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BRIEF COMMUNICATION

Mental health services in Jharkhand

A baffling conundrum

Bakhla, Ajay K.; Mehta, Varun S.1,; Prasad, Surjit1

Author Information
doi: 10.4103/indianjpsychiatry.indianjpsychiatry_871_21
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BACKGROUND

The “right to access mental health care” – Section 18 of the Mental Health Care Act (MHCA, 2017) states that “every person shall” have the right to access mental health care and treatment from mental health services run or funded by the appropriate government, and the government shall make sufficient provisions as may be necessary for a range of services required by a person with mental illness (PMI).[1] A good mental health system has the responsibility of reducing the substantial burden of untreated mental disorders, decreasing human rights violations, ensuring social protection, and improving the quality of life, especially of the most vulnerable and marginalized subgroups in a society. Moving beyond care, it should also integrate and include mental health promotion and rehabilitation components.[2] In this correspondence, we have attempted to highlight the status and deficits in mental health-care provision in Jharkhand. We hope that it would facilitate policymakers in prioritizing key domains for improvement.

MAGNITUDE OF MENTAL ILLNESS IN JHARKHAND

According to the National Mental Health Survey of India, the prevalence of mental illness in Jharkhand was reported to be 11.1%, which is slightly higher than the national average of 10.6%.[3] In terms of individual psychiatric disorders, the prevalence of depressive disorder was 3000 per lakh population, anxiety disorder was 3500 per lakh population, and developmental intellectual disability was 5000 per lakh population (1.7%).[3] A National Survey by the Ministry of Social Justice and Empowerment depicted that about 0.4% of the population in the state has dependence on alcohol (national average, 2.7%), 0.06% has dependence on cannabis (national average, 0.25%), and 1.09% have opioid dependence (national average, 2.06%).[4] As per the National Crime Record Bureau, the average suicide rate is increasing in Jharkhand, which was 3.60 suicides/day in the year 2018 and 4.5 suicides/day in 2019, having further increased during the initial 6 months of 2020 to an average of 5.5 suicides/day.[5] Witch-hunting is yet another manifestation which is attributable to psychiatric illness and absolute neglect of “mental health literacy” among tribal and rural population. Jharkhand was ranked third in witch-hunting cases and recorded 15 murders related to crime during 2019, and 123 people, mostly women, were branded witches and killed from 2016 to May 2019.[6] These figures speak loudly for the need of building awareness about mental health.

CLINICAL SERVICES

For a population of 3.29 crores, the medical colleges and hospitals run only outpatient services and are not equipped with providing emergency care and hospitalizations. The mental health institutions, such as the Central Institute of Psychiatry (CIP) and Ranchi Institute of Psychiatry and Allied Sciences (RINPAS), are the only available facilities which are overburdened with severe psychiatric illnesses. The patients with common mental disorders (CMDs) and those with comorbid medical conditions thus struggle to receive the rightly deserved multidisciplinary care. The district mental health program (DMHP) is operational in only three of 24 districts within the state, despite being approved for all the districts. None of the primary health-care centers provide any form of mental health services.

In the state, there are three mental hospitals solely providing mental health care in the capital, located within 2–3 km away from each other and run under separate jurisdictions.[7] These big institutions represent century-old custodian care for psychiatric patients, but cannot be an alternative to general hospital psychiatric services in these modern times. The community care model is still in its infancy. While both the state-aided and the central government-aided hospitals run their community extension clinics, they have not been adequately integrated within the infrastructure of the mental hospital. There is an absence of any community support system for noninstitutionalized patients and the family remains the only source of support. The lack of adequate primary and district-level support for treatment is a hindrance in avoiding unnecessary mental hospital admissions that could have improved with the provision of community support and facilities.

TEACHING AND MANPOWER

The Medical Council of India (MCI) recommends that the psychiatry department within a medical college should include inpatient facilities with 30 beds and provisions for various forms of treatment including electroconvulsive therapy (ECT). Ideally, a clinical psychologist, a psychiatric social worker, and a psychiatric nurse should also be available. However, none of these are fulfilled within the state.[8] The ignorance by the policymakers has halted the tremendous potential General Hospital Psychiatry Unit (GHPU) could have for postgraduate training in psychiatry, as none of its medical colleges have a seat (MD/DPM/DNB) for training in psychiatry. This is in sharp contrast to the neighboring state of Bihar that has 10 PG seats across four GHPUs. Notwithstanding, manpower availability and psychiatric research in the basic sciences and interdepartmental research have not taken shape in the state.

MENTAL HEALTH SERVICE INDICATORS

The State Mental Health Systems Assessment (SMHSA) report released under the National Mental Health (NMH) survey has several indicators highlighting the existing insufficiencies.[9] The state does not have a stand-alone mental health policy with defined or specified goals, objectives, and mechanisms and has not implemented any of the mental health legislations (Mental Healthcare Act, the Juvenile Justice Act, and the Domestic Violence Act). The health information systems do not include mental health. To the best of our information, there has been no official report released till date on the mental health activities undertaken by the private and public sectors of the state. The state has 14.9 public and private sector facilities per lakh population, which is the lowest among the surveyed states for National Mental Health Survey after Uttar Pradesh. The state has a meager 0.75 mental health professionals per 1,00,000 population against 193.87 health professionals, a reflection of the substantial deficiency and gap. Only 16.67% of the districts have been covered under the DMHP, with only 19.94% of the population being targeted. The number of medical officers at the state and district levels trained to deliver mental health services (per lakh population) was barely 0.1, a reflection of the lack of integration of mental health service delivery in primary care. The percentage of total health budget allocated for mental health by the state was 0.13%, with no report of any of it being utilized due to lack of clear mechanisms and guidelines.

ROLE OF THE INDIAN PSYCHIATRIC SOCIETY

Even after so many years of independence, the medical colleges in Jharkhand do not have psychiatry departments. The society has consistently appraised the Government of India and the then Medical Council of India, the current National Medical Commission (NMC), about the necessity for mandatory psychiatric training of the budding doctors (MBBS students) to address the gap in mental health services. However, its disproportionate focus on the undergraduate and postgraduate training has fallen short of highlighting the glaring deficiencies in the basic standards of psychiatric education throughout the country. The forum of Indian Teachers of Psychiatry (IToP) formed in 2016 can take up a survey of the states to map the minimum standards of psychiatric training. The annual general body can discuss the issue with immediacy and handhold the respective state branches in establishing contact with their respective medical education and health departments. A close liaison and networking with the government can work toward achieving the goal.

CONCLUSION

Jharkhand is tribal state with widely prevalent psychiatric problems, alcoholism, and practices like witch-hunting with low mental health literacy and inadequate mental health-care provisions. Such a scenario necessitates an urgent need to develop training in mental health-care delivery to a wide range of professionals (specialists, MBBS doctors, AYUSH doctors) and peripheral health functionaries ( Accredited Social Health Activists, Urban Social Health Activists, Auxiliary Nurse Midwifes, Lady Health Visitors, registered nurses). The short-term training programs by digital academies such as National Institute of Mental Health and Neurosciences and CIP can be a useful resource. Equipping general hospital psychiatry units with beds for acute admission and provision of long-term residential facilities in the community have been long-standing requirements. There is an increasing need by mental health policymakers to enhance the budgetary allocations to the GHPUs and equip them with full potential.

The teleconsultation services can be operationalized and mapped to districts with poor service delivery. The state government can liaison with institutions such as CIP to provide the needed support. Project “Garima” launched by the state of Jharkhand to identify women suffering from accusations of witchcraft is a welcome beginning. The potential of civil society organizations (CSOs) remains untapped within the state of Jharkhand. The technical expertise of the mental health professionals along with the service delivery and outreach potential of the CSOs can serve a very potent solution to address the unmet needs of the rural and tribal communities. The state society needs to harness the potential of all its mental health professionals in promoting mental health awareness and for advocacy of situations that are local to the state. The strength lies in the local partnerships and shared vision to improve the mental health affairs of the state of Jharkhand.

Financial support and sponsorship

Nil.

Conflicts of Interest

The authors are the office-bearers of the Indian Psychiatric Society, Jharkhand State Branch at the time of submission to the journal.

REFERENCES

1. Mental Healthcare Act 2017 Available from: http://www.prsindia.org/uploads/media/Mental%20Health/Mental%20Healthcare%20Act,%202017.pdf
2. WHO. Everybody's Business:Strengthening Health Systems to Improve Health Outcomes WHO's Framework for Action Geneva World Health Organization 2007
3. National Mental Health Survey of India, 2015-2016 Prevalence, Patterns and Outcomes, Supported by Ministry of Health and Family Welfare, Government of India, and Implemented by National institute of Mental Health and Neurosciences (NIMHANS) Bengaluru In Collaboration with Partner Institutions 2015-2016
4. Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda RK on behalf of the group of investigators for the National Survey on Extent and Pattern of Substance Use in India Magnitude of Substance Use in India New Delhi Ministry of Social Justice and Empowerment, Government of India 2019 Available from: http://www.socialjustice.nic.in/writereaddata/UploadFile/Magnitude_Substance_Use_India_Report.pdf [Last accessed on 2021 Oct 01]
5. Accidental Deaths &Suicides in India (ADSI)-2019 National Crime Records Bureau, Publications 2019 Available from: https://ncrb.gov.in/sites/default/files/Chapter-2-Suicides_2019.pdf [Last accessed on 2021 Oct 01]
6. Witch-hunts:Superstition kills more than naxals in Jharkhand The Times of India 2019 Available from: http://timesofindia.indiatimes.com/articleshow/70336295.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst
7. Nizamie SH, Goyal N, Haq MZ, Akhtar S Central institute of psychiatry:A tradition in excellence Indian J Psychiatry 2008 50 144–8
8. Salient Features of Regulations in Graduate Medical Education Medical Council of India 1997 Available from: http://www.mciindia.org/Rules-and-Regulation/GME_REGULATIONS.pdf [Last accessed on 2021 Oct 01]
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