Mental health care in Karnataka: Moving beyond the Bellary model of District Mental Health Program

Karnataka state has taken many strides forward with regard to the District Mental Health Program (DMHP) and is one of the few states to have dedicated DMHP psychiatrists as team leaders in all the districts. Moreover, some of the recent developments have moved beyond the Bellary model and augur well for the nation. This article attempts to provide a summary of such developments in the state and discusses the future directions.

CORE SERVICES

DMHP in Karnataka offers (a) clinical services, including the outreach services (on a rotation basis), covering the primary health centers (PHCs), community health centers, and taluk hospitals; (b) training of all the medical officers and other health professionals such as nurses and pharmacists of the district; (c) information, education, and communication (IEC) activities – posters, wall paintings in PHCs, IEC activities for schools, colleges, police personnel, judicial departments, elected representatives, faith healers, bus branding, radio talks, etc., In addition, sensitization of Anganwadi workers, accredited social health activists, auxiliary nurse midwives, police/prison staff, agriculture department/horticulture department/primary land development bank staff, village rehabilitation workers, staff of noncommunicable disease/revised National Tuberculosis Control Program, etc.; and (d) targeted interventions are being focused on life skills education and counseling in schools, college counseling services, workplace stress management, and suicide prevention services. These initiatives have led to a phenomenal increase in patient footfalls to clinics [Figure 1] and >100,000 stakeholders are trained in various aspects of mental health (in the past 3 years).

Figure 1.

Chart showing the phenomenal increase in the number of footfalls covered over the past 3 years

SEAMLESS MEDICATION AVAILABILITY

The procurement has been streamlined. The state-level purchase is done by the Karnataka Drugs and Logistics Society, based on the indents collated from each of the districts, and then, sent to their respective district warehouses. Individual indenters (taluk hospitals, community health centers, and primary health centers) then need to procure them from the district warehouses. The amount spent for the purpose has gone up drastically to INR 3 crores (30 million rupees) in the past financial year (2017–2018). However, further streamlining is possible in the sense that the delays can be further curtailed.

THE COLLABORATION WITH THE KARNATAKA STATE WAKF BOARD

The WAKF board of Karnataka runs a “Darga” in south interior Karnataka. Thousands of persons with mental illnesses do come over here for religious cure. On a day of every week, the attendance crosses 10,000 footfalls. Recently, the authorities have agreed to come up with an allopathic PHC inside the campus of the Darga. The idea is to have integrated and comprehensive care for patients without hurting their religious sentiments. Although such collaborative initiatives are spread across the country, this one is occurring at a larger scale with involvement of governmental agencies [Table 1].

Table 1.

Details of the key developments and innovations in mental health care in India

Key developments and innovations	Details
Human resources	More than 213 personnel are working for the DMHP of Karnataka
TMHP	TMHP is functional in ten Taluks[1]
An MOU was signed between NIMHANS and the Government of Karnataka	Formation of state implementation team for overseeing the implementation, monitoring, and research aspects
CAD services	Assertive community treatment for persons with severe mental illnesses who have dropped out of the treatment. Based on the success of the pilot, CAD services have been extended to more than 6000 patients across the state in the past financial year
PCPP[2]	NIMHANS has developed a module for training primary care doctors who are the first contact for the majority of patients with psychiatric disorders. PCPP includes the “CSP” and OCT, particularly the tele-OCT for PCDs. An offshoot of PCPP, the KTM has been introduced and since January 2019, more than 400 PCDs are trained. With this, the identification and treatment of the psychiatric disorders for the general patients is expected to be increased[3]
v-CSD	Video conferencing-based mentoring program being conducted separately for DMHP nurses, DMHP social workers, and DMHP psychologists of Karnataka. 313 nurses, 532 social workers, and 675 psychologists have been trained, till now
E-monitoring software for DMHP	NIMHANS, Government of Karnataka, and the International Institute of Information Technology, Bengaluru collaboration to develop a software solution to monitor DMHP in Karnataka
MCP	MCP, also called the “Super Tuesday” program, was started in 2014.[4,5] Consultant psychiatrist/BMHP team goes to taluk hospitals (on the first Tuesday of every month) to provide outpatient-based clinical services
Maanasadhara Program	Day-care rehabilitation service facility exclusively dedicated to those with severe mental illnesses. As on today, 15 are functional incorporating vocational training in simpler jobs, recreation, and physical exercises.
Maanasakendras	Half-way homes meant to cater to those with severe mental illnesses. A maximum of 6-month stay is allowed. Inpatient activities include activity scheduling, physical exercises, and vocational training.
Clinical postings of MD residents to DMHP	From August 2017 onward, the NIMHANS has started posting MD students every month for 2-weekly postings into the DMHP. Students will be part of all the DMHP activities, including clinical services, training initiatives, and the administrative activities

TMHP – Taluk Mental Health Program; MOU – Memorandum of understanding; CAD – Care at doorsteps; PCPP – Primary Care Psychiatry Program; v-CSD - Video-based-Continuous Skill Development program; MCP – Manochaitanya Program; CSP – Clinical Schedules for Primary Care Psychiatry; OCT – On-consultation training; PCDs – Primary care doctors; KTM – Karnataka Telemedicine and Mentoring and Monitoring Program; NIMHANS – National Institute of Mental Health and Neurosciences; DMHP – District Mental Health Program

RESEARCH INITIATIVES

Although excellent evidence-based studies have come out in community settings, actual involvement of government machinery in these kinds of initiatives is few and far. Their involvement is imperative for the evidence to become pragmatic and generalizable. Of course, by doing so, the methodological rigor compromises a bit. NIMHANS and Government of Karnataka have been collaborating for such service-driven research initiatives for over a decade and a half. Community-based interventions are going on in three taluks – Thirthahalli, Turuvekere, and Jagaluru, wherein cohorts of severe mental disorders are being cared for. In addition, several research questions (of public health significance) are being answered.[6,7] Exciting new initiatives are also underway: examining the magnitude of reduction of treatment gap by these community interventions, impact of care at doorsteps (CAD) services from the DMHP machinery, impact of technology-based mentoring program for DMHP staff, evaluation of the impact of tele-OCT, etc.

DISCUSSION AND FUTURE DIRECTIONS

All the above-mentioned activities in Karnataka take it beyond the Bellary model of DMHP. For example, the Memorandum of understanding (MOU) between NIMHANS and the state gives the flexibility and easy maneuverability for active collaboration. Odisha is another state which has taken this path of MOU. This collaborative activity can be expanded pan India as there are several Centers of Excellence spread throughout India. Another aspect of the Karnataka story is collaborative research activity. As described above, many activities going on across the state have the potential to inform public health policies. Karnataka has also been able to counter long-standing and well-known criticisms of DMHP/NMHP: for example, issues related to human resources, availability of medications, funding, mentoring and monitoring, and sustenance, etc., at least to an extent. Of course, the state needs to do much more for mental health care. For example, compliance with Mental Health Care Act-2017; handling unequal distribution of mental health human resources; rigorous involvement of local administration to tackle micro-level issues; refining DMHP to suit special populations such as geriatric, children, and adolescents; and perinatal and upscaling urban DMHP, in areas such as Bengaluru Metropolitan City. Another area for improvement is that the DMHP evaluation strategies should move beyond head counting and consider meaningful patient-related outcomes, including cost-effective analysis. Digital technology should further be exploited. The upcoming Karnataka Mental Healthcare Management System is a step in the right direction.[8] Finally, the DMHP should involve health and wellness centers to cater to the mental health needs, particularly for follow-up services, case detection, providing basic counseling, stress management, advocating lifestyle changes, relapse prevention strategies, and other preventive and promotive strategies.