District Mental Health Program - Need to look into strategies in the era of Mental Health Care Act, 2017 and moving beyond Bellary Model

District Mental Health Programme (DMHP) was started under the National Mental Health Programme (NMHP) to decentralize mental health services and to provide mental health service at the community level by integrating mental health with the general healthcare delivery system. NMHP was adopted in the year 1982. India was one of the first developing countries to adopt this program. Main objectives of the program were as follows:

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. Encourage the application of mental health knowledge in general healthcare and social development

3. Promote community participation in mental health service development and to stimulate efforts toward self-help in the community.[1]

To achieve the objective of the program, it was decided to increase workforce development, training of health professionals in mental health, and the integration of mental health and physical health. To achieve this objective, pilot projects were implemented in Bellary district of Karnataka, and this model was developed for DMHP. The Bellary model demonstrated that the primary health center doctors and workers could be trained and supervised to identify and to manage the certain types of mental disorders as well as epilepsy along with their routine work at the primary health centers. Thus, the DMHP was launched in the year 1996 (in IX^th 5-year plan) in four districts under the NMHP.[2] Now, it has developed to include 123 districts under the XII^th 5-year plan.

DMHP has been highly successful in providing mental healthcare to the community at least to the district level. However, providing mental healthcare beyond the district level has been very difficult. The goal of training doctors and handing over of mental health to primary physicians has faced many hurdles. A lot of emphasis has been given on training medical officers and other health professionals in diagnosing and treating mental health disorders. It has been emphasized that awareness about mental illness will lead to early detection and starting of treatment and referral to tertiary centers, and the aim is to follow-up management by primary care physicians in consultation with the higher centers.

The National Institute of Mental Health and Neurosciences (NIMHANS) has been providing 3 months’ training of medical officers to empower them in treating psychiatric disorders at the primary level.

Research conducted by Indian Council for Market Research has shown that most of the centers started under the IX^th 5-year plan are operational but mostly at district and subdivisional levels. Outpatient Department services are operational, but the district team is providing service, and it has not been possible to transfer the care to general healthcare physicians. It was also found that for majority of patients, 68%–98% first contact hospital remains a district hospital or mental hospital.[3]

Medical officers trained under the program have better awareness of mental illness but still lack of confidence in treating mental disorders. There is also lack of confidence on the part of beneficiaries from taking treatment from nonmental health professionals even after so many years. The National Mental Health Survey conducted by NIMHANS found that the treatment gap for mental disorders ranged between 70% and 92% across different disorders as follows: common mental disorders – 85.0%; severe mental disorders – 73.6%; psychosis – 75.5%; bipolar affective disorder – 70.4%; alcohol use disorder – 86.3%; and tobacco use – 91.8%. The median duration for seeking care from the time of the onset of symptoms varied from 2.5 months for depressive disorder to 12 months for epilepsy. In majority of the cases, a government facility was the most common source of care.[4]

This huge treatment gap is an area of concern, and many strategies are being planned such as the use of smart phones for reaching the unreached and hand-holding of different stakeholders by higher centers. One of the major impediments to care by other health professionals and medical officers has seen them being overburdened with physical care and fear of using psychotropics and their side effects.

In this era of litigations and courts coming down heavily on any deviation from standard of care, it will become increasingly difficult to provide mental healthcare through primary physicians and health workers. If some medication is given by health workers under the guidance of psychiatrist and some serious adverse reaction occurs, it may be considered a culpable offense by the court of law. Even in telepsychiatry services, the primary care physician will be reluctant to take responsibility.

The Mental Healthcare Act (MHCA), 2017 allows only emergency treatment for 72 h by a physician before referral to higher center, and there is no provision for treatment by a nonmental health professional during follow-up. Even there will be serious limitation in treating drug abuse cases in primary care. MHCA requires diagnosis by internationally recognized classificatory systems like International Classification of Diseases 10^th Revision.[5] It will be an uphill task for primary care physicians to become familiar with such systems.

Hence, there is a need to strategize and look beyond the Bellary model to empower primary care physicians and health workers in diagnosing and treating psychiatric disorders in primary healthcare or making adequate legal framework to safeguard them. Resource building and workforce development become imperative in this regard.