Taluk Mental Health Program: The new kid on the block?

This article highlights the platform and framework for the new public mental health initiative, the Taluk Mental Health Program (TMHP), rolled out by the Government of India, as part of the expansion of the District Mental Health Program. In this initial phase, TMHP has been approved for ten taluks of Karnataka state. In the authors' collective opinion, few of the initiatives in the country could be considered as foundations for conceptualizing the TMHP (a) research programs and projects in the community, (b) community intervention programs running in two taluks of Karnataka since the past one and a half decade (Thirthahalli and Turuvekere taluks of Karnataka), and the (c) Primary Care Psychiatry Program of National Institute of Mental Health and Neurosciences. The article briefly describes the above initiatives and ends with further suggestions to scale up TMHP. Copyright:

INTRODUCTION

A new, refreshing development has occurred the previous year (2018–2019) in the history of the National Mental Health Program (NMHP). Funds have been allocated to start mental health programs in ten taluks (tehsils) of Karnataka. This, first of its kind initiative, tentatively named the Taluk Mental Health Program (TMHP) will have one psychiatrist and one social worker (for each taluk). This taluk-level program could be conceptualized based on the format of the current District Mental Health Program (DMHP) in the context of the vast need (for such public health initiatives) to penetrate deeper into the communities. Taluks have been selected based on their population and lack (relative) of readily available services. The taluks with respective districts are Jamkhandi (Bagalkot), Chikkodi (Belagavi), Hospet (Bellary), Basavakalyana (Bidar), Sindagi (Bijapur), Gauribidanur (Chikkaballapur), Chittapur (Gulbarga), Madhugiri (Tumkur), Sirsi (Uttara Kannada), and Gangavathi (Koppal). In this article, a conceptual framework for TMHP is proposed based on the extensive work (detailed below) that has gone at various places of India in the past two decades or so.

Pilot projects and programs aimed to show that psychotic disorders in the periphery can be effectively identified and managed by nonspecialist community-level resources. There has always been a demand for community-based interventions (CBIs) due to nonavailability of specialists and increasing burden of these disorders in the background of huge treatment gap in the community. CBIs are models of collaborative care involving hospital-based care focusing on pharmacology and acute care followed by community care that include psychoeducation, adherence management, and brief psychotherapy essentially delivered by nonspecialist health workers (lay health workers). CBIs have found to be effective for severe and common mental disorders (CMDs) in low- and middle-income countries (LAMICs). This has been demonstrated in comparison with only hospital-based care groups with lay health workers providing such interventions under specialists' supervision at the community level. These lay health workers are social workers, rehabilitation staffs, and other volunteers including lay counselors. They are recruited with minimum required educational qualification, trained for a substantial period on administration of the specific research tools and interventions under respective programs, and then let out to cater for delivering clinical services for patients. With the supervised and collaborative model, these programs have achieved to show that CBI is accessible and feasible in LAMICs to cover the treatment gap.[1234567]

Community intervention programs aimed at identification, management, and follow-up of patients with psychotic disorders in the community. These are examples of co-location models,[8] wherein psychiatry clinical services (by specialists) along with either general primary care services or other specialty services are available under the same roof (either in the primary health centers or taluk general hospitals). Active case-finding techniques were employed in these taluks using the key informant as well as the snowballing techniques. These programs do not have research as their primary agenda. The overall aim of these programs is to identify, treat and follow up all patients with psychoses in the entire taluks (schizophrenia in Thirthahalli and Turuvekere taluks; schizophrenia and bipolar disorder in Jagaluru taluk). For each person with psychosis, 4–5 persons with other disorders have been treated. A number of public education/awareness programs have been conducted. Disability camps have been conducted in which more than 1000 beneficiaries have received disability certificates. Of course, many important publications have emanated from these initiatives.[9101112131415]

Finally, the recently conceptualized and operationalized Primary Care Psychiatry Program (PCPP) of NIMHANS, Bengaluru, is a digitally driven innovation to bridge the treatment gap further. It uses a hub and spokes model to mentor primary care physicians (PCPs) in detecting and providing basic treatment for psychiatric disorders. PCPP uses an eight-page adopted psychiatric curriculum called the Clinical Schedules for Primary Care Psychiatry (CSP) that has a screener for psychiatric disorders followed by management guidelines. Psychiatric disorders covered include tobacco and alcohol use disorders, psychotic disorders, somatoform, anxiety, and depressive disorders. This schedule contains culturally appropriate questions and transdiagnostic classification. Another important part of PCPP is the Tele-On Consultation Training (Tele-OCT). Principles of Tele-OCT include incorporation of adult learning principles, bottom-up approach, and entry to exit consultation approach with minimal disruption of clinical work of the PCPs.[16] After the success of Tele-OCT in Mandya district, the same (along with other two modules of PCPP) is being expanded throughout the Karnataka state.

In this concept article, the authors argue that the proposed operational plan for TMHP suits well for the sanctioned human resources, while retaining the potential for reducing the treatment gap in the context of a public health perspective.

CONCEPTUAL OPERATIONAL PLAN FOR THE TALUK MENTAL HEALTH PROGRAM

Severe mental illnesses

Schizophrenia and bipolar affective disorders rank among the top disabling disorders of all medical illnesses,[17] causing huge burden.[18] They have specific characteristics that help to target them under the TMHP: (a) they are easily recognizable and diagnosable by even the nonspecialists. (b) They are the face of psychiatric disorders to the communities, contributing the most to stigma. Hence, better outcomes with treatment could pave the way for reducing stigma and thereby integration into the community.[19] (c) Definitive psychopharmacological treatments for these disorders are available free of cost under DMHP. A combination of pharmacotherapy and low intensity psychosocial interventions can bring about long lasting positive changes in the course, outcome, functioning and family burden.[20] (d) These are low prevalence disorders at primary care, thereby causing lesser burden to the already existing primary health-care (PHC) system. Identification and initiation of treatment: They are easily identified using the “Symptoms in Others” tool, an instrument designed for use by nonspecialist health workers such as accredited social health activist (ASHA) to identify severe mental illnesses (SMIs) in the communities during her routine household visits.[21] ASHAs can be trained en bloc in its administration in about an hour and a half and subsequent use with patients in <2 min that has been demonstrated successfully both at Jagalur and Turuvekere. Any positive screen can be referred to the taluk psychiatrist or a medical officer who would diagnose, investigate (if necessary), and start treatment along with basic psychoeducation (the medical officer should receive a brief training at a mental hospital or psychiatry department of any medical college/hospital). The social worker/psychologist at the taluk hospital and community nurse at the PHC can then take over their respective roles for community care alongside PHC medical officer following up pharmacotherapy. The positive evidence to this approach is robust with a number of outcomes including the course and outcome, work functioning, and course of disability over a period of time.[45791012] Follow-up, house visit, and rehabilitation: If the patient drops out of the outpatient or postinpatient services, house visits can be planned to sort out issues and bring back the patient into the treatment loop with subsequent regular follow-ups. Further link-ups with various government and nongovernment organizations (NGOs) present locally can also be facilitated on a case-based necessity.

Ensuring such services over a period of time could cater to about 70% of persons with SMIs. The remaining 30% will be treatment-resistant requiring specialized inputs from secondary/tertiary care centers.[9] In addition, a couple of beds can be reserved for admitting persons with SMIs. If anesthetists are available, electroconvulsive therapy (ECT) can also be considered besides OP services being the predominant service provided.

Common mental disorders

These disorders are more prevalent than SMIs.[22] About 10%–40% of any patient attending the primary care doctors (PCDs) do have a CMD.[23] Hence, if PCDs are adequately empowered, they can treat such patients at ease without an increase in the count of their regular consultations. The dictum is to empower them to identify and start first-line treatment which can be continued if there is a considerable response. The Clinical Schedule for Primary Care Physicians (CSP) module can be utilized for this purpose.[16] Nonresponsive and resistant cases can be referred to the taluk psychiatrist. The psychiatrist can be the lead in this task and if necessary can undergo training on “how to conduct Tele-OCT” and get certified. Once the psychiatrist undergoes training himself, he/she can in turn train PCDs of the taluk. In CSP, the authors have used the transdiagnostic approach to simplify the diagnostic method, easy-to-understand prescription guideline making it less time-consuming for consultation. While the collaborative approaches will be better suited to manage SMIs, true integration of mental health into general health care can occur with CMDs as medications used for treating CMDs are generally safe and effective and can be easily prescribed by PCDs.[24]

Substance use disorders and providing clinical coverage for other special populations

These services could be provided during their routine consultation with a course of training in managing withdrawal symptoms and relapse prevention strategies. The authors believe that any complicated withdrawal should not come under the purview of PCDs and should be promptly referred to higher center for specialist care, i.e., the taluk hospitals. As regards the special populations (children, adolescents, geriatric, and perinatal), basic management can occur at the taluk level and could use referral services for complex cases. Resources available in other parallel national programs such as the reproductive and child health programs and the national programs for the elderly and the Non-Communicable Diseases programs need to be harnessed in order to provide specialized care to this population.

Other activities are as follows:

Inpatient services: Inpatient services can be started with a small unit in the taluk hospital. Acute psychiatric emergencies can be managed at the facility, however, not before fulfilling prerequisites for support staffs

Training other health-care staffs including auxiliary nurse midwives (ANMs), nurses, pharmacists, and ASHA workers on their roles in identification, referral, provision of basic psychosocial interventions, etc.

Involving faith healers and practitioners of alternative medical systems, namely Ayurveda, Siddha, Unani, and Homeopathy. This area particularly requires further exploration and inquest to co-ordinate and work in tandem toward the benefit of patients/families. This is essential as they cater to a huge chunk of population, particularly in rural taluks, so missing this vital link in providing care to those affected by mental illnesses can be avoided

Information, education, and communication (IEC) activities for school and college teachers, police, judiciary and social welfare departments, postofficers, banks, co-operative societies, etc.

Targeted interventions. These are a set of interventions given by the Ministry of Health and Family Welfare, Government of India, that is run as a mandate by all DMHPs which can be provided even at the taluk level. The interventions are listed below:

College counseling services: Can be started in colleges where adolescent-specific issues could be handled, namely coping skills, interpersonal skills, conflict resolution skills, anger management techniques, and skills to be away from illicit drugs and stress management

Suicide prevention program initiation such as gatekeeper training programs in jails, workplaces, colleges, etc.

Life skills education in schools, particularly in primary and high schools

Workplace stress management.

Linkages with other agencies: The taluk headquarters is a nodal point containing offices of all major government departments. Links with judiciary, education, police, and social welfare departments along with local NGOs can help improve and scale up delivery of mental health care.

Role of psychiatrist/medical officer in Taluk Mental Health Program

To fulfill the role as a program officer by supervision and monitoring of the TMHP services and workforce

Running outpatient department services and maintaining records of patients along with prescription of psychotropic medications

Handling inpatient unit along with emergency care

Involving in training of PHC medical officers, social workers, community nurse, ASHAs, and ANMs for detection and basic intervention for mental illness in the community

Conducting camps, IEC programs, home visits, and outreach programs.

Role of Psychiatric Social Worker/Psychologist in Taluk Mental Health Program

Being the first contact for patients/families for their needs, reminding follow-up dates, and assisting to follow life-style modifications

Handle interpersonal, psychosocial issues and rehabilitation aspects including prevocational assessment, placement, and support of persons with mental illness

Coordinating IEC, school mental health program, deaddiction camps, disability certificate camps for intellectual and developmental disability, mental disorders, etc.

Coordination of disability certificates and rehabilitation plans by liaising other departments, especially social welfare (Village rehabilitation workers, Multipurpose rehabilitation workers, etc.), education department (for children with special needs), and clinical psychologists

Initiation of self-help groups, coordination with NGOs and other agencies for psychosocial issues of women in distress

Planning for homeless patients and address distress of suicide attempters in the taluk.

Role of Community Nurse in Taluk Mental Health Program at the primary health-care level

Ensure continuity of care by networking with ASHAs and ANMs

Home visits during challenges for follow-up

Maintaining specific registries for those patients on lithium, depot antipsychotics, clozapine, and ECT at the PHC.

All these could be made systematic, and accountability would be ensured if electronic records are available.

Challenges anticipated in implementation

Difficulty in recruiting psychiatrists

Absorption of staff of TMHP by the taluk health administration for other purposes which might push mental health to become their secondary task!

“Contractual” nature of jobs with related difficulties

Challenges related to frequent transfer of trained staff

Estimate the burden on exchequer when state has to own it up on its own.

DISCUSSION AND FUTURE DIRECTIONS

For the first time in the history of NMHP, funds have been granted to extend the program to taluks (tehsils). This marks a great beginning toward the aim of (a) reducing burgeoning treatment gap and (b) achieving the ideal state in terms of doctor: population ratio.[25] Considering the average population of each taluk being 0.2 million,[26] provision of one psychiatrist/medical officer to serve that population can be assumed to be reasonable. In addition, one social worker/psychologist would be a part of the TMHP. Alongside these personnel, one or two community nurses at the PHC level would involve in identification of possible cases as a part of NMHP as a whole.

One conceptual difference between DMHP and TMHP lies in their preparatory phase. The DMHP Bellary pilot project testing started with specific objectives aligning with those of the NMHP with successful outcome. For TMHP, however, the conceptual framework was drawn on from multiple pieces of pilot work as described above. The research projects had taluks as their area of operation and the feasibility of CBIs were established. As regards the community intervention programs at Thirthahalli (Shivamogga district) and Turuvekere (Tumkur district), liaising with the local health administration was part of the plan right from the beginning. Also, only the available human resources were made use of, without burdening their routine work for case identification, follow-up and low intensity psychosocial interventions. OP services were started either at the PHC or the taluk hospital, and a psychiatrist visit happens once in 2 months for providing the same. It may be noted that a team of one psychiatrist and a social worker can provide a reasonable degree of OP services catering to the entire taluk. Another background work that was responsible is the PCPP of NIMHANS in association with Government of Karnataka, wherein a host of PCDs are trained via telementoring process who in turn have catered to hundreds of patients with psychiatric disorders in a short span of time. With these experiences in the background, a proposal was sent to the central government requesting for funds to start TMHP.

As regards the nature and structure of TMHP, it can broadly mirror that of DMHP but with greater penetrance into the community. Greater assertive outreach services are another possibility of TMHP. Training medical officers and other health staff can be covered in relatively lesser period, as is the possibility of better monitoring. Linkages to other stakeholders can actually be better, and disability boards can be set up in taluk-level itself. Ideally, small inpatient services for acute psychiatric problems could also be started in taluk hospitals; however, it could predominantly function as OP services including the outreach services. Overall, the issue of treatment gap can be attacked more aggressively and in a better-focused fashion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.