MENTAL HEALTH CAREPLAN Country- India State- Maharashtra District- Ratnagiri City- Chiplun

Population characteristics Size: 80, 000 Semi urban setup Gender distribution: 55:45 (more women as compared to men) Income: mainly low to middle Occupation: Factory jobs, service delivery jobs in city and farming and farm labour in the outskirts. Family structure: Nuclear (city) and joint families (outskirts)

Population characteristics Religion: Hindu (70%) and Muslim (20%) and Buddhist (10%). Language: Marathi and Urdu Operant socio-cultural dynamics like caste, literacy and financial status operant indirectly affecting access to health care

Existing health resources Government sector: Sub district hospital with specialist care providing IP and OP care situated 7 km outside city. CHC provides OPD service inside the city. PHC situated 13 km outside city. Private sector: Multispecialty Hospital in Dervan 17 km away. 1 small multispecialty and 7-8 small specialty hospitals inside Chiplun. Around 50 General Practitioners(various systems of medicine) providing OP care. 3 Academic institutions (nursing and medical college in neighboring city) providing health care.

Existing health resources Qualified Mental Health Professionals 2visiting Psychiatrists offer once a month OP service Recent addition of 1 Psychiatrist resident in Chiplun who wishes to increase service availability Unorganized care provider 1.Hypnotherapist 2.Counsellors 3.Herbal doctors 4.Traditional Midwife 5.Traditional Healers 6.Religious healers

Burden of mental health conditions Mood, anxiety and somatoform disorders (50%-60%) Alcohol related disorders (20%- 23%) Developmental disorders and seizure disorders (10%- 12%) Psychotic disorders (10%- 12%) Data based on one visiting Psychiatrists undocumented rough estimate, based on his out patient list.

Treatments available Private out patient clinics run by a psychiatrists once a month Private practitioners/ general practitioners providing eclectic interventions Paraprofessional services offering hypnotherapy, counselling etc.

Gaps in Service Resource constraints affecting access Affordability an issue in low income group Cultural and social barriers to access care Katkari tribe have high prevalence of mental health problems but not accessing health care

Gaps to be addressed Lack of research data about prevalence and burden of mental health problems Lack of adequate availability of mental health service, especially for child and adolescent, elderly and substance users. Lack of treatment options as focus mainly on pharmacotherapy Economic burden on caregivers. Lack of awareness in community and will from medical fraternity to recognize and treat mental health issues Stigma associated with help-seeking for mental health issues

Mission of the mental health care plan Easily accessible, affordable, equitable, quality mental health care integrated with physical health care system.

Easily accessible, affordable, equitable, quality mental health care integrated with existing health care system AccessibilityAffordabilityEquityQuality Community PHC level Sub-district level Self help Awareness Teacher training Police, ASHA ANM, MPHW, CMHW, mobile Other Prof. Self help Family support Self help group Teacher training Fund raising activities Self help Family support Teacher training Family support Screening Dr K, CMHW,MO ASHA ANM, MPHW PHC staff, GP, other providers, training Screening ANM, MPHW, ASHA Trained PHC staff GP,ANM, MPHW, ASHA, CMHW and Dr K Medication Club with other health programmes Medication Screening, diagnosis and treatment at sub- district hospital Screening Dr K, MPHW, MO, specialists, nurses

Modus Operandi Values Be the change, have a plan(short term and long term) Learn from other similar initiatives(IPH/Banyan/Sangath) Collaborate and Mobilise existing resources- build bridges Care led by stakeholders particularly user group Innovate and seek sustainable options Make health care a means to community building Monitor progress and and learn from mistakes Start small and scale up steadily Have SMART goals

Modus Operandi Start with team of 1 psychiatrist and 2 trained nurses (CMHW) with ongoing support from Psychologist based in Mumbai, local NGO and well-wishers in the community Start a private mental health clinic offering dedicated service to self referred clients with service informed by needs of stakeholders Establish links with partners in care through inreach and outreach programmes Offer regular training and supervision to partners in care Evaluate service through formalised procedures

Modus Operandi Inreach 2 private sector clinics(GP/paraprofessional/speciality clinic ) and 1 public sector clinic- twice a month service Outreach 1 School, 1 College, 1 Corporate,1Remote community-once a month service OP clinic in private multispeciality hospital-weekly service Clear guidelines on what and what will not be offered Initiate wallpaper and regular workshops promoting mental wellbeing to raise profile of service Plan and execute activities during the mental health week to raise profile of service Internal audit every 6 months External audit every 2 years (IPH/ Sangath) Celebrate success and learn from failures

Stepped care interventions for CMD in community Packages of care 1)Self help- maintain routine, increase enjoyable activities, sleep hygiene, physically activity, seek support, reduce demands, yoga, meditation, spiritual pursuits, grief work in case of loss, avoid self medication 2)Family/friend/colleague/ volunteer- encourage self help, informal support through counselling and task sharing, raise local awareness in order to encourage help seeking and reduce stigma, encourage treatment adherence, recovery and reintegration

Stepped care interventions for CMD PHC onwards 1)CHC-Screening, diagnosis and treatment offering choice delivered by staff with supervision from specialist team (CMHW as link with Psychiatrist) 2)GP practices offering similar service with CMHW as link with Psychiatrist 3)Efforts to engage with paraprofessionals, offer training and supervision 4)Emergency mental health first aid available through CMHW presence at PHC and GP practise at regular clinics and on phone at other times 5)Regular training and monitoring of service utilisation and clinicians level of confidence

Stepped Care interventions for SMD in community Packages of care 1)Self help- maintain routine, sleep hygiene, physical activity, seek support, reduce demands, avoid self medication, concordance of medication 2)Family/friend/colleague/ volunteer- encourage self help, informal support through counselling and task sharing, raise awareness in order to reduce stigma, encourage treatment adherence, encourage recovery and reintegration through CBR

Stepped Care interventions for SMD PHC onwards 1)PHC- diagnosis and treatment offering choice of treatment options delivered by staff with support from CMHW and Psychiatrist. Case management to encourage treatment adherence. Offer regular physical health check, relapse prevention work, lifestyle modification and coping skills with continuing model of care. 2)GP practices offering similar service through CMHW acting as link with Psychiatrist 3)Efforts to engage with paraprofessionals, offer training and supervision 4)Emergency mental health first aid delivered by CMHW at PHC and GP at regular clinics and on phone at other times. Availability of emergency respite bed locally and support for carer 5)Regular training and monitoring of service utilisation and clinicians level of confidence

Stepped care intervention for developmental and behavioural problems in community 1.Parents-Premarital life skills training, Parenting workshops, SHG, measures to simplify routines and schedule activities, encourage normal schooling with remedial measures to improve performance, coping skills along with yoga, meditation and spiritualism 2.Career guidance, livelihood and life skills training for children and adolescents 3.Family support during pregnancy, protection from domestic violence, encourage literacy,and prevent child and consanguineous marriages 4.Teachers trained to detect and address special needs and prevent bullying

Stepped care for developmental and behavioural problems PHC onwards 1.PHC- good perinatal care, monitoring of developmental milestones, early detection of sensory deficits,,Screening all mothers, for diagnosis and treatment of post natal depression and puerperal psychosis, by trained staff with regular supervision( CMHW and Psychiatrist), 2.GP practices offering similar service with supervision (CMHW and Psychiatrist) 3.Efforts to engage with paraprofessionals, offer training and supervision 4.Emergency mental health first aid available through CMHW presence at PHC and GP at regular clinics and on phone at other times. to support carer 5 Screening children and adolescents through outreach clinics 6 Regular training and monitoring of service utilisation and clinicians level of confidence

Stepped care intervention for Substance Use disorders in community 1)Self help-acknowledge drinking as a problem and harms caused, gradual and safe reduction, exploring healthier coping skills, look out for underlying CMD seek timely help. If CMD identified, maintain routine, increase pleasurable activities, sleep hygiene, stay active, seek support, reduce demands, yoga, meditation, spiritual pursuits, grief work in case of loss 2)Family/Friend/Colleague/ Volunteer/ Police- encourage seek help, self help interventions, informal support through counselling and task sharing, raise awareness locally in order to tackle stigma, encourage treatment adherence, recovery and reintegration. Support groups for carers

Stepped care intervention for Substance Use disorders PHC onwards 1)PHC- diagnosis and treatment offering choice of treatment options delivered by staff with support from CMHW and Psychiatrist. Case management to encourage treatment adherence. Offer regular physical health check, relapse prevention work, lifestyle modification and coping skills with continuing model of care along with yoga, meditation and spiritualism as appropriate 2)GP practices offering similar service through CMHW acting as link 3)Efforts to engage with paraprofessionals, offer training and supervision 4)Emergency mental health first aid delivered by CMHW at PHC and GP at regular clinics and on phone at other times. Availability of emergency respite bed locally and support for carer encourage problem solving and ventilation 5)Regular training and monitoring of service utilisation and clinicians level of confidence

Models of care Facility based care Existing mental health clinics provided by visiting Psychiatrists New dedicated mental health clinic offering comprehensive regular mental health care and acting as nodal agency to develop and expand a mental health services locally General Practitioners, Primary care physicians and paraprofessionals offering mental health care with support from dedicated mental health clinic

Care delivered at Facility Mental health awareness Screening, diagnosis and delivery of various evidence based treatment options Training offered to other partners in mental health care Mental health promotion- access to stress reduction programmes(yoga, meditation, hobby classes, art groups) Providing for physical and mental health care

Models of care Outreach/ Inreach services Outreach clinic in schools and colleges Outreach clinic in remote community Inreach clinic at GP/PHC/Sub-district hospital Outreach clinic in Corporate sector Outreach clinic in Private general hospital

Care delivered at outreach clinics Liaise with community leaders, create awareness and demand generation Identify resourceful personnel to take on role of community health volunteers and link persons Screening, diagnosis and delivery of various evidence based treatment options Capacity building of key professionals in delivering stress management skills, remedial measures and life skills training Encourage continuing care, livelihood training for community based rehabilitation integrated with other government schemes Enhancing productivity in corporate sector and mobilise funds through CSR

Monitoring and evaluation MIS to record number of consultations, diagnosis and treatments given which will help monitor service needs,inform planning and effective service delivery and can also act as tool for supervision and training Daily register to document in short person specific information for follow up used especially by CMHW which can also act as tool for supervision and training Client case notes having detailed accounts of assessment, diagnosis, and treatment given at primary care used as tool to train and supervise professionals Feedback sought from partners of care with mechanism to keep it anonymous to make it more effective Rating scale given to clinicians to measure clinical confidence Audit cycle every year

Barriers Limited human resources Lack of funds Lack of motivation of overburdened partners in care Lack of operational facilities for inreach and outreach services Lack of engagement of service users in mental health framework Competing priorities of service user, family and partners in care Power dynamics inherent in society

Strategies to address Barriers Fundraising activities Liaising with the NGOs and corporate sector to mobilise funds Improvement in working relationships through regular feedback mechanism for effective communication smooth working of systems Team building to keep partners in care interested in agenda Acknowledging mistakes and learning lessons to inform ongoing work ethics Incentivizing mental health care package for partners in care Liaising with the ward members in municipality for operational issues Regular Monitoring and evaluation of interventions,

Thankyou Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has Margaret Mead

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MENTAL HEALTH CAREPLAN Country- India State- Maharashtra District- Ratnagiri City- Chiplun