District Mental Health Program, Trichi, Tamil Nadu

National mental health program was initiated in Tamil Nadu during the year 1986. Since then several training programs and workshops were conducted. Following the successful performance of the state unit of the National Mental Health Program, the state of Tamil Nadu was selected to implement the District Mental Health Program (DMHP) under the National Mental Health Program with financial assistance from Govt. of India.

District Mental Health Program (DMHP)

District mental health program envisages implementing the aims and objectives of the National Mental Health Program .The program is based on the district mental health program of NIMHANS Bangalore in Bellary district of Karnataka with suitable modifications. This pilot program of five years duration sponsored by Ministry of Health & Family Welfare, Government of India has commenced from the year 1997. Institute of Mental Health is the nodal agency identified by the Government of India for implementing the program. The health care delivery of the districts and villages were administered by Director of Medical and Rural Health Services (DMS). Hence, the Institute of Mental Health has submitted a joint proposal with DMS to Govt. of Tamilnadu under the guidance of Director of Medical Education. The services and guidance of Director of Public Health and Preventive Medicine were utilised for the implementation of the program

The Govt of Tamilnadu has selected Trichi district to implement the district mental health program. The Trichi District was selected for the DMHP program for the following reasons:

  • Trichi district is situated at the centre of the state

  • It has a well established Governmental and non-Governmental health care delivery system
  • One of the psychiatrist at Trichi had been trained under Training of Trainers program on Community mental health
  • Trichi is well connected by road and rail with Chennai

Heath Care Delivery of Trichi District:

Government and Non-Governmental agencies provide health care needs of Trichirapalli. District Government Hospital, Taluk Hospitals, panchayats Dispensaries and Primary Health Centres are the government agencies involved in the health care delivery system. There is one District Head Quarters Hospital, 6 Taluk hospitals, 4 dispensaries, 1 Tamilnadu special police hospital and 50 Primary Health centres including 2 upgraded primary health centres.

Govt Annal Gandhi Memorial Hospital, which has recently been affiliated to K.A.P.V Medical College, at Trichirapalli, has 603 beds with 12 speciality departments including Psychiatry. 76 Asst surgeons including one psychiatrist, 107 nurses, one extension educator and one social worker are posted to the Headquarters hospital. Total number of bed strength of six Taluk hospitals is 378. In addition Trichirapalli district has central Govt. hospitals like Railway hospital, Ordinance factory hospital, and BHEL hospital, which also cater the health needs of the industrial population. Private practitioners of medicine including Psychiatrists and private hospitals are the non-governmental agencies involved in the health care delivery system of Trichirapalli.  

Since the mental health care at primary care level needs the involvement of administrators at different level, a broad based team for the implementation of DMHP was formed.

The DMHP has three components namely training of medical, para medical and community leaders, Mental Health Care delivery and Information, Education and Communication activities (IEC activities). Implementation of the program will be done jointly by Director of Medical Services and Institute of Mental Health. Services of the Director of Public Health and Director of Primary Health Centres will be utilised.

Mental Health Care Delivery:

The Mental Health Care Delivery under the DMHP has been planned taking into consideration the Governmental and Non Governmental agencies into account. Govt. Annal Gandhi Memorial Hospital, Trichirapalli will be the head office and administrative centre for the district mental health program. Psychiatrist attached to this hospital will be called DMHP psychiatrist and the psychiatrist recruited for the District Mental Health Team will be DMHT Psychiatrist. The Joint Director, Medical Services will be in charge of the whole program at district level and all the communications. The DMHP psychiatrist with the help of DMHT psychiatrist will carry out liaison activities. In addition to his routine duties the DMHP psychiatrist will guide the district mental health team, attend the inpatients and conduct review meetings to monitor the program. Whenever possible he will also take part in IEC activities of the district mental health program.

District Mental Health Team is a multidisciplinary team exclusively recruited for Mental Health Care Delivery of the DMHP. It consists of one psychiatrist, one clinical psychologist, one psychiatric social worker, 4 nurses, and one male nursing attendant and a driver. The Psychiatrist recruited for the district mental health Team will be called as DMHT psychiatrist and he will lead the Mental Health Team under the guidance of DMHP psychiatrist.  For the purpose of mental health care the district is divided into six units belonging to six Taluks of the district. Six to eight primary health centres has been allotted to each Taluk. The existing psychiatric ward at the Annal Gandhi Hospital Trichi has been strengthened with additional 10 beds and equipment with the funds from DMHP. The DMHP psychiatrist will be in charge of the psychiatric ward. Cases requiring admission in the ward may be referred by DMHT psychiatrist from Taluk and villages to the psychiatric Out Patient room at Annal Gandhi Hospital, Trichi.

District mental health team with one psychiatrist, one nurse, one psychiatric social worker, and one male nursing attendant will visit satellite Psychiatric clinics at one Taluk hospital a day for six days a week. Medical officers and paramedical staff of Taluk hospitals will collect cases to be shown to the DMHT on prescribed days. Other than these cases, PHC medical officers and health workers of the respective Taluk will bring the cases to be treated by mental health team. The follow-up of cases treated at The Satellite Clinic will be done at the primary care level. Whenever necessary mental health team will also make visits to villages to deliver mental health care subject to feasibility of the visit. In addition to mental health care the team will also engage in IEC activities with the help of the local health workers and community leaders.

            Following is schedule of Taluk level satellite Psychiatric Clinics:

      Monday:                    Srirangam                        10 am to 1 pm
      Tuesday:                   Manapparai                      10 am to 1 pm
      Wednesday:              Thuraiyur                         10 am to 1 pm
      Thursday:                  Musiri                              10 am to 1 pm
      Friday                       Lalgudi                             10 am to 1 pm
      Saturday                   Manachnallur                    10 am to 1 pm 

The satellite mental health clinics were started during the month of June 1998. From June 1998 to March 1999, 783 new cases and 2950 old cases were treated at satellite mental health clinics. And during the current year 986 new cases and 12326 old cases were treated at satellite mental health clinics. Totally 13312 patients were treated.  

Following table gives the number of patients treated at satellite mental health clinics from April 1999 to March 2000.

S.No. Month No. of New Cases No. of Old Cases Total
1

April 1999

90 624 714
2

May 1999

77 729 806
3

June 1999

18 744 762
4

July 1999

137 914 1051
5

August 1999

142 993 1135
6

September 1999

107 1143 1250
7

October 1999

69 1025 1094
8

November 1999

67 993 1060
9

December 1999

85 1320 1405
10

January 2000

59 1198 1257
11

February 2000

45 1008 1053
12

March 2000

90 1635 1725

Following personnel were redeployed for mental health care delivery

        1. One Psychiatrist
        2. Four Staff Nurses
        3. One Clerk cum statistician
        4. One Attender
        5. One Driver

Following Medicines were supplied to Taluk hospitals and Primary Health Centres under DMHP:

List of Drugs with the quantity supplied:

No Name of the drug Dose
1.

Tablets:
Tab. Chlorpromazine

25mgs

 

 

100mgs

2.

Tab. Haloperidol

1.5mgs

 

 

5mgs

3.

Tab. Trihexyphenidyl

2mgs

4.

Tab. Trifluperazine

5mgs

5.

Tab. Phenytoin Sodium

100mgs

6.

Tab. Sodium Valproate

200mgs

7.

Tab. Carbamazepine

200mgs

8.

Tab. Imipramine

25mgs

9.

Tab. Amitryptaline

25mgs

10.

Tab. Diazepam

5mgs

 

Injections:

 

1.

Inj. Diazepam

10mgs

2.

Inj. Promethazine

50mgs

3.

Inj. Haloperidol

10mgs

4.

Inj. Chlorpromazine

50mgs

5.

Inj. B1, B6 and B12

 

6.

Inj. B-Complex

 

Infra structure for health care delivery was established by purchasing following equipment and medicines.

      1. Vehicle - Tata Sumo 
      2. Office furniture for DMHP Office at Trichi and Nodal Centre, Chennai
      3. Computer furniture for Trichi and Chennai
      4. Ten Hospital Cots, Mattresses, Pillows, Pillow Covers and Bed Sheets
      5. Electro Convulsive Therapy Machine
      6. Refrigerator
      7. One Plain paper copier
      8. One Over head projector
      9. One Public address system
      10. One cordless public address system for field visits
      11. Two computer, printer, ups etc. - one for DMHP Office, Trichi and other for Nodal Centre, Chennai
      12. Boyles Apparatus

Stationary:

Certain forms, case sheets and registers were printed for the DMHP. The forms, case sheets and registers have been designed by the Institute of Mental Health. Following are the forms, case sheets and registers printed for the Mental Health Care delivery:

1.   Referral Slip for Health workers in Tamil 

  • Quantity printed: 15,000 copies

  • Justification: The health workers should be provided with referral forms to enhance the precision in information gathering and uniformity in referral data, which will be used in the later for program evaluation and research

2.   Referral Slip for Medical officers:

  • Quantity printed: 15,000 copies

  • Justification: Medical officers require separate referral slips as to suit their clinical expertise and training. The referral forms will enhance the precision in information gathering and uniformity in referral data, which will be used for program evaluation and research

3.   Psychiatric Case sheet to be used by DMHT at Taluk hospitals:

  • Quantity printed:  6000 copies

  • Justification: Management of mentally ill patients requires elaborate history elicitation and mental Status Examination. A structured case sheet to record the information gathered is mandatory for diagnosis and follow-up.

4.   Nominal Register for DMHT:

  • Quantity printed: 1000 copies

  • Justification: Since DMHP is a central Govt. funded project, it has to report with documentary evidence the number of mentally ill person benefited from the program. Moreover a separate nominal register will be helpful in the periodic evaluation of the program.

5.   Evaluation Forms:

  • Quantity printed: 500

  • Justification: The whole program will be evaluated periodically. A standardised format will aid in comprehensive evaluation

6.  Patients Follow up Books

  • Quantity Printed: 20,000

  • Justification: Many patients on psychiatric medicine would require long term treatment. More over the follow up books can also be used to educate the patients about mental illness. 

The copy of the forms printed under DMHP, Trichi are annexed in the book titled Mental Health available in the same web site 

II. Training:

Training is imparted at three levels. The medical officers, para-medical workers of Govt. Taluk and primary health centre and non-medical persons were trained in basic mental health diagnosis and care. District psychiatrists and faculty members from Institute of Mental Health took part in the training as resource persons.

  • Details of training programs conducted during 1997 - 1998 under DMHP

    • Training programs for medical officers  
      • From 03.11.97 to 15.11.97
      • From 16.11.97 to 27.11.97
    • Training programs for Para medical personnel  
      • From 03.11.97 to 08.11.97         
      • From 15.11.97 to 20.11.97
    • Training programs for Non medical persons
      • From 01.12.97 to 03.12.97           
      • From 04.12.97 to 06.12.97         
      • From 08.12.97 to 10.12.97         
      • From 11.12.97 to 13.12.97

Totally 23 medical officers, 40 Health Inspectors and 135 non-medical personnel were trained during the first year of implementation. All the training programs were conducted at the KAPV Medical College, Trichi. The training for non-medical persons were conducted at PHCs

  • Details of Training program conducted during 1998 - 1999:

    • Training program for Medical officers of Primary Health Centres:
      • From 24.05.99 to 05.06.99
      • From 07.06.99 to 19.06.99
    • Training program for Village Health Nurses from PHCs:
      • From 24.05.99 to 29.05.99 
      • From 31.05.99 to 05.06.99
      • From 07.06.99 to 12.06.99
      • From 14.06.99 to 19.06.99
      • From 21.06.99 to 26.06.99
      • From 28.06.99 to 03.07.99

Totally 36 medical officers and 290 Village Health Nurses were trained during the year 1998 - 1999

  • Details of Training program conducted during 1999 - 2000:

    • Training programs for Health Inspectors of Primary Health Centres of Trichi:
      • From 03.4.2000 to 10.4.2000
      • From 11.4.2000 to 18.4.2000
      • From 19.4.2000 to 26.4.2000
      • From 27.4.2000 to 03.5.2000

Totally 130 Health Inspectors were trained during the year 1999 - 2000

So far totally 59 medical officers, 290 Village Health Nurses, 170th Health Inspectors and 135 non- medical personnel were trained under District Mental Health Program.

  • Training consisted of the following components:

    • Pre-training Evaluation
      • Lecture classes on causes, symptoms and classification of mental illnesses
      • Identification and treatment of mental illnesses in the community
      • Case demonstration
      • Case presentation by the trainees and discussion
      • Demonstration of case record and referral
      • Field visit to Primary Health Centre to demonstrate IEC activities and community intervention
      • Field visit to a temple by name 'Gunaseelam', which is about 35 kilometres from Trichi, where mentally ill are given magico-religious treatment. Field visits are organised to demonstrate the misconceptions about the mental illnesses and to highlight the plight of mentally ill in the community.
      • Post training evaluation and feed back from the trainees about the training program

Medical officers were trained for two weeks and para medical personnel had undergone one week training. All the training programs for medical and para medical were conducted at KAPV medical college, Trichi. Faculty members of Institute of Mental Health, DMHT psychiatrist, DMHP Psychiatrist and psychiatrist of Dept. of Psychiatry, KAPV Medical College have participated in the DMHP training program as resource persons.

III. Information, Education and Communication Programs (IEC):

The Information, Education and Communication (IEC) activities were planned according to the needs of the community. Following methods were used to create awareness about mental health and District Mental Health Program.

  • To create awareness among fellow psychiatrist about the DMHP, a meeting of local Govt. and private psychiatrists was held at Trichi

  • The DMHT Psychiatrist had delivered a talk in All India Radio about mental health
  • 500 Flip Charts depicting signs and symptoms of various mental illnesses were printed with colourful illustrations and messages in Tamil. Flip charts were distributed to the Village Health Nurses who have close contact with the community.
    • 5000 copies of 16 pages booklet on mental health were printed for general public

  • Following books on mental health one in English for medical officers and the other two in Tamil for para medical personnel and general public were printed.

    • Mental Health Manual for Primary Care Doctors
    • Mental Health Manual for Para Medical Personnel
    • Mental Health Manual for General Public
  • Mental health awareness meeting for school children and teachers were conducted at four schools at Trichi
  • 500 copies of quarterly bilingual (Tamil and English) News Letter titled "MENTAL HEALTH" containing mental health messages and DMHP news were printed and circulated.
  • Mental Health Festivals: Mental Health Festival is a unique concept, which incorporates a popular village program with mental health awareness program. In the villages of Tamil Nadu it is customary to arrange fairs and music programs during festivals. Usually during these festivals popular cine music troupes will play devotional and cinema songs. These programs are very popular and people come in large number to attend these programs. Hence it was planned to conduct similar programs at villages and deliver mental health messages. The programs were named " Mental Health Festivals" to make it more attractive.

    During these mental health festivals popular cine music troupe was hired for musical program. Carefully selected cinema songs having mental health messages were played by the music troupe. A drama troupe was hired to five skits on the following themes were scripted:

      • Depression
      • Paranoid Disorder
      • Alcohol Dependence
      • Anxiety Disorder
      • Obsessive Compulsive Disorder
    These skits were played in between the cinema songs. Psychiatrists from Chennai and Trichi participated in the program and delivered short messages about mental health and also answered questions raised by the general public about various mental illnesses.
    Totally six such mental health festivals were conducted at the interior villages of Trichi district. All the programs were conducted on Sundays between 6.30 and 10.00 PM.

Following are the details of mental health festivals:

Mental Health Festivals:

Programme Date  Day Village

First Mental Health Festival

30.05.1999 Sunday

Thiruvembur

Second Mental Health Festival

06.06.1999 Sunday

Inamkulathur

Third Mental Health Festival

13.06.1999 Sunday

Sirugambur

Fourth Mental Health Festival

20.06.1999 Sunday

Uppiliyapuram

Fifth Mental Health Festival

27.07.1999 Sunday

Kulumanii

Sixth Mental Health Festival

04.07.1999 Sunday

Thandalai puthur

The mental health delivery system is streamlined and more number of patients are attending the satellite clinics. Most of the referrals to the satellite clinics are from old patients of satellite clinics, which show the quality and popularity of the satellite clinics. Psychiatric medicines are issued to the patients for 14 days, which eliminates the frequent visits to the clinic and reduces the expenditure involved in travelling. The network for mental health care has been established at the Taluk level and the next logical step in mental health care under DMHP will be to extend the service to Primary Health Centres.

As far as training is concerned fairly good number of medical and para medical personnel had been trained in basic mental health care. 290-village health nurses and      out 170 health inspectors and 59 of medical officers had been trained. With this the training component of DMHP comes to an end. Henceforth services of trained personnel should be utilized to extend the service to PHC and Sub centre level. Short refresher courses should be planned to maintain the mental health skills of the trained personnel.

DMHP has done extremely well in the sphere of IEC activities. Especially the mental health festivals had been a grand success in creating awareness about mental health. The mental health festivals were conducted from May to July. Success of the programs is reflected in the sudden increase in the new cases attending the satellite clinics during these months. Number of printed materials was prepared for awareness activities. School awareness meeting were inspiring and encouraging.

With these achievements, it is time to intensify the IEC activities and extend the mental health services to the Primary Health Centre level. During the coming years following activities will be undertaken:

      1. Continuing and Strengthening the Taluk level Satellite Mental Health Clinics
      2. Purchase of certain furniture and equipment
      3. Psychiatric Medicines
      4. Organizing DMHP Orientation Camps at all the Primary Health Centres at Trichi District
      5. Organizing a Mental Health Exhibition at Trichi as part of the IEC activity
      6. Creating a Website for DMHP
      7. Conducting External Evaluation
      8. Conducting an survey of mental health problems in Trichi District
      9. Community based Rehabilitation of Mentally ill and Disabled
      10. School Mental Health