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/ 11
A Guide to Mental Health and Psychiatric Nursing
mental disorders, besides 12,000 patients in
Government mental hospitals in the country
(Reddy, et al. 1996).
Various community based surveys show
the prevalence of mental disorders in India as
6-7% for common mental disorders and 1-2%
for severe mental disorders. In India, the rate of
psychiatric disorders in children. aged between
4 to 16 years is about 12%. Treatment gap for
severe mental disorders is approximately 50%
and in case of Common Mental Disorders it
is over 90% (Ministry of Health and Family
Welfare, Annual Report. 2012-13, p.161),
MENTAL HEALTH ACT
Indian Lunacy Act (ILA), Act 4 of 1912,
replaced the Indian Lunatic Act, Act
36 of 18587 It was enacted to govern reception,
“detention and care of funatics and their
Property and to consolidate and amend the
laws relating to lunacy.
The Act was divided into 4 parts and 8
chapters consisting of 100 sections. The”
enactment of Indian Lunacy Act of 1912 was
followed by opening of many new asylums,
an improvement in the general conditions
of asylums and an increase in awareness
regarding the prevailing situation of lunatics
in such asylums,
In 1946, the Bhore committee submitted
its recommendations. The Indian psychiatric
society, established in January 1947, was
quick to react to the recommendations of
Bhore committee. In January 1949, an ad hoc
drafting committee was appointed which
consisted of 3 distinguished psychiatrists,
They prepared a draft bill called as the
“Indian Mental Health Act’, which was
redrafted and finalized in January 1950
and forwarded to the Government of India.
Alter 37 years the Mental Health Act (MHA)
1987 was finally passed by the Lok Sabha on
19th march 1987. Later, the Government of
India issued orders that the Act came into
force with effect from April 1, 1993 in all the
States and Union Territories of India. It is
an “Act to consolidate and amend the law
Telating to the treatment and care of mentally
ill persons, to make better provision with
Tespect to their property and affairs and for
matters connected those with or incidenta}
there to” The Act is divided into 10 Chapters
consisting of 98 sections,
(Refer Chapter 14, Page 343 for Indian
Mental Health Act)
The Mental Health Care Bill, 2013
‘The Mental Health Care Bill, 2013 was
introduced in the Rajya Sabha on August 19,
2013. The Bill abolishes the Mental Health
Act, 1987.
Reasons to the Bill
‘The Government approved the United Nations
Convention on the Rights of Persons with
Disabilities in 2007. The Convention requires
the laws of the country to align with the
Convention. The new Bill was introduced as
the existing Act does not adequately protect
the rights of persons with mental illness nor
promotes their access to mental health care,
Key Features of the Bill
* Every person shall have the right to access
funded by the Government
A mentally-ill person shall have the right
to make an advance directive that states
ow he wants to be treated for the illness
ST rrr and who
his nominated representative shall be
Every mental health establishment has
to be registered with the relevant Central
or State Mental Health Authority. These
on: 1
supervising and maintaining a register of
allmental health ishments
‘The Mental Health Review Commission
will be a quasi-judicial body that will
periodically review the use of and the
procedure for making advance directives chapter 1 Perspec
‘oyernment on protectio
‘entally ill persons
‘empts suicide shall be
be suffering from mental
thatsimeand willnotbepunished
indian Penal Code
i thera] is allowed
f muscle relaxants and
es
jlinessat
under the
Electroconvulsi
aly with the use of
Sresthesia "the therapy is prohibited for
ininors
—
Chapters
chapter Preliminary information on
definitions, short titles, extent
and commencement,
Mental illness and capacity to
Chapter?
make mental health care and
treatment decisions.
Chapter’3 Advance directive.
Chapter4 Nominated representative,
Chapter Rights of persons with mental
illness.
hapter6 Duties of appropriate Govern-
ment.
Chapter? Central mental health authority.
Chapter® State mental health authority.
Chapter9 Finance, accounts and audit.
Chapter 10 Mental health establishments.
Chapter 11 Mentalhealthreview commission.
Chapter 12 Admission, treatment and di
charge.
Chapter 13. Responsibilities of other agencies.
Chapter 14. Restriction todischarge functions
by professionals not covered by
profession.
Chapter 15 Offences and penalties.
Chapter 16 Miscellaneous.
NATIONAL MENTAL HEALTH
POLICY VIS-A-VIS NATIONAL
HEALTH POLICY
National Mental Health Policy 2014
In April 2011, the Government
Pi the it of India
Constituted a policy group to recommend
in:
ves of Mental Health and Mental Health N
policy for the country. After
an eliberations and intense discussions, the
group has submitted recommended policy.
‘The suggested Mental Health Policy has been
duly considered by the Ministry of Health
‘ind Family Welfare, Government of India i
2014, This National Mental Health Policy is ip
secordance with the intent of World Health
‘Assembly resolution. This policy incorporates
‘anintegrated, participatory ightsand evidence
based approach.
a mental health
Vision
‘the vision of the National Mental Health
Policy 2014 is to promote mental health,
prevent mental illness, enable recovery fort
Frontal illness, promote destigmatization and
desegregation and ensure socioeconomic
inclusion of persons affected by mental illness
by providingaccessible, affordable and quality
‘mental health and social care to all persons
through their life-span, within a rightbased
framework.
Goals
+ To reduce distress, disability, exclusion
morbidity and premature mortality
associated with mental health problems
across life-span of the person
« To enhance understanding of mental
health in the country
+ Tostrengthen the leadership in the mental
health sector at the National, State and
District levels.
Objectives
+ To provide universal access to mental
health care
+ To increase access to and utilization of
comprehensive mental health services by
persons with mental health problems
+ To increase access to mental health
services for vulnerable groups including
homeless persons, persons in remote and
difficultareas, educationally, economically
and socially deprived sections ‘The strategic ar
iy
ge
A Guide to Men
alence and impa
factors associated with mental health
To red
peodle ;
‘ reduce risk and incidence of suicide
and attempt suicide
To ensure respect for rights and protection
from harm of persons with mental health
problems
To reduce stigma associated with mental
health problems
To enhance availability and equitable
distribution of skilled human resources for
mental health
To progressively enhance financial
allocation and improve utilization for
‘mental health promotion and care
To identify and address the social,
biological and psychological determinants
of mental health problems and provide
appropriate interventions.
' identified for action are:
Effective governance and delivery
mechanisms for mental health
= Develop relevant policies, programs,
Jaws, regulations and adequate budgetary
provisions to implement evidence-based
mental health actions
= Motivate and engage stakeholders,
civil society leaders, caregivers, family
members, persons with mental
health problems in the development,
implementation and evaluation of
mental health policies, laws and services
and also develop suitable mechanisms
at the Central, State, District and local
levels to plan, monitor and evaluate
implementation of mental health
policies, laws and programs.
Promotion of mental health
— Redesign anganwadi centers and train
anganwadi workers and school teachers
with knowledge and skill to provide
positive environment for the growth
and development of children and for
providing protection against harmful
behavior
J Health and Psychiatric Nursing
) pro,
should be offered to school chiles
and college going young people
- Signs and symptoms of many mental
disorders first appear during the
adolescent years. Individual attention
in the school by, teachers trained in
mental health promotion is important
Design appropriate curricula and
pedagogy, teacher-student relationship,
provision of suitable infrastructure
including access to toilets within the
school system
Programs to assist adults in handling
of stressful life circumstances should
be incorporated in workplace and
residence support programs
Mass media programs should be
organized to disseminate mental health
information
Encourage actions to change poor
living conditions such as homelessness,
overcrowding, lack of access to safe
drinking water, toilets and sanitation
and provide adequate nutrition to
prevent mental health problems and
‘mental illness. The role of social factors,
low grade infections, micronutrient
deficiency (iron, folate, vitamins and
other trace elements) is also linked
to increased incidence of mental
disorders, and slow and poor recovery
response to treatment
Implement programs to reduce risk
factors for women’s mental health, such
as acts of violence against women
Practitioners of Ayurveda and Yoga
systems are a resource who need to be
included as activists for promotion of
mental health:
Create an environment and encourage
persons with mental health problems to
take partin social, economicand regular
activities and are not discriminated
against. Mental disability should be
treated on par with any other form of
disability. Chapter 1_ Perspectives of Mental Health and Mental Health Nursing
3, Prevention of mental illness, reduction of
” suicide and attempted suicide
— Implement programs to address alcohol
abuse and other drugs of abuse
~ Restrict access to means of suicide, in
particular distribution and storage of
highly toxic pesticides
_ Frame guidelines for responsible media
reporting of suicide
— Decriminalize attempted suicide
- Train key community leaders in
recognizing risk factors for suicide
- Set up crisis intervention centers and
help-lines as part of the district mental
health program
= Improve data collection on suicides
and attempted suicides by the National
Crime Records Bureau to improve
understanding of the issue
- Address alcohol abuse/dependence
and depression as key risk factors for
suicide and attempted suicide
4, Universal access to mental health services
- Mental health services should be family
centric to address needs of persons with
mental health problems across life-
span. All multispecialty government
hospitals should provide mental health
services to improve access,
= Increase availability of community
based rehabilitation services like day
care centers, short stay facilities and
long stay facilities to promote recovery
with support from local bodies and
other sources of support.
~ Caring for the caregiver is a neglected
area. Formation of caregivers groups
with professional inputs to facilitate a
better and accurate understanding of
the particular mental health problem
their family member is having.
Caregivers to be encouraged to pursue
other activities to give them space for
their own personal growth.
. Implement programs for screening, early
identification and treatment
it of mental
health problems and mental illness,
patient beds for acute
mental health care needs to be
addressed by making provisions for the
Same in general health facilities, such
as district hospitals, teaching hospitals
attached to medical colleges and other
Beneral hospitals
Improve infrastructure and enhanced
Tesources to provide quality services in
mental hospitals
Monetary benefits and tax benefits
to the primary caregivers needs to be
addressed
A multidimensional, dynamic and well-
Deing oriented approach is essential to
address the needs of homeless persons
with mental illness
Extending assisted living in one’s
own home could be a good option for
various categories of families across the
social strata.
Shortage of iny
. Improved availability of adequately trained
mental health human resources to address
the mental health needs of the community
~ Toreduce the gap between requirement
and availability of trained mental health
professionals psychiatrists, psychiatric
hurses, psychologists, counselors, and
psychiatric social workers, etc. should
be trained
~ Persons affected by mental health
problems and their caregivers are
an important mental health human
resource. This group should be used at
appropriate places to support recovery
and disseminate information on mental
health
All health personnel-general or
specialists should be trained on mental
health so as to positively influence
mental health of the patient and the
caregiver
~ Shortage of mental health nurses
has been observed in the country.
Psychiatric nursing courses such as
masters and diploma courses should be
started to increase supply of this trained
cadre e-—
AGuide to
women health e
: Ser js that of auxiliary nursing,
midwives. This group should be offered
fill upgradation in mental health as it
directly caters to mothers and children
and hence their involvement In child
and adolescent mental health services
will be useful
~ Training programs must acknowledge
that along with biomedical approach
psychosocial interventions are also
equally important, which need to be
incorporated into programs across all
disciplines that would help to alleviate
distress in small ways. This would help
broaden scope and reach of mental
health interventions, and thus help
decrease stigma and position mental
health more positively.
6. Community participation for mental health
and development
~ ‘There is a need to simplify procedures
for disability certification of persons
with mental illness and enhancing
compensation for mental disability
— Remove legislative policy and
programmatic barriers to protect rights
of persons with mental illness
= Promote the full participation of
persons with mental illness in all areas
of life including education, housing,
employment and social welfare
= Involve persons living with mental
illness and caregivers in village
health, sanitation, water and nutrition
committees (Swasthya Gram Samiti)
and patient welfare committees
(Rogi Kalyan Samiti) so that they can
participate in community planning and
monitoring of the public health system
and in community action for health
Increase the space for voice of persons
with mental illness and caregivers in
planning and feedback of mental health
services.
Mental Health an'
d Psychiatric Nursing
— Invest in bui
mental health both through existing
institutions and developing new
institutions focused on specific areas
— Commit equitable funds for promoting
mental health research, with a target
consistent with the burden of mental
health problems in the country
Foster partnerships between centers
of excellence for mental health and
college departments of
with district mental health
ind with appropriate NGOs
and research institutions to implement
priority ‘mental health research
Conduct research to evaluate the
potential of traditional knowledge,
practices and alternative therapies to
address mental health problems
Develop and facilitate mechanisms for
dissemination of research findings and
for translating research findings into
action at the service delivery level.
medical
psychiatry
program a
National Health Policy
National Health Policy (NHP) was formulated
in 1983 and revised in 2002.
Objectives
‘The main objective of NHP-2002 is to achieve
an acceptable standard of good health
amongst the general population in the
country. The approach would be to increase
access to the decentralized public health
system by establishing new infrastructure
in deficient areas and by upgrading the
infrastructure in the existing institutions.
Specific Recommendation with
Regard to Mental Health
© Upgrading infrastructure of institutions
at Central Government expense so as to Chapter 1 Fessps
Fe uman rights ofthis vulnerable
re the
secment 5002
'g network of decentralized
. Envistealth services forameliorating the
more common categories of disorders.
ific Discussion Regarding
al Health
salbealthdlsorersareactuallymuch more
alentthan| isapparenton the surface. While
Mtsorders do not contribute significantly
sie aly, they have a serious Dearing on
0 moriny-oblife of the affected persons and
the ilies. Sometimes, based on religious
she Mental disorders are treated as spiritual
.d to the establishment of
‘ation. This has le
mental institutions as an adjunct (0
jous institutions where reliance is placed
jth cure.
Serious conditions of mental
: wuire hospitalization and treatment
Maer wrained supervision. Mental health
jons are woefully deficient in physical
veture and trained manpower, NHP-
il address itself to these deficiencies in
the public health sector.
NATIONAL MENTAL HEALTH
PROGRAM
Governme! unched
ional ‘Mental Health Program (NMHP)
i eping in view the heavy burden
‘Frmental illness in the community, and the
Apcolute inadequacy of mental health care
nt of India launched the_
Mental Health and Mental Health Nui
Objectives
+ To ensure availability and accessibility of
minimum mental health care for all in the
foreseeable future, particularly to the most
vulnerable and underprivileged sections
of the population.
‘To encourage application of mental health
knowledge in general health care and
social development.
+ To promote community participation in
the mental health services development
and to stimulate efforts towards self-help
inthecommunity, 6 fy. 22
Strategies Hn
+ Integration of mental health with primary
health care through the NMHP.
Provision of tertiary care institutions for
treatment of mental " orders.
Eradicating stigmatization of mentally
ill patients and~protecting their rights
through regulatory institutions like the
| Mental Health Authority, and State
c
‘Mental Health Authority;
Approaches
«Integration of mental health care services
with the existing general health services.
* Utilization of the existing infrastructure
of health services and also deliver the
minimum mental health care services.
+ Provision of appropriate task-oriented
(cainingyb the existing health staff.
« Linkage of meritaf health services with
jnfrastructure in the country to deal with it the existing community development
program.
Aims
_pAevention and uetment of mena nes Components
“Togical disorders “and their sore « Treatment: Multiple levels
; “ 3 i
Geabilities (AC) C1 &1 SY IP A - Village and Sub-center Level Multi-
aoe ment pplirpose Workers (MPW) and Health
“Use of mental health technology to
improve general health services,
Application of mental health principles
in total national development to improve
Supervisors (HS), under the supervision
{fMedical Officer (MO) fo be trained for:
Mariagement” of psychiatric emer-
gencies . Textbook of Mental Health & Psychiatri« 8
Ly hep
alo / {
AGuide to Mental
pervision of
£ administration and Su]
for chronic
maintenance treatment
psychiatric disorders
/ Diagnosis and management of grand
mal epilepsy, especially in children
« Liaisonwith local school teachersand
parents regarding mental retardation
and behavioral problems in children
A counseling problems related (0
alcohol and drug abuse
_ Medical Officer of Primary Health Center
(PHC) aided by HS, tobe trained for:
_/ Supervision of MPW's performance
Elementary diagnosis
Areatment of functional psychosis
~ Treatment of uncomplicated cases of
psychiatric disorders associated with
ysical diseases
fanagement of uncomplicated psy-
chosocial problems
_/Bpidemiological surveillance of
mental morbidity
~ District hospital: It was recognized that
there should be atleast one psychiatrist
attached to every district Hospital as
fan integral part of the district health
services. The district hospital should
have 30-50 psychiatric beds. The
psychiatrist in a district hospital was
envisaged to devote only a part of his
time to clinical care and 2 greater part
in training and supervision of non-
specialist health workers.
= Mental hospitals and teaching
psychiatric units: Major activities of
these higher centers of psychiatric care
include:
- Help in care of ‘difficult’ cases
- Teaching
Specialized aciestkeoecupational
ae a
+ Rehatgyteling ond behav therapy
this ‘subsprogam ne components of
; include treatm
eplleptics and psychoticear eee wee
level and development of rehabilitate’
of rehabilitation
Health and Ps;
HY.
sychiatric Nursing,
centers at both the istrict level and higher
referral centers.
Prevention: The prevent!
to be community-based,
on prevention and control of
related problems. Later 0% probler
addictions, juvenile delinquency 4
eute adjustment problems like suicidal
attempts are to be addressed.
AL HEALTH TEAM OR
(TIDISCIPLINARY TEAM
Multidisciplinaryapprom referstocollabore
tion between members of different disciplines
who provide specific services 10 the patient
The multidisciplinary team includes:
« Apsychiatrist
+ Apsychiatric nurse
+ Aclinical psychologist
+ Apsychiatric social worker
«An occupational therapist or an activity
therapist
+ Apharmacist and a dietitian
* Acounselor
+ Adietitian
A Psychiatrist is a medical doctor with
specialtrainingin psychiatry. Heis accountable
on component is
with initial focus
alcohol-
ms like
and
Psychiatic\
Social |
worker
Dietitian
Counselor
Fig. 1.1: Mental health team or
multidisciplinary team the medical diagnosis and treatme:
Wo poe Other Important functions are
admitting patient into acute care setting
“ prescribing and monitoring
7 snarmacologic agents
Administering electroconvulsive therapy
7” Conducting individual and family therapy
« Participating in interdisciplinary team
meetings
+ Owing to their legal power to prescribe and
* owrite orders, psychiatrists often function
asleaders of the team.
A Psychiatric nurse is a registered nurse
with specialized training in the care and
treatment of psychiatric patients; she may have
Diploma, MSc, MPhil or PhD in Psychiatric
nursing. She is accountable for the bio.
hosocial nursing care of patients and their
vei, Other functions includes
‘A Administering and monitoring medic-
ations
Psycho
« Assisting in numerous psychiatric and
hysical treatments
se nicipate in interdisciplinary team meet-
ings ;
« Teach patients and families
+ Take responsibility for patients’ records
+ Actas patient's advocate
« Interact with patients’ significant others.
A Clinical psychologist should have a
Masters Degree in Psychology or PhD in
clinical psychology with specialized training
in mental health settings. He is accountable
for psychological assessments, testing, and
treatments, He offers direct services such as
individual, family or marital therapies.
APsychiatric social worker should havea
Masters Degree in Social Work or PhD degree
with specialized training in mental health
settings. He is accountable for family case
work and community placement of patients,
He conducts group therapy sessions. He
emphasizes intervention with the patient
insocial environment in which he will live.
An Occupational therapist or an Activity
therapist is accountable for recreational,
ee
Mal Health
and M
“