District mental health program: Then and now

Abstract

District Mental Health Program (DMHP) is part of the broader National Mental Health Program (NMHP) launched in 1982. In India, DMHP has evolved over the years, moving from a pilot project to an integrated component of the NMHP. Efforts have been made to expand services, protect the rights of individuals with mental illness, and integrate mental healthcare into the primary healthcare system. Recent updates and efforts taken by the Government of India and state governments (60% and 40% budget share respectively) have improved the quality of services provided under DMHP. With the increasing use of the internet and mobile technology, DMHP has spread its arena of services more deeply and widely in the last few years reaching up to 738 districts in the country. However, there is still work to be done to address many challenges associated with mental health in India though the recent developments seem promising as a substantial number of patients are now having access to the programme. This narrative review is the summary of information available to date on the evolution of implementation and expansion of DMHP over the years and provides a gist of the positive aspects as well as limitations of the DMHP witnessed in recent years.

INTRODUCTION

The District Mental Health Program (DMHP) is an Indian government initiative that is aimed at providing mental health care services and support at the district level. It is part of the broader National Mental Health Program (NMHP) that was launched in 1982 and has evolved over the period of years with the broadening of functions including awareness and education, training of health care workers, addressing the mental health needs of the population, providing the telepsychiatry services, etc., When NMHP was launched in 1982, the objectives were

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 mental health service development and to stimulate efforts towards self-help in the community.

These were based on the high treatment gap due to poor awareness about signs and symptoms of mental illness, myths and stigma related to it, and lack of awareness about treatment facilities available and potential benefits of treatment. The contribution of mental disorders to the total disease burden in India has doubled since 1990 and the current prevalence of mental health disorders is roughly calculated as one in seven.[1]

DMHP was hence launched in 1996 to decentralize mental health services and to provide mental health care services at the community level. This was to be achieved by integrating mental health with the general healthcare delivery system.[2] The DMHP was the first such program that was a ‘state-led mental health initiative’ among low- and middle-income countries. The initial objectives of DMHP were 1. Early detection and treatment, 2. Training and capacity building, 3. Public awareness generation, 4. Monitoring and Evaluation of the program, 5. Promote community participation, 6. Integration with Primary Healthcare.

DMHP has evolved over the years since its inception in 1996 to cover more districts, involve more health care workers, increase the arena of objectives, and improve the quality and quantity of mental healthcare services at the district level. Researchers found that, though the progress of NMHP (and DMHP) was relatively slower till recent years, in the last few years there have been rapid strides with several initiatives, including the expansion of DMHPs to around 90% of the total districts of the country, the National Mental Health Policy foundation and strengthening of the Mental Health Legislation by making specific provisions for rights of mentally ill persons. Other factors responsible for this accelerated growth included the easy accessibility of digital technology and judicial activism. Federal and State cooperation is another notable feature of this expansion.[3]

METHODOLOGY

Scope: This narrative review discusses various aspects of DMHP from its launch to the different amendments/updates, inclusion of newer projects, widening of its functioning, improvement in the quality of care provided, its spread to deeper and wider level, its effectiveness in reducing the treatment gap, assessment and monitoring, various timely reports/recommendations (evaluation and budgetary) by various agencies and its implementations, lacunae in the functioning of DMHP and, various challenges and limitations at planning, working and policy level. This review comprehensively addresses how DMHP has evolved over a period of years in its impact on mental health care delivery in India.

Article selection: Articles and reports related to DMHP and NMHP published to date (June 2024) are searched on PubMed, Scopus, and Google Scholar, and those relevant to the review are included. Among articles, those available in full length are considered. Most of the articles included are review articles (narrative or systematic). As per the title of this review authors tried to project the changing picture of DMHP from its inception to its current status with a wide range of services.

Some information is also included after discussion with a number of psychiatrists working under DMHP across the country to describe the realistic ground-level picture of DMHP functioning and the system of its monitoring.

Historical events till date

Year 1943: The Government of India appointed “Bhore Committee” that conducted a survey about health status and infrastructure in India and provided recommendations based on that.[4,5] The Committee recommended a plan for improvement of services by increasing the healthcare facilities, resources, enhancing the healthcare access, and special provisions for people with disabilities and mental illness along with women and children.

Year 1947 and around: The establishment and strengthening of the psychiatric services began in 1947. The focus was on increasing the number of beds for the mentally ill along with improving their living conditions.[6] During this period, the role of the family in the care of the mentally ill was recognized and promoted.[7]

Year 1959: “Mudaliar Committee” aimed at reviewing the implementations of the Bhore Committee’s recommendations and making recommendations for the subsequent Five Year Plans (FYP). In its report submitted in 1962, it was mentioned about the gap in treatment availability.

Year 1974: “Srivastava Committee” aimed to provide inputs about medical education in the context of national needs and priorities and to develop a curriculum for health workers. The Committee proposed the need for “Community health volunteer” (CHV) scheme along with their training for the identification and treatment of common mental illnesses.

For the initial 2 decades “post-Independence,” the focus was on improving infrastructure and manpower deficits for mental health services. Community psychiatry was seen as a means of providing basic mental health care to a large population with limited resources.

Year 1975: The concept of “Community Psychiatry” emerged and focus was given on integrating psychiatric services with general health services.

Year 1975 to 1981: Efforts were focused on including mental health care in primary health care and the adoption of the community psychiatry model globally. Alma Ata Declaration (1978) of primary healthcare services, being the key to attaining health for all, and, the World Health Organization (WHO) project about strategies for extending “Mental Health Services into the Community,” (1976–1981) were some of the international milestones leading to the launch of NRHM.[8]

Year 1982: NMHP was launched and influenced by local needs, situations, and global developments.[9]

Year 1985 to 1990: A pilot project was carried out in Bellary district of Karnataka-state by NIMHANS. The services provided during the pilot project included “Out patient services,” 10 bedded inpatient facility, services for referral, educational and awareness programs, and community screening. The pilot project showed the effectiveness of providing basic mental healthcare services at the district level and primary health center level by staff trained under the program. The “Bellary Model” created the foundation for the launch of DMHP, as a component of NMHP in other districts of India too.

Year 1996: Introduction of DMHP.

Year 1996–2002 (Expansion): DMHP was expanded to cover more districts throughout the country with an increase in the number of activities.

Year 2003 onwards: The functioning of DMHP was widened and included various other components such as community-based interventions, capacity building, and the establishment of more mental health institutions.

Table 1 mentions the key milestones in the development and progress of mental healthcare in India.

Table 1:

Key milestones

Year	Historical event
1943	Bhore Committee
1959	Mudaliar Committee
1975	Srivastava Committee
1978	Alma Ata Declaration
1976-1981	WHO Project- Strategies for extending Mental Health Services into the Community
1982	Launch of National Mental Health Programme
1992	Eighth Five Year Plan
1996	Launch of District Mental Health Programme
1997	Ninth Five Year Plan
2002	Tenth Five Year Plan
2007	Eleventh Five Year Plan
2012	Twelfth Five Year Plan

Year 2007 to 2017 (11^th and 12^th Five-Year Plans): During the 11^th and 12^th Five-Year Plans (2007–2012 and 2012–2017), increased focus was given to mental health within the healthcare system. The DMHP continued to expand along with the goal of reducing the treatment gap for mental illnesses. Ministry of Health and Family Welfare (MOHFW) also launched Rashtriya Kishor Swasthya Karyakram (RKSK) in 2014 for the holistic development of adolescents. Mental Health is one of six key thematic areas identified under RKSK for prioritization under the program including sexual and reproductive health, nutrition, injuries and violence (including gender-based violence), non-communicable diseases, and substance misuse.

Under the heading of the School Health Programme in the Ayushman Bharat project, NCERT has developed a detailed package named “Training and Resource Material- Health and Wellness of School-going Children.” A specific module has also been considered on “Emotional Wellbeing and Mental Health” which consists of activities on the mental health and well-being of students and school teachers.[10]

Year 2017: Integration of primary health care in accordance with MHCA 2017.

Year 2018 to 2024:

Taluk Mental Health Program (TMHP): As an extension of DMHP, TMHP was started by the Indian Government in 2018–2019. Initially, TMHP was approved in 10 taluks of Karnataka state. The goal was to ensure deeper penetration of mental health services in the community. The initiatives considered were the psychiatric research and projects incorporation, increasing and enhancing the community mental health services and interventions, and promoting a primary care psychiatry program (PCPP). It is considered to be a good initiative to bridge the treatment gap by covering more mental healthcare services, training non-psychiatrists (ASHA workers, pharmacists, auxiliary nurse midwives/ANMs, nurses, etc) in-person as well as digitally in the identification of mental illnesses and referral when needed, expansion of facilities (indoor facility, involvement of faith healers, etc), covering management of severe mental illnesses along with common mental illnesses and substance-related disorders and various other activities promoting positive mental health (awareness campaigns, school mental health programs, information and education activities, etc) along with the provision of a psychiatrist and a social worker for each taluk.[11] Thus, with greater penetrance into the community and greater assertive outreach services, the issue of the treatment gap can be attacked more aggressively and in a better-focused fashion under TMHP.

Tele MANAS: The Government of India launched a “National Tele Mental Health Programme” (Tele MANAS) as a digital arm of NMHP on World Mental Health Day, 2022, to improve access to quality online mental health guidance, counseling, and care services in the country. This was done in the context of the mental health crisis during the COVID-19 pandemic and an urgent need felt about establishing a digital mental health platform and network that will be useful and sustained during a challenging period like COVID-19. “Tele-MANAS” aims to provide free “tele-mental health” services to people across the country for 24/7, particularly serving people in remote and under-served areas. The program included a network of 23 centers of excellence, with NIMHANS being the nodal center and the International Institute of Information Technology-Bangalore (IIITB) providing technology support. There are proposed five regional coordination centers along with 51 State/UT Tele MANAS cells as per the operational guidelines of the National Tele Mental Health Programme of India, 2022.

Under Tele MANAS, a toll-free, 24/7 helpline number (14416) has been set up allowing callers across India to avail services after selecting a language of their choice. Service is also accessible at 1-800-91-4416. The calls would be routed to Tele-MANAS cells in the respective state and union territory. Tele-MANAS is organized in the mechanism of two-tier system. Tier 1 comprises state Tele-MANAS cells including trained counsellors and mental health specialists. Tier 2 includes specialists at DMHP and Medical College resources for physical consultation and/or e-Sanjeevani for audio-visual consultation (TeleMANAS is soon getting linked with E-Sanjeevini, which caters to prescription and provision of telepsychiatric consultations).

As per the report of MOHFW dated 12 December 2023, 34 States/UTs have set up 46 Tele MANAS Cells and have started online mental health services. As of 4/12/2023 around 5 lakh calls have been handled through Tele MANAS.[12]

For Tele MANAS functioning, Government has established a set-up of online consultation/counseling at various district health centers with technical support and resources (like laptop/tablet/computer and internet facility), and, healthcare workers and professionals working at district level are being trained for the utilization of the same.

The government is also providing online training courses to healthcare medical and paramedical workers to augment the availability of manpower for the delivery of mental healthcare services in underserved regions through Tele MANAS. This is done through Digital Academies, since 2018, established at three Central Mental Health Institutes namely NIMHANS, Bengaluru, Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam, and Central Institute of Psychiatry, Ranchi.

Addition of other programs under DMHP: Mental health care services have also been added to the package of services under Comprehensive Primary Health Care under “Ayushman Bharat”– HWC Scheme. Operational guidelines on Mental, Neurological, and Substance Use Disorders (MNS) at Health and Wellness Centres (HWC), the term now replaced by ‘Ayushman Arogya Mandirs’ (AAMs) have been released under the ambit of Ayushman Bharat. As per the recent report (12 December 2023) by MOHFW 1.6 lakh SHCs, PHCs, UPHCs, and UHWCs have been upgraded to Ayushman Arogya Mandirs.[12]

DMHP

DMHP was one of the very first efforts to provide a decentralized mental health services at the primary level of the healthcare system. The specific objectives of DMHP include providing “sustainable primary mental health care services” to the community, integrating these services with general health care services, “early detection and treatment” of mental illnesses in the community, ensuring the availability of services as near as possible to the needy, reducing the stigma with public awareness and educational programs and, rehabilitation of the patient with mental illness in the community. It was a centrally funded mental health program initially launched in four districts which gradually increased to 27 districts during the IX FYP. During the 10^th FYP, it was expanded to 94 districts. Efforts are taken to expand it to the whole country since XII FYP along with undertaking initiatives to expand infrastructure and upgrade Psychiatry wings to medical institutes and general hospitals besides capacity building of the hospitals.

DMHP is based on multidisciplinary interventions and the roles and responsibilities of multidisciplinary team members are detailed in DMHP guidelines and operational manuals. Typically, each professional provides interventions specific to his/her discipline, although there may be variations across states. Psychiatric Social Workers and nurses conduct scheduled home visits, provide care at the doorsteps and are actively involved in disability assessment and facilitation.

Over 25 years of the implementation of the DMHP, there have been only two systematic evaluations of the DMHP sanctioned by the Central Government. The first was done by NIMHANS in 2003 in 27 districts across the country.

The key recommendations included in the “evaluation report” by NIMHANS in 2003 were as follows.

The DMHP implementation should be extended for a further period of 5 years at all the existing centers as a centrally funded scheme. DMHP should be implemented in at least one district of the states and union territories that have not taken up the scheme already. The states and union territories that have already requested to start more districts in their respective states should be given priority in further expansion of the DMHP scheme all over the country. During the next phase of the scheme, resource allocation to the districts should be proportional to the area and population of the district. The budget allocation of the DMHP should be reviewed and revised. Districts could be classified as small, medium, and large, and budget allocation should be made accordingly. Clear guidelines about the use of funds with adequate autonomy and flexibility for the state-level authorities should be developed. The salary of the DMHP staff should be revised appropriately with the inclusion of fixed additional allowances for fieldwork at the peripheral healthcare institutions. A “central coordinating and monitoring cell” should be in place to oversee the overall implementation and development of the DMHP. Such a support and supervisory body should have the DMHP scheme as its exclusive full-time responsibility and should be handled by an individual of adequate seniority and mental health care experience. An advisory group of experts with adequate mental health and public health expertise and experience should be set up to provide technical advice to the DMHP scheme. A revised workshop should be organized to review the results and recommendations of the current evaluation of DMHP and to plan future expansion of the scheme. The nodal officer should be possibly a trained psychiatrist and the nodal institution should be a Department of Psychiatry or an Institute of Psychiatry. Participation by private consultant psychiatrists as well as general practitioners in the DMHP should be explored and facilitated. Since trained psychologists and social workers may not be available easily for appointment in the DMHP, there may be a need to develop suitable specific short-term programs for personnel to be conducted at NIMHANS. There is a need to develop feasible community-based models of care for common mental disorders, alcohol and substance use-related problems which can be implemented by the general health care personnel under the supervision of a psychiatrist. It was also recommended to actively take up the issue of strengthening psychiatric education and training in undergraduate medical education in all the medical colleges in the country. Psychiatric teaching should be integrated with the overall medical education. It was felt that facilities for training in-service candidates as psychiatrists should be increased. The specific suggestion was to increase the DPM seats for in-service candidates so that following training they could work as personnel for DMHP. During the next phase of development of DMHP preventive and promotive aspects of mental health should also be considered and taken up wherever possible. This could include school mental health programs, programs with NGOs, involvement of Anganwadi teachers, etc., Most of these recommendations were implemented in the further course of DMHP development.

The second evaluation was conducted by the Indian Council for Market Research, from 2008 to 2009 which was based on an analysis of DMHP functioning in 20 districts across India.[13,14]

Indian Council of Market Research (ICMR) evaluated the DMHP in various districts and based on the inputs given by ICMR, the program was expanded to include activities like “School Mental Health Services,” “College Counselling Services,” “Stress Management at Workplace,” and “Suicide Prevention Services.”[8]

Other important evaluation included that by NIMHANS in 2011 (covering 23 DMHPs in Karnataka, Tamil Nadu, Maharashtra, and Andhra Pradesh). The goals of these evaluations were to assess the effectiveness of DMHP in different states and union territories. An important development in this context was the constitution of the Mental Health Policy Group (MHPG) by the MoHFW in 2012 to review DMHP implementation and to provide recommendations for the better functioning of DMHP under the XII FYP by conducting regional workshops and Consultations.[15,16] Besides these evaluations, there are numerous research studies on the DMHP, in the form of reviews, critical and focused analyses, and pilot intervention studies.

MHPG formulated the guidelines and gave some recommendations in 2015 which were implemented and DMHP was revised. Some of its components were (1) service provisions, (2) capacity building, and (3) awareness generation. However, DMHP continued to be implemented based on the recommendations published in 2015 under the XII FYP. DMHP has been currently sanctioned for implementation in 738 districts of India for which support is provided to States/UTs through the National Health Mission. Since 2015, DMHP’s coverage has expanded to encompass more than 90% of the revenue districts in India.[3] At present, the facilities available under DMHP at the “Community Health Centre (CHC)” and “Primary Health Centre (PHC)” levels include outpatient services, screening/assessment, counseling/psychotherapy, psycho-social interventions, continuing care and support to patients with severe mental illnesses, medicines, outreach services, ambulance facility, etc., Besides this, the provision of 10 10-bed indoor facility for hospitalization at the District level is also made available.

The next evaluation was by the National Human Rights Commission (NHRC) Technical Committee on Mental Health Report published in 2016.[17,18] The XII FYP ended in 2017, after which the “Government of India” discontinued the Five-Year Plan Programme.

Also, in the years, after the implementation of the Mental Healthcare Act 2017, there has been a growing recognition and awareness about the importance of mental health in India, and activities under DMHP are planned considering the MHCA 2017 context. The COVID-19 pandemic has also highlighted the need for mental health support for needy people even in rural regions, leading to increased awareness and funding for mental health programs including DMHP.

Monitoring of DMHP

Though there is no robust mechanism for the monitoring of the functioning of DMHP and supervision of the mental healthcare workers working under DMHP, implementation of DMHP has been increasingly streamlined over the years. Also, the hierarchy and reporting structure within DMHP vary across states and districts.

There is regular reporting by medical superintendents of rural hospitals (RH) and sub-district hospitals (SDH) to the civil surgeon of the district regularly about the number of patients who received consultation (new and follow-up), availability of common psychotropic drugs, difficulties in implementing DMHP, training and working of the mental health care workers, etc., Depending on this report further steps are considered. Second, there is a monthly executive committee meeting of key persons of RH, SDH, and Primary Health Centers (PHC) with the CEO, Zilha Parishad, and district collector regarding all the monthly events of DMHP. Third, there is a meeting of all the program coordinators (DMHP and other programs) with the state mental health authority as per the Health department protocol for monitoring and evaluation and to propose suggestions and recommendations accordingly.

As far as community awareness programs are concerned, social workers coordinate with the gram panchayats of the villages of the district and ASHA workers of the respective regions and use the modules of information related to common mental illnesses to spread awareness among people. They give monthly reports to the program coordinators about all the community mental health activities.

The NHRC report found that DMHP had ensured good access to essential psychotropic drugs and that DMHP was considered and accepted as an effective, feasible, relatively low-cost, and higher-yield public health intervention as observed in a few states like Kerala and Gujarat.

As per the authors Gangadhar BN et al., 2023,[3] the mechanisms for evaluation and monitoring of DMHP, effective delivery of the services, improvement in accessibility and affordability in the primary mental healthcare services at the community level, considerable streamlining of the funding are developed. Indian Government had also set up a task force for primary mental healthcare, to come up with the recommendations in this context.

Drivers of DMHP

National Human Rights Commission (NHRC) and Judicial Activism: Judicial activism in India dates back to >3 decades and has continued to pay rich dividends with regard to mental health. The NHRC monitored mental hospitals across the country and suggested recommendations for improving the mental health scenario in the country. The recommendations included at least two psychiatrists to be posted at the district level for the DMHP along with psychologists, social workers, and nurses. Recommendations are also given for the taluka-level hospitals and primary health centers. Honourable Supreme Court has given directions to both the State governments as well as the union government to take necessary actions based on these recommendations.[19]

The National Mental Health Policy of India: The first ever dedicated policy for mental health was released in 2014 with the vision of promoting mental health and preventing and enabling recovery from mental illnesses.[20] There were many problems, missing links, and systemic issues creating obstacles in the implementation of DMHP. But, positive reports of DMHP implementation (WHO report on the Thiruvananthapuram district of Kerala, 2008), the Tamil Nadu story of having the maximum number of districts with functional DMHPs, and the independent evaluation of DMHP by the Indian Council for Market Research, led to the recommendation of expanding this program to districts across the country. The NHRC report found that DMHP ensured wide access to essential psychotropic drugs and that DMHP was accepted as a feasible, relatively low-cost, and highly impacting public health intervention as shown in the States of Kerala and Gujarat.[21]

Mental Healthcare Act (2017): In 2017, India passed the Mental Healthcare Act, with the main aim of protecting the rights of a person with mental illness and ensuring access to mental health services. The Act emphasizes the importance of community-based care and integrated mental health services into the primary healthcare system.

Cooperative federalism by the State governments and proactiveness of the governments: Many states are becoming centers of excellence in mental healthcare delivery at the rural and community levels. They can mentor and guide other states in the training of mental health professionals, formulating strategies for effective implementation of DMHP and helping to fulfill the objectives of DMHP. To ensure the smooth implementation of NMHP and DMHP, NIMHANS, and Niti Aayog have charted a course that emphasizes the need for a comprehensive and integrated approach to mental healthcare.[22]

Other positive changes that have been incorporated in the context of mental health in India are as follows.

1. Human resource development program under NMHP[23]: With Separate budgetary, to date, in India, 25 centers of excellence have been started, 88 departments of psychiatry in medical colleges have been upgraded and 29 mental hospitals have been modernized.

2. The Karnataka story: There is a notable development in Karnataka’s DMHP. It has moved much beyond the Bellary Model and included clinical services, capacity building, research, etc., along with many innovations in implementing the strategies. DMHP services are extended to specialized mental healthcare services at taluka and bock level, to community health centers and primary healthcare centers, the Manochaitanya Programme and the Karnataka Tele-mentoring and Monitoring Programme.[24]

3. National level initiatives from NIMHANS and NIMHANS digital academy: NIMHANS has been conducting many activities to scale up the DMHP across India. These activities mainly included training workshops/courses and capacity-building programs in collaboration with other state mental health authorities. NIMHANS digital academy offers digital/online courses on mental health for doctors, psychologists, social workers, and nurses. The certified professionals can work for the DMHP (nimhansdigitalacademy.ac.in). As of September 2020, 578 medical officers, 211 psychologists, 120 social workers, and 147 nurses have received diplomas in Community Mental Health. Two other mental health institutes in the country offering these services are Central Institute of Psychiatry, Ranchi, and Lokamanya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur.[3]

   There are various digitally driven initiatives across the country to enhance the functioning of DMHP through various digital methods. Training of primary Care Doctors and Rural Medical Assistants to screen, identify, and treat or refer patients of mental illness visiting primary care settings to higher centres.[25,26,27] Training ASHA workers for better retention of skills and better identification of patients with mental illness along with task shifting and task sharing in mental health.[28] Primary Care Psychiatry Programme (PCPP) for acquiring psychiatry knowledge, skills; retention of skills and utilizing those skills in providing psychiatric care in general practice with a positive impact on the provision of primary mental health care[29] and primary care Psychiatry training using blended methods (traditional classroom learning with e-leaning).[30]

4. Research: Research activities have been carried out at three levels. 1. Involving nonspecialist medical officers in identifying and treating common psychiatric conditions, 2. Focused on specific psychiatric disorders and populations and 3. Third category of research includes a wide variety of disparate dimensions including understanding the prevalence of psychiatric disorders, increasing the awareness about public mental healthcare further than the district level, changing the perception of healthcare workers, evaluating indicators for mental healthcare and its success, cross-country situation analysis on maternal mental health and available services, innovations at the community level and providing evidence to strengthen mental health systems.[31,32,33,34,35,36,37,38,39]

Recommendations

Following are a few recommendations for better functioning of DMHP. [Box 1]

Box 1:

Recommendations for improving the functioning of DMHP

• The national body of mental health professionals (Indian Psychiatric Society) can work jointly with the Government in promoting the extensive reach of DMHP in deeper sections of the country.

• Local psychiatrists associations can be involved in awareness and educational activities under DMHP.

• Awareness campaigns “in-person” or “online” can be prepared with uniform modules (short videos/PowerPoint presentations) by mental health professionals in the local understandable language on common mental illnesses to have a wide dissemination in rural areas.

• Incorporation of mental health education into the school curriculum will ensure mental health awareness and understanding from an early age.

• Health care workers or professionals working at the district level can be trained by online modules or in-person programs on how to identify and manage common mental disorders by the psychiatrists working in respective districts.

• Regular workshops and seminars can be organized to update doctors, nurses, and community health workers in mental health to improve the detection, diagnosis, and treatment of mental illnesses and best practices in mental health care.

• Availability of mental health professionals and commonly used psychotropic drugs should be ensured and frequency of mental health service provision should be increased wherever possible.

• Referral services to higher centers should be available free of cost and on time with sensitization of the resource persons about promptness in action and the way of communication with the person with mental illness and family members.

• Electronic and Social media can be effectively utilized for increasing the spread and impact of awareness and educational activities.

• Engaging communities in mental health initiatives and encouraging them to open discussions on mental health issues is significantly impactful and should be considered.

• It is needed to establish support groups and helplines within communities to provide emotional support and guidance to individuals and their families suffering from mental health problems on “regular basis.”

• Separate programs need to be formulated to deal with stigma related to mental illness effectively to prevent crucial time wasted in faith healing or other religious activities with the thought of relieving the mental illness.

• Authorities (state and central) need to ensure the sustainability and effective utilization of Tele”—mental health services and applications for remote patient monitoring and therapy (e.g. ensuring better integration of Tele MANAS with DMHP and e- Sanjeevani, better advertisement of Tele MANAS and integrating Tele MANAS with other national helplines for mental health issues, such as the Kisan Call Centres, the helplines related to TB, HIV, etc).

• Establishing State level digital academies with mentoring from AIIMS that are set up across India, on the model of Tele MANAS.

• Better streamlining of systems to make psychotropics availability seamless at PHCs and AAMs, particularly.

• Ensuring adequate funding, resources, and a supportive legal framework for mental health programs is needed at the district, state, and national levels to improve the quality of services provided.

• Encouraging implementation research in DMHP. Support for research initiatives to gather data on the prevalence of mental health disorders, treatment outcomes, and the effectiveness of various interventions is needed. Research findings can be utilized to adapt and improve mental health programs, making them evidence-based and tailored to the needs of the population.

Recently, in the context of DMHP, a few authors suggested abandoning the concept of community psychiatry to increase the arena of positive and preventive mental health services (mental wellness activities) in the community. They conceptualized Psychiatry as subdivided into “Clinical Psychiatry” and “Public Psychiatry” with clinical psychiatry being further divided into primary, secondary, tertiary, and quaternary care. On the other hand, activities under public psychiatry include wellness psychiatry, preventive psychiatry, disaster psychiatry, awareness creation, role of alternative and complementary medicine, mental health, and climate change, Screening of vulnerable populations at non-healthcare settings, lessons from COVID-19 pandemic and, policy-making activities.[40] This may increase the overall impact of DMHP in improving the quality of mental health services.

Evidence suggesting poor impact of DMHP

Goel DS in 2011, reviewed the status of mental health services in India and found that the top-down approach to planning, not related to the ground realities, improper governance, incompetency at the managerial level, and unrealistic expectations from primary healthcare workers play an important role in the failure of many programs despite of adequate funding. NMHP failed to achieve its targets over subsequent decades after its implementation. NMHP was revamped in 2001 and re-launched as part of the Tenth Five-Year Plan (2002-2007) and 7 fold increase in budgetary allocation. But the programme faltered due to the underperformance of those involved.[41]

Gupta S 2018, in a narrative review, mentioned that the impact of NMHP was limited by human resource and budgetary constraints, minimal participation of the community, ineffective training, poor collaboration with NGOs or private firms, and no mechanism for robust monitoring and evaluation method. The National Mental Health Policy has given a new force to the ongoing NMHP, however, its implementation has not yet evaluated.[42]

Ranade K 2022 mentioned that mental health programs in India have been limited to the administration of bio-medical psychiatry at the community level. The functioning of NMHP and MHCA are at completely different frames. MHCA is conceptualized on the basis of asserting a human rights and social model of disability whereas NMHP is based on the concept of global mental health that is bridging the treatment gap and providing bio-medical solutions to mental health problems.[43]

As per the India Mental Health Observatory (IMHO) part 1, there has been no comprehensive evaluation of the DMHP since the revision of the program done under the XII FYP based on recommendations suggested by the Mental Health Policy. Also, many recommendations from previous evaluations of DMHP remain unaddressed.[44]

As per the India Mental Health Observatory (IMHO) part 2 (June 2021), the implementation of DMHP is not uniform across the country. As states are free to make adaptations in DMHP implementation depending on various factors, there is a range of variations in the implementation of DMHP across various states of India.[45]

The India Mental Health Observatory (IMHO) part 3 with a focus on mapping the fiscal process highlighted funding-related issues in DMHP implementation. In this report, DMHP mentioned inconsistent fund flow, underutilization, difficulties in accessing funds due to administrative delays, and poor coordination between disbursement authorities at a state level.[46]

As per the India Mental Health Observatory (IMHO) part 4, the MHP group provided various recommendations to improve the functioning of the DMHP, such as transparency in program management, monitoring, and creating the space for technical support. Also to encourage greater community participation. (XIIth Plan DMHP Prepared by Policy Group.; 2012.) This report also highlighted that most issues in the implementation of DMHP, like administrative delays, require interventions outside the NMHP and are difficult to address solely by the specialists involved. Also, there are no clear guidelines about how “Ayushman Bharat Yojana” (2018) can affect the DMHP implementation and the comprehensive analysis of DMHP data is incomplete.[47]

The India Mental Health Observatory (IMHO) part 5 (Sept 2023) highlighted that there is no clear information about the allocation and utilization of the fund for DMHP. The system of integration of other programs like Ayushman Bharat Yojana with DMHP and converting primary health centers into Health and Wellness Centres (that provide mental health services) and then integrating it with existing DMHP services and infrastructure is not clear. Understanding the functioning and utilization of the fund in DMHP can help to improve its efficiency.[48]

Fund allocation and utilization

The most recent report about funding is available till 2021. Between FY 2015 and 2021, a total of Rs 52,224 lakh was allocated by the Centre to 37 states/UTs of India for the functioning of DMHP. It is found that funds have consistently been underutilized by the states over the years. Only 38% (Rs 19854.75 lakh only) of the total allocated amount was utilized by states/UTs. Only 10 states/UTs were found utilizing >40% of the allocated funds, and 14 states used less than 25% of the funds. Andhra Pradesh (78%), West Bengal (71%), and Chhattisgarh (64%) are the states with the highest percentage utilization of the funds compared to Telangana (5%), Uttarakhand (12%), and Jharkhand (12%) with lowest utilization rate as per the IMHO report in Sept 2023. The budget contribution by Central Government and State Government is 60% and 40%, respectively.[48]

Challenges and limitations

Despite the evolution and constant progress, India still faces challenges in providing comprehensive mental health care services to the increasing population. The stigma associated with mental illness and the limited awareness and significance given to mental illnesses in rural areas remain significant hurdles. Shortage of Mental Health Professionals is one of the most significant limitations including psychiatrists, clinical psychologists, and psychiatric nurses. India has a disproportionately lower number of mental health professionals compared to the population, making it difficult to provide comprehensive mental health services in all districts. The contractual nature of most of the jobs and problems related to the frequent transfer of trained staff are important challenges in implementing DMHP.[11] The Hindu (10 October 2019) reported that DMHP is severely understaffed with one psychiatrist catering to around one lakh to 10 lakh population in a district. Though there has been an increase in the number of psychiatrists throughout India in the last few years, most of them are practicing in cities and hence, psychiatrists available for working in rural areas or under DMHP are less. The distribution and utilization of these professionals also vary by state, and the data is currently unavailable. Also, the total number of Psychiatry postgraduate seats (including both Government and private colleges) in India is 1293 (as per the data available on the National Medical Commission website 2024) which is far less compared to the Indian population. The historical data on the number of MD/DPM psychiatry seats when DMHP started can be found on the National Medical Commission (NMC) website. This includes current figures as well. Infrastructure and Resources are comparatively inadequate. This can impede the effectiveness of mental health services delivery. Many districts do not have “well-equipped” mental health facilities, like there is a shortage of essential psychotropic medications and places for the care of the mentally ill. DMHP still has limited reach in rural and tribal areas. There are challenges related to the distance, transportation, and resources for communication which can be the obstacles for providing and receiving timely care. The need for seamless coordination and integration between mental health services and the broader healthcare system is another important challenge, this integration is needed for catering holistic care to people with mental or physical illnesses. Budgetary constraints can be an important limitation. Adequate funding is crucial for the sustainability and impact of programs like DMHP. Budgetary constraints can limit the expansion as well as the quality of services to be provided.

Training and retention of human resources is a key component of DMHP which is difficult in rural areas as health professionals prefer to work in urban areas due to the availability of better opportunities and overall living conditions. Data on the deployment and effectiveness of trained personnel under DMHP is often lacking in scientific literature. Direct feedback from trained individuals and PHC medical officers would provide better insights. Effective monitoring and evaluation of the program is difficult due to restrictions in data collection and system of reporting. India is a country of cultural and language diversity, tailoring the mental health services specific to the cultural contexts and addressing the language barriers can be complex but necessary for effective mental healthcare. The possibility of disparities in the quality and availability of services can not be overlooked while providing the services under DMHP. Addressing social determinants like poverty and unemployment though fall beyond the scope of the DMHP, is crucial for improving mental health and mental health services in the long run.

As per the Mental Healthcare Act (MHCA), 2017, an emergency treatment for up to 72 hours is allowed by a physician before referring the patient to a higher center. There is no provision for treatment of the mentally ill by other health professionals during the follow-up visit. Also, there is a limitation in the treatment of substance abuse patients in primary care settings. MHCA 2017 requires diagnosis to be made with classificatory systems (approved internationally) like the International Classification of Diseases 10^th Revision[49] It will be a tedious task for primary care physicians to get tuned to such classification systems.

Detailed case studies and data from states and districts performing well in mental health services are needed to identify best practices and areas for improvement. This information is typically not consolidated in scientific literature. There is limited information available in the public domain about the allocation and utilization of the funds for DMHP, it is further complicated by the introduction of Ayushman Bharat Health and Wellness centers.

Despite these limitations, the District Mental Health Program in India plays a vital role in increasing access to mental health services and reducing the treatment gap for mental illnesses. To enhance its effectiveness, continuous efforts are needed to address these challenges and improve the program’s reach and quality of care.

CONCLUSION

In conclusion, the District Mental Health Program in India has evolved over the years, moving from a pilot project to an integrated component of the National Mental Health Program. Efforts have been made to expand services, protect the rights of individuals with mental illness, and integrate mental healthcare into the primary healthcare system. Recent updates and efforts taken by the Government of India and state governments have improved the quality of services provided under DMHP. With the increasing use of the internet and mobile technology, DMHP has spread its arena of services more deeply and widely in the last few years. However, there is still work to be done to address many challenges associated with mental health in India though the recent developments seem promising as a substantial number of patients are now having access to the programme. After a couple of years, with an increasing number of Psychiatry teaching departments, there would be a sufficient number of Psychiatrists to work under DMHP for better functioning. Proposed recommendations need to be implemented for proper functioning, appropriate utilization of funds, regular evaluations, and adequate monitoring of DMHP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.