New Pathways New Hope National Mental Health Policy of India Ministry of Health & Family Welfare, Government of India October 2014New Pathways New Hope National Mental Health Policy of India Ministry of Health & Family Welfare, Government of India October 2014sia a. areq ol gftare wean At 5 = rea WER po Minister of Health & Family Welfare Sed ata Government of india Dr. Harsh Vardhan iota Mesape Iedian’ culture’ front time inmriemorinl reeoptses: the relutionship between mind, body and soul and its impact on menial health. tn todays woeld, lifestyle changes, along -with social and ‘economic ilequalities have increased the individual and societal stress. ‘making ws more vulnerable to mena iit health, 2. ‘The bi- directions relationship of mental ill hcalih and poverty is evidences! in many. reports: inckiding the World Disability. report, 2010, thot places persons with disubilities at the Botton of the pyrsinid. This alerts ws to what could ‘well become a hea crisis, with consequences that urge us to view this phenomenon as both a health and. development iniperative, 3. Taking cognizunce-of this issue, and the megative impact that it could precipitate in the fives of yuilnerable people, our Government Proposes to take firm action: Towards this end, we mre introducing 3 progressive Mental Heath Policy that outlines a ¢lear plan to tackle this. problem, Qur sarong ‘intent to promote: equity and Justice fs feinfersed in ovr commitment to allevinte distress, build capabilities amd reach marginalized erowps, 4. This: policy attempts fo build 4 robust response to a complcs problem that affects multipte dimensigns of Tife. Most imporantly, India’s first National Mental Health Policy is cmbodded in x. yaluc System that upholds 1 participatory and rights based upproach and sims to promote quality in service provision and effectivencss in delivery. $F congratulate the ‘members: of the: Policy Group for their continued engngewent in developing this document. With this vislon. tour Goverment: aspires to reacl the Last mile and provide cars in a conten tha respeets dignity and fife. Our efforts will nemusia Wedicsiod vnc this got. 6, | ape all stakeholders will come together to cnsune the success ‘of this pati bh lave (br. Harsh Yardhany $48, rain, Guten ser, ef feeeh-110017 348, A-Wing, Nirman Bhawan, New Dethi-110011 Tale = (O}) | 491-11-23061647, 23061661, 23061751, Telefax : 23062358. 23061648, E-mail drhrshvardhan@gmail. com, drharshvardhan@nic in» Website | dmarshvardhan:comare ESE wa at waren ud wftare erscrer fier . rer et afters era sare ‘Government of indict COV VERMA, == Department of Health and Family Welfare Secretary Ministry of Health and Family Welfare id Foreword ‘On the eccssian of the World Menta: Heath Day, the Ministry of Health and Family Wolfare, Government of India is announcing the frst Natonal Mental Heallh Policy of India. This policy is an attempt to decrease the treatment gap, disease burden and exlent of itabilty dug to mantel pene Th fle ts ie stot naan Soe cullual realities. and is embedded in a value sysiem thal promotes integrated and evidence based care, governsnos and eflective provision of quality services. Further, lt addresses needs of persons with mental linesses, their care-providere and other stake holders There is evidence weanowide: inal mantat dnanen: see amongst: te nating -oalnen: for disability burden. Thay impose high economic costs and impact qualty of Ste of persons affected wah mental heath problems. The health system of the country does not, as yel, have a comprehensive response system to address mental heslih igeues, integration f mental heath with genera! heath, inter-sectorsl coordination that Focuses on both dines. and disabilly, promotion of human vights, raforme in mental steeper cee eat ey = i wath mentat lines, sorte otha felures of he Meri! Pain Pokey , plenenied |r) subsequent chapters, ‘The pelley formulated purstiant to tecomméndations of an expert group, after deters ad conslon bot in We ro at wth oer sites | thank 8 the members of tha policy group- Saiendra: Kumar Deuri, Akhilesherar come ‘Aloe Satin, Anitudh Kala, Nirmala Srinivasan, Sanjeev Join, Soumiiva Pathare, Thoima Narayan, Viera Patel, Vikram Gupta and Vandana Gopicumar, : ‘Me, Anehus Prakash and Deputy Director General Dr. SK Saigh for binging ws poacy acumen ta a logical conclusion. | trust sind hope that this Poicy will pave the path for coordinated and eomsorative ‘care in the mentelibeaith secler, carn 4156, e—r4, Pais wey, ae Beef—110001 Room Na. 156, 4-Wing, Ninman Bhawan, New Delhi-110011 Tele : (0) 011-23081963, Fax: 011-23061252, E-mail : secyhtwgagmailcom:Terminology ... Preamble Executive Summary .. 1 2 3 3.1 3.2 44 42 43 44 45 46 47 48 49 Contents Vision... Values and principles ... Goals and objectives . Goals... Objectives... Cross-cutting issue: Stigma .. Rights based approach Vulnerable populations Adequate funding... Support for families... Inter-sectoral collaboration ... Institutional care Promotion of mental health . Research ..541 5.2 5.3 5.4 5.5 5.6 5.7 . 12 Strategic directions and recommendations of action Effective governance and accountability for mental health . 12 Promotion of mental health Prevention of mental illness and reduction of suicide and attempted suicide. 15 Universal access to mental health services .. 16 Improve availability of adequately trained mental health human resources to address the mental health needs of the community .. 18 ‘Community participation for mental health anddevelopment.... 19 ResearchTerminology Mental Health is not just the absence of mental disorder. It is defined as a state of well-being in which the individuals realize their own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and are able to make a positive contribution to their community. Mental health refers to a broad array of activities directly or indirectly related to mental well- being. This is in keeping with World Health Organisation's definition of health: A state of complete physical, mental and social well-being, and not, merely the absence of disease. Mental health is also related to promotion of mental well-being, prevention of mental disorders, and treatment and rehabilitation of people affected by mental disorders. Mental health problems refers to conditions ranging from psych-osocial distress affecting a large number of people to mental illness and mental disability affecting a relatively small number of people. Mental illness refers to specific conditions such as Schizophrenia, Bipolar Disorder, Depression or Obsessive Compulsive Disorder. Mental disability refers to disability associated with mental illness. While mental illness is a medical construct, disability is better understood using a medico-social model and the two terms are not used synonymously in this document. Not all persons with mental iliness will have a disability, although many will experience it due to various barriers which may hinder their full and effective participation in society on an equal basis with others, Persons with mental illness and person(s) with mental health problems refers to persons who have mental illness and mental health problems respectively. It is necessary to emphasize that mental health illness or mental health problem does not constitute a person's identity and that a person andan illness and/or problem are distinct from each other. Persons affected by mental illness include person(s) with mental illness and significant others such as family members and care-givers. Recovery is defined as a process of change through which individuals improve their health and wellbeing, live a self-directed life and strive to reach their full potential.Preamble Both incidence and severity of mental illnesses are on the rise. The World Health Organisation estimates that at any given time 10% of global population suffers from some form of mental illness and one in four persons will be affected at least once in their life time. Further, estimates suggest that by 2020, depression, the most common mental disorder, will be the second leading cause of disability wordwide, trailing only ischemic heart disease. The accurate figures for India are not available. Mental illness is a key predictor for an increase in suicide and suicide attempts that affect a cross section of society particularly the youth and distressed. Poverty, deprivation and other vulnerabilities further exacerbate the ground situation. Untreated mental illness results in stigma, marginalization and discrimination often worsening one's quality of life. This leads to a substantial loss of social and human capital, adversely impacting a large number of individuals and families. While the National Mental Health Programme addresses this concern partially, a holistic approach to alleviating distress is necessary. The access to mental health care is not universal and significant treatment gaps are experienced by many, as a result of which individuals cannot pursue life to the fullest. Owing to the enormity of the problem, it is considered prudent to have a strategic, integrated and holistic policy that will guide future course of action including a pan India scaling up of existing Mental Health Program. This policy will pave the path to address the mental health problems as they exist, currently, and to understand the mental health issues in context of our country. This policy allows stakeholders to initiate action across a wide spectrum of mental health issues to enhance our understanding of its different contours, refine our response system and showcase to the world a comprehensive mental health response. In that sense, this policy is intended to be dynamic; all encompassing and growing with regular review and feedback from people.Executive Summary In April 2011, the Government of India constituted a Policy Group to recommend a mental health policy for the country. After due deliberations and intense discussions, in accordance with the mandate, the group has submitted recommendations. The suggested mental health policy has been duly considered by the Ministry of Health and Family Welfare, Government of India. After minor amendments, additions and changes, the first National Mental Health Policy has been formulated. The Policy envisages dynamic engagement and is expected to accommodate future thinking and developments in this field, This Policy acknowledges the significance and importance of relevant and useful local knowledge and practices. While some of the policy recommendations are generic in nature, details have also been incorporated where necessary, especially to highlight neglected issues. Global thinking has been taken into account along with ground realities and variations of the Indian context. Significantly, the need to address the social determinants of mental health such as poverty, environmental issues and education are duly recognized. This Policy is inclusive in nature and incorporates an integrated, participatory, rights and evidence based approach. Mental health issues are addressed in a comprehensive manner to address medical and non-medical aspects of mental health. This Policy does not reduce mental health interventions to merely disease and disability prevention and it takes into account the need for all stakeholders to work synergistically and achieve common policy goals. The strategic areas identified for action are, inter alia, effective governance and accountability, promotion of mental health, prevention of mental disorders and suicide, universal access to mental health services, enhanced availability of human resources for mental health, community participation, research, monitoring and evaluation. The Government believes that mental health is an integral part of our overall health endeavour. A holistic approach that recognizes strong linkage ofbody, mind and soul is necessary. Strengthening of health infrastructure must be effected along with addressing the social determinants of health and mental health. It is significant that the 65" World Health Assembly held in 2013 approved and adopted Resolution WHA 65.4 on global burden of mental disorders and the need for a comprehensive, co-ordinated response from the health and social sectors at the community level. India was one of the main sponsors of this resolution. This National Mental Health Policy is in consonance with the intent of this WHA Resolution.1. Vision The vision of the National Mental Health Policy is to promote mental health, prevent mental illness, enable recovery from mental illness, promote de- stigmatization and desegregation, and ensure socio-economic inclusion of persons affected by mental illness by providing accessible, affordable and quality health and social care to all persons through their life-span, within a rights-based framework. 2. Values and Principles Fundamental values and principles representing the ethos of this policy are discussed below: 2.1 Equity + Mental health services should be sensitive and relevant to diverse social and cultural situations and groups and, to the need of remote and rural areas + An equitable share of the national health budget should be consistent with the burden of mental health problems and mental illness * Non-discrimination and equal opportunities for education, employment, housing and social welfare should be provided to promote inclusion of persons with mental health problems and mental illness 2.2. Justice * The needs of vulnerable and excluded members of the community should receive particular attention. 2.3 Integrated care * Mental health services should be provided within the existing health care system using the Primary Health Care approach. * Some mental illnesses are chronic in nature. Persons suffering from chronic illness would require provisions for medium and long term, in some cases even life-long the provision of services should keep this requirementin consideration.2.4 25 2.6 27 + These services should espouse the principles of universal access, equitable distribution, community participation, inter-sectoral coordination and use of appropriate technology. It is essential to. make mental health services universally available and accessible ina time bound manner. + Mental health services should be comprehensive and address the needs of person with mental illness, their care providers and health care professionals. Evidence based care + Evidence based interventions should inform decisions regarding provision of services. * Decision making should be based on various evidences for instance: findings from research, practice based evidence and feedback from clients. Quality + Mental health services should meet quality standards as mandated globally and perceived suitable by local users and care-givers. Participatory and rights based approach + Service users and caregivers should be involved in the planning, development, delivery, monitoring and evaluation of mental health services. + Human rights and dignity of persons with mental health problems should be respected, protected and promoted + Mental health care should promote and protect the autonomy and liberty of person(s) with mental health problems. + The tights of the caregiver and service provider should also be respected by ensuring good working conditions, adequate training and support. Governance andeffective delivery + The union and state governments, have a major role in actions for promotion of mental health, prevention of mental illness and treatment of mental illness in the country. However governments alone cannot ensure effective delivery. Other stakeholders such as private care providers, civil society organizations, user groups, academic and research institutions also have a crucial role in delivery and guiding policy. 4+ Services and professionals involved in health care planning and delivery whether in public, private or non-government sector should at all times display the utmost devotion to duty and be responsible for their actions. * Services and service providers are ultimately accountable to person(s) with mental illness and their care-givers. 2.8 Value base inall training and teaching programs * Core values such as quality, integrity, justice, accountability and empathy should be built into all forms of training and academic teaching. 2.9 Holistic approach to mental health * A holistic approach to health including recognition of the relationship between mind, body and soul is more effective in dealing with mental health problems. * Cultural ethos, Indian traditions and their impact on behavioural patterns must be recognized and leveraged to achieve policy goals and objectives. 3. Goals and Objectives Based on the vision and drawing on the values and principles outlined in the previous Sections, the goals and objectives of the mental health policy are as follows: 3.1 Goals 3.1.1 To reduce distress, disability, exclusion morbidity and premature mortality associated with mental health problems across life-span ofthe person. 3.1.2 Toenhance understanding of mental health in the country. 3.1.3 To strengthen the leadership in the mental health sector at the national, state, and districtlevels. 3.2 Objectives 3.2.1 Toprovide universal access to mental health care. 3.2.2 To increase access to and utilisation of comprehensive mental health services (including prevention services, treatment and care and support services) by persons with mental health problems. 53.2.3 Toincrease access to mental health services for vulnerable groups including homeless person(s), person(s) in remote areas, difficult terrains, educationally/socially/economically deprived sections. 3.2.4 To reduce prevalence and impact of risk factors associated with mental health problems. 3.2.5 Toreduce risk andincidence of suicide and attempted suicide. 3.2.6 To ensure respect for rights and protection from harm of person(s) with mental health problems. 3.2.7 Toreduce stigma associated with mental health problems. 3.2.8 Toenhance availability and equitable distribution of skilled human resources for mental health 3.2.9 To progressively enhance financial allocation and improve utilisation for mental health promotion and care. 3.2.10 To identify and address the social, biological and psychological determinants of mental health problems and to provide appropriate interventions. 4. Cross cutting issues Mental health is characterized by cross cutting issues that have a tar reaching impact on the fulfilment of goals and objectives spelt out as policy strategies and need to be addressed through efforts across society. 4.1 Stigma Persons with mental health problems face stigma and discrimination in many ways. Families are frequently unwilling to recognize the presence of illness; even where recognized, families, parents and others care-givers may sometimes be reluctant or afraid to seek professional help. Absence of available, effective and affordable services is a major bartier in large parts of the country. There is a widespread lack of knowledge on the nature and prevalence of mental health problems including mental illness. This lack of knowledge is often accompanied by fear and even hostility towards those with mental health problems, due to which such persons face exclusion from society. Government, opinion-makers, media and community leaders should encourage discussions for better understanding of the nature of mental health problems. There is a need for compassion and responsibility in our interaction with persons affected with mental health problems instead of stigmatizing such persons. 642 4.3 43.4 4.3.2 Rights-based approach Violation of their rights is a common reality for persons with mental health problems. The design and implementation of policies, programmes and services for persons with mental health problems should therefore, be based on a rights-based perspective. Respecting the rights of persons with mental health problems will reduce stigmatizing and discriminatory behaviours. This Policy envisages that there be more discussions in public space on Rights of persons with mental health problems and in design of a system that upholds their rights. Vulnerable populations Mental health services and related activities should take into account the special condition and needs of vulnerable populations who bear a disproportionate and higher burden of mental health problems. Vulnerable populations may include inter alia, children (both school going and out of school), women, economically and socially deprived, older persons and persons with physical disabilities. It should be ensured that there is no discrimination against vulnerable populations in the provision of services. Conditions that increase vulnerability and need to be addressed to improve mental health are discussed below: Poverty Poverty and mental ill health are inextricably linked in a negative vicious cycle. Persons from lower socio-economic groups are more vulnerable to mental health problems. Out-of-pocket health spending to access mental health services and lost productivity due to disability can also lead to poverty. Homelessness There are several linkages between homelessness and mental ill- health. Homelessness can occur as an adverse consequence of a mental health problem. Persons could either be abandoned by a poorly resourced, helpless or uncaring family or wander away in the absence of accessible and appropriate mental health care. Conversely, the stress of living on the streets and sleeping rough can contribute to the risk of developing mental health problems. Person(s) with mental health problems with high support needs and no cate givers (either due to death or abandonment by family or care-giver) are especially vulnerable. In the absence of existing care-givers, there is almost no provision for care and support for these persons. 743.3 43.4 43.5 4.3.6 Persons inside custodial institutions Person(s) inside custodial institutions fall into different categories and frequently have multiple vulnerabilities. They include women and children in rescue homes, children in institutions under the Juvenile Justice Act, 2006 (as amended in 2011), people in “beggars’ homes’, long stay homes under the Government and under-trials and convicts in prisons. An important aspect to be kept in mind is the issue of deprivation of personal liberty in custodial care. As with other forms of social disadvantage, the relationship between mental health problems and being in custody is bi- directional. At present, mental health services for these vulnerable groups are inadequate. Orphaned persons with mental illness (OPMI) Itis believed that 70% to 80% of the persons with mental disorders in India live with their families, and this is true across all demographic and social variables. Once the existing care givers are no more, there is no provision for home care and support of these persons. As a result, many of them languish till death due to starvation and lack of critical support systems like monitoring medicines, personal hygiene and food etc. Not all of them fall under category of poor, yet, those with high support needs - irrespective of rich or poor -are highly vulnerable due to their incapacity for selt- care. This Policy recognizes that needs of this category of persons with mental disorders have been neglected for a longtime. Children of persons with mental health Problems Children of persons with mental health problems are vulnerable and their needs have not been adequately addressed. They are likely to be exposed to a range of adversities including, but not limited to, poor parental care, disruption in parenting and schooling and increasing poverty. Elderly care-givers Elderly care-givers whose own physical and mental health care needs are high are vulnerable. Unmet needs have a negative impact on their lives as well as the lives of those for who they provide care. There has been little policy or service delivery action to meet the needs of such elderly care-givers. There could be other vulnerable care-givers such as adolescents, single person responsible for livelihood as well as care giving, and many such others. 843.7 43.8 4.3.9 Internally displaced persons There is a significant demographic shift from rural to urban areas, often across state/regional boundaries. These individuals and families are usually engaged in work in the unorganized sector and have poor access to local health services. There is very little information on the mental health needs of this group. Persons affected by disasters and emergencies Natural or man-made disasters are frequent causes of psychological distress, Many local ‘disasters’ (building collapses; slum-evictions; floods; riots etc.) do not get sufficient attention. Adequate recognition of mental health consequences and provision of both medical and social welfare responses is necessary for persons affected by disasters. Other marginalized populations Marginalization and exclusion in any form are major determinants of poor mental health. Marginalised persons such as commercial sex workers, victims of human trafficking, victims of riot, sexual minorities, children and those living in situations of conflict bear disproportionate burden of mental health problems. 4.4 Adequate funding 441 442 Provision of Funds Provision of adequate funds to realise the vision and goals of the National Mental Health Policy is crucial. There is a reasonable expectation and demand that in near future, funding for the health sector should increase. Allocation to activities for mental health promotion, prevention and treatment should also therefore increase. Spending on health by the government is not expenditure but a social investment and a social right. On-going activities under the national and district mental health programmes must continue in a strengthened and more responsive manner. The expansion of mental health programme to the entire country will require more funds. New activities especially in the area of community based rehabilitation and continuing care must be supported with adequate funding. The work of non-governmental organizations must be encouraged and supported, in order to achieve a collaborative and sustainable response system. Provision of Funds across related departments The interdependence and interlink of health and non-health sectors (including government departments) is true for non- 945 46. 47 communicable diseases including mental health. It is important that funds are allocated for mental health in various departments and ministries such as health, social welfare, women and child development, school education. It is also important to keep in mind that additional funding may not be required for many social sector programmes where, however, it is imperative to ensure that persons with mental illness are also integrated as beneficiaries of existing programmes. Supportfor families Currently, families are the main-stay of long term care for persons with mental health problems. Such families bear direct financial costs of treatment as well as associated indirect costs such as loss of wages consequent to having to give up employment to look after sick family member. The emotional and social costs of providing care for a family member with mental illness cannot be quantified but exacts a huge toll on families. The care-giving role impacts the physical and mental health of the care-giver. All too often, it is elderly care-givers (usually parents or grand-parents) who are left to look after the person with mental illness without any support from health and social care services. Families need access to information, guidance in accessing services for their family member and support in performing their care-giver role. The families and care-givers of persons with mental illness should be adequately supported to help them perform their role, especially those with long term and chronic mental illness. Inter-sectoral collaboration The needs of persons with mental illness cannot be met by the health sector alone and there is need for inter-sectoral collaboration. Collaboration is also needed within the health sector for example between specialist mental health and general health services as well as outside the health sector with education, employment, housing and social care sectors. Similarly there is need for collaboration between the government (public) sector and the non-governmental sectors (non-profit as well as private) Institutional care Mental hospitals have traditionally been a major source of treatment of persons with mental illness. Over the last few decades, government 1048 49 4.91 has undertaken their reform. Even then, their access is limited, staff inadequate and funds low. This compromises the quality of care. There are nowa number of similar institutions operating in the private sector. All in-patient facilities must be linked to community care to support persons who are discharged (as indicated by the principle of continuing care), or who are being managed in the community. This policy recognises a spectrum of needs, ranging from appropriately transitioned community care for a majority to long term institutional care for a small number. As such, the need is of developing multiplicity of care models that may be seamlessly integrated with each other. Promotion of mental health A healthy, safe and enriching physical and social environment promotes individual and community mental health. The predictable negative influences on mental health of poverty, discrimination, malnutrition, environmental factors (including access to safe water, toilets and sanitation), exposure to violence and absence of parental figures (death, divorce or displacement) affect individuals across their life span. Certain life stages have unique challenges which should be recognised and addressed to promote mental health and overall health and wellbeing of a population. Negative influences have varied impact depending on life stage for example malnutrition affects children worse than adults. There has been a relative neglect both in policy and practice of the promotion of mental health at the community lavel. There are however organisations and institutions that have experimented, studied and worked on different mental health promotion measures this experience will be built upon. Research Research questions Primary role of research is to generate knowledge which will lead to a reduction in the burden of mental health problems in India. Key research questions include implementation research issues - how to provide effective treatments in routine health care (for example identification of barriers to integration of mental health into primary health care), causes of mental disorders in the Indian context, identification of effective treatments including those from indigenous systems of medicine which can increase the therapeutic choices for persons with mental health problems, "4.9.2 4.9.3 developing a deeper understanding of the bio-psycho-social determinants of mental health and mental illness and pathways for action onthe same; among others. Monitoring and evaluation There is a need for continued monitoring of the mental health of populations both to assess changing patterns of burden over time as well as to evaluate the impact of mental health programs. Building research capacity A key challenge to implement these research priorities is that of capacity and resources to implement research; knowledge translation; and for practitioners to use research findings and an evidence base ina scientific and socially accountable manner. 5. Strategic directions and recommendations ofaction The strategic areas for action are linked to the situation analysis, cross cutting issues and goals and objectives of the Mental Health Policy. Each strategic area lists actions to achieve the vision of this policy. These intervention areas are all equally relevant and need to be pursued in parallel 51 5.2 5.3 5.4 5.5 5.6 5.7 Effective governance and delivery mechanisms for mental health Promotion of mental health Prevention of mental illness, reduction of suicide and attempted suicide Universal access to mental health services Improved availability of adequately trained mental health human resources to address the mental health needs of the community ‘Community participation for mental health and development Research 5.1. Effective governance and accountability for mental health 5.14 5.1.2 Develop relevant policies, programmes, laws and regulations within all relevant sectors in line with Mental Health Policy with associated implementation and monitoring mechanisms. Appropriate plans with adequate budgetary provision across sectors to allow implementation of evidence-based mental health plans and actions 125.1.3 Motivate and engage stakeholders from relevant sectors, in particular persons with mental health problems, care-givers and family members, civil society leaders and those with management and strategic implementation expertise in the development, implementation and evaluation of mental health policies, laws and services, through a formal mechanism. Develop and sustain technical capacity and suitable mechanisms at the Centre, State, District and local levels to plan, monitor and evaluate implementation of mental health policies, laws and programs. 5.2 Promotion of mental health 5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 5.2.6 Re-design Anganwadi Centres to cater to the early child care, developmental and emotional needs of children below six years Separate attention should be given to children under the age of three years, Introduce mother-child sessions on parenting skills education, address threats to healthy mother- child bond. Train Anganwadi workers and school teachers with knowledge and skills that support and build the self-confidence of parents and care-givers in understanding the physical and emotional needs of children to facilitate an affirmative and positive environment for the growth and development of children and for providing protection against harmful behaviour. The Life Skills Education (LSE) programme should be offered to school children and college going young person(s) using interactive learning methods that are age and context specific, facilitated by teachers and trainers who are appropriately skilled LSE should also provide a forum for discussion on issues such as gender and social exclusion in a manner that is appropriate and applicable in different contexts. Provision of LSE skills to young people outside the formal schooling system should be ensured via youth clubs, or any other suitable fora. Signs and symptoms of many mental disorders (schizophrenia, mood disorders, etc.) first appear during the adolescent years. Individual attention in the school by teachers trained in mental health promotion and distress alleviation is therefore important. Similarly, equipping teachers in the primary education system with life skills training coupled with an environment where young students can benefit rom the same is critical 135.2.7 5.2.8 5.2.9 5.2.10 5.2.11 5.2.12 5.2.13 5.2.14 5.2.15 Design appropriate curricula and pedagogy, teacher student relationship, provision of suitable infrastructure including access to toilets within the school system. Programmes to assist adults in handling of stressful life circumstances should be incorporated in workplace (workplace policies) and residence support programmes. Workplace policies should cover those employed in the organized as well as unorganized sectors. Reliable mental health information should be easily available. This will inform people to protect and promote their mental health. Mass media events, contact programmes should be organised to disseminate such information. To supplement information, counselling services, help lines, dedicated websites should be made available for easy flow of information Increase awareness amongst policy-makers, planners and Governments of the need to reduce poverty and income disparities to improve mental health outcomes. Social exclusion, unequal opportunities, income disparities and perceived lack of control over ones social and economic life is linked to high rates of depression ‘Addressing these issues at a systemic level is linked to preventive strategies. Encourage action 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 these social factors, low grade infections, micro-nutrient deficiency (iron, foliate, vitamins, other trace elements) is also linked to increased incidence of mental disorders, and slow and poor recovery (and response to treatment) Implement programmes to reduce risk factors for women's mental health such as acts of violence against women. Mental health promotion actions should be broad based, embedded in all spheres of life, and not become sole prerogative or responsibility of the mental health program, failing which this could stigmatise mental health initiatives. Gender sensitisation programs for health system staff should be introduced. Practitioners of Ayurveda and Yoga systems are a resource who need to be included as activists for promotion of mental health. 145.3 Prevention of mental illness and reduction of suicide and attempted suicide 5.3.1 5.3.1.1 5.3.1.2 5.3.1.3 5.3.1.4 5.3.1.5 5.3.1.6 5.3.1.7 5.3.1.8 5.3.2 5.3.3 5.3.3.1 5.3.3.2 5.3.3.3 5.3.3.4 5.3.3.5 Address stigma, discrimination and exclusion Enable access to treatment and to other care-giving facilities to promote early recovery. Encourage persons with mental health problems to actively and fully participate in social and economic activities. Ensure there is no discrimination against persons with mental health problems in all aspects of seeking and retaining work, including participating in all work related activities. Mental disorders should be treated as a disability and suitably factored in employmentpolicies. Create an environment where persons with mental health problems are enabled to take part in regular activities (e.g. operate bank account, obtain identity documents, obtain driving licence, writing a will, etc.) and are not discriminated against. Mental disability should be treated on par with any other form of disability. ‘Amending and/or replacing policies, laws and regulations which discriminate against persons with mental illness. Facilitate education for person(s) with mental health problems to improve their employability. To undertake communication programmes to reduce stigma Police and judicial officers should be sensitized on mental health andits interface with legal issues. Implement programmes to address alcohol abuse and other drugs of abuse Specific action plan should be formulated to reduce the consumption and abuses of alcohol and other addictive substances. The action plan should include taxation, licensing, production and other relevant issues. Susbstance use and abuse is a problem of significant proportion hence should be addressed on priority. Implement suicide reduction programmes to reduce the likelihood of suicide and attempted suicide 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 centres and help-lines as part of the district mental health programme. 155.3.3.6 Improve data collection on suicides and attempted suicides by the National Crime Records Bureau to improve understanding of the issue, 5.3.3.7 Address alcohol abuse (and dependence), and depression as key risk factors for suicide and attempted suicide. 5.4 Universal access to mental health services 5.4.1 5.4.2 5.4.3 5.4.4 5.4.5 5.4.6 5.4.7 5.4.8 Comprehensive services for mental health problems should be made universally accessible. A continuum of such services should be available across facility, community and family. Services should be family centric to address needs of persons with mental health problems across life-span. All multi-speciality Government hospitals should provide mental health services to improve access. Increase availability of a range of community based rehabilitation services including day care centres, short stay facilities and long stay community facilities to promote recovery with support from local bodies and other sources of support. Develop norms and standards for mental health services and implement clinical and social audits for continuous quality improvement. Facilitate mental health service users and their families and care- givers formally and supported by law, if necessary, in designing, implementing and monitoring of mental health services. Implement community based programmes to support families and care givers to foster recovery for persons with mental health problems and mental illness family provides care and plays a critical role in fostering recovery. The needs of 70-80 million care givers (usually family care-givers) remain unaddressed. Caring for the carer is a neglected area. There is a need to implement programmes to address the economic needs of this very important stakeholder group. Formation of care-givers groups with professional inputs to facilitate a better and accurate understanding of the particular mental health problem their family member is living with. Care givers to be encouraged to pursue other activities to give them space for their own personal growth. Implement programmes for screening, early identification and treatment of mental health problems and mental illness. The absolute shortage of inpatient beds for acute mental health 165.4.9 5.4.10 5.4.11 5.412 5.4.13 5.4.14 5.4.15 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 general hospitals. Build effective leadership and management systems. Develop a comprehensive mental health information system for data collection and digitization of data. The reform of mental hospitals should be continued to provide them with improved infrastructure and enhanced resources to provide quality services Institutionalize a culture of respect for rights of persons with mental illness and a culture of openness and integration with their local communities. Financial support including monetary benefits and tax benefits to the primary care-giver needs to be addressed. These can be based on criteria which take into account age of the care-giver, family income, number of hours of caregiving, whether care is provided in hospital or at home and whether the care-givers had to give up their job to provide care. A multidimensional, dynamic and well-being oriented approach is, essential to address the needs of homeless persons with mental illness. While some homeless people with mental illness may require in-patient facilities, others need access to open shelters, community kitchens, adequate clothing, medical support and other social entitlements. These services may be coordinated between Local Self Government Institutions and Social Welfare/Disability Departments based on a National Policy on Homelessness. The Government Policy should formulate a response towards homeless person with mental health problems. This should include adequate attention to preventive measures and rehabilitative measures. Assisted Living Services for persons with mental health problems is a type of domiciliary care for persons with chronic and long term illness. Those on recovery pathways can have integrated independent housing with some minimal support systems. Thereby the exit of family care givers does not become a critical setback in their recovery progress. However, the majority who live in their families face a sudden withdrawal of all forms of support once the care-givers are no more. The emerging contours of Indian families as urban prototypes worsen the situation. This policy recommends to explore ways and means of finding a solution to the question - “Who after me". A suitable mix of all three different models of care - 17institutional, community and family- has to be identified to suit the needs of the orphaned persons. Extending assisted living in one's own home could be a viable option for various categories of families, across the social strata. The question of the State monitoring such services has an element of legal obligation to ensure safety and protect dignity of the afflicted persons living alone on low or nil support. 5.5 Improve availability of adequately trained mental health human 5.5.1 5.5.2 5.5.3 5.5.4 resources to address the mental health needs of the community To reduce the gap between requirement and availability of trained mental health professionals (psychiatrists, psychiatric nurses, psychologists, counsellors, medical psychiatric social workers, etc.) higher number of such professionals should be trained Persons affected by mental health problems and their care-givers are an important mental health human resource. At appropriate places, this group should be used to support recovery and disseminate information on mental health Integration of mental health in training programmes of other allied fields is necessary. Anyone with a mental health issue should have a seamless transition from a general practitioner / service to specialised care; such should be the role and responsibilities of each of the treating medical professionals. Itis therefore imperative that a systems perspective be the driving value / strategy in the training of these professionals to ensure a collaborative and informed approach to treatment and referral. All health personnel — general or specialists should be trained on mental health to positively influence mental health of patient and care giver. Shortage of mental health nurses has been observed in the country. Psychiatric nursing or mental health nursing courses such as Masters and Diploma courses should be started to increase supply of this trained cadre. Training in dealing with common as also severe mental disorders is of paramount importance. A clear defined role along with required skills should be outlined so that nursing services are used appropriately. The large numbers of Auxiliary Nursing Midwives should be offered an opportunity for skill upgradation in mental health. This work force caters to mothers and children hence their involvement in child and adolescent mental health and mental health services for the mothers will be useful. This is also perhaps the largest women health work force in the country. 185.5.5 5.5.6 5.5.7 Similarly, appropriately trained lay and community based counsellors, psychiatric social workers, development workers, psychologists, occupational therapists, other mental health professionals and those trained in the social sciences should be encouraged to understand and advocate the importance of a healthy ecosystem and robust development programmes. For specialised mental health services, the policy recommends that more jobs be envisaged in the government sector which will encourage youngsters to take such courses that lead them to jobs in the mental health sector. There should be a cadre of specialised mental health service providers in district hospitals. Mental health should be recognised as everybody's business. Training programmes must acknowledge that while the bio- medical approach to understanding mental health problems is undoubtedly important, there are equally important psycho-social interventions which need to be incorporated into programmes across all disciplines that would help alleviate distress in small ways. This would also help broaden the scope and reach of mental health interventions and thus help decrease stigma and position mental health more positively. 5.6 Community participation for mental health and development 5.6.1 5.6.2 5.6.3 5.6.4 5.6.5 Remove legislative, policy and programmatic barriers to protect rights of persons with mental illness and promote the full participation of persons with mental illness in all areas of life including education, housing, employment livelihood and social welfare. In particular, there is a need to simplify procedures for disability certification of persons with mental illness and enhancing compensation for mental disability Increase availability of appropriate housing with necessary supports for homeless and other poorly resourced persons with mental illness living in poverty and deprivation. Implement programmes to help persons with mental health problems to pursue education and vocational training schemes to help improve their chances of employment. Include person(s) with mental health problems in all social welfare and disability benefit programmes and make suitable modifications to such schemes to take into account the unique requirements and contexts of persons with mentaliliness. Co-ordinated actions between different government departments 195.6.6 5.6.7 and ministries, between government and civil society, private sector and any other stake-holder to ensure full participation of persons with mental illness. Involve persons living with mental illness and care-givers in Village Health, Sanitation, Water and Nutrition Committees (Swasthya Gram Samiti) and in Rogi Kalyan Samiti (Patient Welfare Committees) 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 person(s) with mental illness and care-givers in planning and feedback of mental health services. 5.7. Research 5.7.4 5.7.2 5.7.3 5.7.4 5.7.5 5.7.6 5.7.7 Develop and implement a comprehensive research agenda for mental health incorporating epidemiological, clinical and health systems research together with sociological, ethnographic and other multi-disciplinary methods, with recognition of the role of diverse disciplines and methodologies including participatory research methods. ‘Commit equitable funds for promoting mental health research, with a target consistent with the burden of mental health problems in the country, Invest in building research capacity in mental health, both through existing institutions and developing new institutions focused on niche areas, such as people who are homeless or children's mental health Foster partnerships between Centres of Excellence for Mental Health and Medical College Departments of Psychiatry with the District Mental Health Program and with appropriate NGOs and research institutions to implement priority mental health research. Develop sites in different regions of the country, around such partnerships, which can monitor population mental health and evaluate mental health programs. 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 20