the initialcum intervention project titled “Severe Mental Morbidity” demonstration projects at Chandigarh and Bangalore9-11,in four centres3. The “Strategies for Mental Health in the last two decades, the pilot programmes ofResearch”, based on six task forces that identified integration of mental health with primary health care wereresearch priorities in mental health in 1980 was a major initiated at several centres. The district model of mentalmilestone. Two of these task force projects focused health (DMHP) care was developed by National Instituteon acute psychosis and course and outcome of of Mental Health and Neuro Sciences (NIMHANS),schizophrenia4,6. Findings of the studies have not only Bangalore during the latter part of 1980s12. The next biginfluenced mental health care in India, but contributed to step was extending of DMHP to 25 centres around thethe inclusion of acute psychosis as a separate diagnostic country with central funding during the 9th Five Yearcategory in International Classification of Diseases (ICD) Plan13. Currently, during the 10th Plan period, the goal is10th Edition, of the World Health Organisation. Other to cover 100 districts with about 150 millionstudies were mental health care of the aged and child population14,15.psychiatric problems. Many of the trainees whoparticipated in the community mental health training India enters the new millennium with many changesprogrammes initiated their own community mental health in the social, political, and economic fields with an urgentprojects. These initiatives demonstrated both the need need for reorganization of policies and programmes.for research support to the developing NMHP The mental health scene in India, in recent times, reflects(formulated in 1982) as well as the willingness of the complexity of developing mental health policy in aprofessionals to work as teams. The 1980s also saw developing country. There has been a critical examinationthe Council set up Advanced Centers for Research on of the existing mental hospitals in the country by the 63
  2. 2. 64 INDIAN J MED RES, AUGUST 2004National Human Rights Commission of India16. The document Neurological, psychiatric, and developmentalSupreme Court of India is continuously examining the disorders: meeting the challenges in the developing world,wide variety of issues relating to mental health care, published by the Institute of Medicine in 2001 alsofollowing the Erwadi Tragedy in which 28 mentally ill focusses on the research needed to support mentalpersons were burned to death while chained to pillars. health programmes in developing countries21.The National Health Policy17 clearly spells out the placeof mental health in the overall planning of health care. The scope of mental health in the new millenniumThese developments have occurred against the over should include care of the mentally ill persons, prevention25 yr of efforts to integrate mental health care with of mental disorders and promotion of mental health asprimary health care (from 1975), replacement of the outlined by Dr Govindaswamy, the first Director of AllIndian Lunacy Act 1912 by the Mental Health Act 1987, India Institute of Mental Health (now NIMHANS),and the enactment of The Persons with Disabilities Act Bangalore22 over 50 yr back: “Mental health in India1995 focusing on the equal opportunities, protection of has three objectives. One of these has to do with mentallyrights and full participation of disabled persons18. The ill persons. For them the objective is the restoration ofgrowth of voluntary action for mental health care in the health. A second has to do with these people who areareas of suicide prevention, disaster mental health care, mentally healthy but who may become ill if they are notsetting up of community mental health care facilities, protected from conditions that are conducive to mentalmovement of family members (care givers) of mentally illness which however are not the same for everyill individuals, drug dependence, public interest litigation individual. The third objective has to do with the promotionto address the human rights of the mentally ill; research of mental health with normal persons, quite apart fromin depression, schizophrenia and child psychiatric any question of disease or infirmity. This is positive mentalproblems are other major developments19. The rapid health. It consists of the protection and development ofgrowth of private psychiatry with associated spread of all levels of human society of secure, affectionate andservices to peripheral cities and small towns and satisfying human relationships and in the reduction ofchallenges of regulation is an another significant hostile tensions in the community.”development of the last 10 yr. The challenge for professionals working in India is Against the above positive developments, the main the competing demand to provide services to largechallenges are the extremely limited number of mental numbers of persons with mental disorders and generationhealth professionals (about 10,000 professionals of all of new knowledge through research. The researchcategories for one billion population) and the very limited agenda for the Council could have the goals ofmental health service infrastructure (about 30,000 (i) reduction of the incidence, prevalence and burden ofpsychiatric beds for over a billion population); limited mental and behavioural disorders; (ii) develop andinvestment in health by the government (estimated public evaluate the mental health services so that they becomesector expenditure on health is only 17 % of total health available and accessible to the total population;expenditure) and problems of poverty (about 30% of (iii) enhance the positive mental health of the population;population live below poverty line) and low literacy with and (iv) create structures to promote long-term mentalassociated stigma and discrimination for persons with health research and dissemination of mental healthmental disorders. information. At the International level, the World Health Report The following four strategies can be used by the ICMR2001 on Mental Health has been a landmark in the to achieve the above goals: (i) provide research anddevelopment of policies and programmes relating to evaluative foundation to the expanding national levelmental health in the world and specifically in developing mental health services, both as part of NMHP and incountries 20. The Report provides a framework for the private sector psychiatry; (ii) help generate newcountries with different development levels to initiate knowledge about the nature, course and outcome ofactions appropriate to their resources. Already there is mental disorders; (iii) develop measures for monitoringevidence of change in many countries. Another important of the mental health of the community; and (iv) build
  3. 3. MURTHY : MENTAL HEALTH IN THE NEW MILLENNIUM: RESEARCH STRATEGIES FOR INDIA 65capacity for mental health research and dissemination roles clearly cut out.of mental health information among the public, policymakers and professionals. Acknowledgment Research in service development should focus as a I am thankful to Drs Somnath Chatterji and Shekhar Saxena ofpriority, on areas like integration of mental health in WHO, Geneva for the technical inputs towards the development of the goals, strategies and priority research areas during the yearprimary care, early intervention in psychosis, use of family 2001 and Prof. N.K. Ganguly for initiating these discussions duringsupport, models of community long-term care, evaluation one of his visits to Geneva.of suicide prevention initiatives and mental health inschools. The topics for generation of new knowledge R. Srinivasa Murthycould focus on course and outcome of different mental STP-Mental Health and Rehabilitation ofdisorders; treatment by pharmacological and Psychiatric Servicesnon-pharmacological methods of common mental Regional Office for the Eastern Mediterraneandisorders; mental health of women; mental health of W.H.O. Post Box 7608adolescents; disaster mental health; health and behaviour, Abdul Razak Al-Sanhouri Streetdevelopment of culturally appropriate assessment tools; Naser City, Cairo-11371, Egypthealth system research; spirituality and health; and basic e-mail: murthys@emro.who.intbiological studies of mental disorders. The developmentof mental health indicators is an important strategy to Referencesgive greater acceptance of mental health programmes.These indicators could be at the community level relating 1. Director General of Health Services (DGHS). National Mentalto services, studies of burden of mental disorders and Health Programme: The Research Agenda. New Delhi: DGHS.the impact of alcohol and substance abuse. 24 March 2004. 2. Dube KC. A study of prevalence and biosocial variables in Capacity building through setting up of centres of mental illness in a rural and an urban community inexcellence or advanced centres to support young Uttar Pradesh -India. Acta Psychiatr Scand 1970; 46 : 327-59.professionals; regular compilation of psychiatric researchdata and periodic publications; greater use of information 3. Collaborative study on severe mental morbidity, Report of an ICMR-DST Task force Study, ICMR and DST. New Delhi:technology for dissemination of information is essential. Indian Council of Medical Research and Department of Science and Technology; 1987. The last two decades of research efforts of theCouncil allow for focused national level workshops in 4. Factors associated with the course and outcome of schizophrenia, Report of an ICMR Task Force Study. Newthe areas of disaster mental health, schizophrenia and Delhi: Indian Council of Medical Research; 1989.organization of mental health care. Such workshops cannot only allow consolidation of knowledge but greater 5. Collaborative study on phenomenology and natural history ofdissemination of information. acute psychosis. Report of an ICMR Task Force study. New Delhi: Indian Council of Medical Research; 1989. India is thus entering the new millennium with many 6. Verghese A, John JK, Rajkumar S, Richard J, Sethi BB,challenges like promoting mental health of the Trivedi JK. Factors associated with course and outcome ofpopulation and developing mental services involving schizophrenia in India: Results of a two-year multicentric follow-up study. Br J Psychiatry 1989; 154 : 499-503.different social institutions. Professionals have been inthe forefront to find solutions appropriate to the country 7. Murthy RS. Evolution of disaster mental health care in India.and towards developing an Indian system of mental In: Disaster mental health in India. Diaz P, Srinivasa Murthy R,health care. There is need for a vision for the Lakshminarayana R, editors. New Delhi: Indian Red Cross; 2004development of mental health that is broad-based, p. 56-69.inclusive of all the needs of all the people, which is 8. Wig NN. General hospital psychiatry units - a right time forcommunity based and community intensive. The ICMR evaluation. Indian J Psychiatry 1978; 20 : 1-5.and the mental health professionals in India have their
  4. 4. 66 INDIAN J MED RES, AUGUST 20049. Wig NN, Murthy RS, Harding TW. A model for rural psychiatric 15. Srinivasa Murthy R. India: Towards community mental health services- Raipur Rani experience. Indian J Psychiatry 1981; care. In: Morall P, Hazeltron M, editors, Mental health global 23 : 275-90. policies and human rights. London: Whurr Publishers; 2004 p. 93-111.10. Murthy RS, Wig NN. The WHO collaborative study on strategies for extending mental health care, IV: A training approach to 16. Quality assurance in mental health care. New Delhi: National enhancing mental health manpower in a developing country. Human Rights Commission; 1999. Am J Psychiatry 1983; 140 : 1486-90. 17. National Health Policy. New Delhi: Ministry of Health and11. Isaac MK, Kapur RL. A cost-effectiveness analysis of three Family Welfare, Government of India; 2002. different methods of psychiatric case finding in the general 18. The persons with disabilities act. New Delhi: Ministry of Social population. Br J Psychiatry 1980; 137 : 540-6. Justice and Empowerment, Government of India; 1995.12. Isaac MK, Chandrasekar CR, Srinivas Murthy R, Karur BV. 19. Ranganathan S. The empowered community: a paradigm shift in Decentralised training for PHC medical officers of a district- the treatment of alcoholism. Madras: TTR Clinical Research the Bellary approach. In: Continuing medical education, Foundation; 1996. vol. VI, Verghese A, editor. Calcutta: Indian Psychiatric Society; 1986. 20. World Health Report 2001. Mental health: New understanding, New hope. Geneva: World Health Organization; 2001.13. Annual Report. New Delhi: Ministry of Health and Family Welfare, Government of India; 2000. 21. Institute of Medicine. Neurological, psychiatric, and developmental disorders: meeting the challenges in the14. Khandelwal SK, Jhinghan HP, Ramesh S, Gupta RK, developing world. Washington: National Academy Press; 2001. Srivastava VK. Indian Mental health - country report. Int Rev Psychiatry 2004; 16 : 126-42. 22. Govindaswamy MV. Compilation of Lectures by Dr M.V. Govindaswamy. Bangalore: Popular Press; 1948.