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Chapter 1-INTRODUCTION
In the past 2 decades, mental health has gained publicity in international literature. Mental health is as important as physical health to the overall wellbeing of individuals, societies and countries. An estimated 450 million people suffer from mental or behavioural disorders. Poor mental health affects one in four people over their lifetime. (WHO, 2001) Governments are as responsible for the mental health as for the physical health of their citizens. As the ultimate stewards of any health system, governments must take the responsibility for ensuring that mental health policies are developed and implemented. Nevertheless, more than 40% of countries have no mental health policy and over 30% have no mental health programme. Moreover, health plans frequently do not cover mental and behavioural disorders at the same level as other illnesses, creating significant economic difficulties for patients and their families. (WHO, 2001) The low budget accorded to health and the unenviably low priority of mental health does not make this picture any easier. Alternative healing

practices, especially religious healing, are still the first resort for many. Health care workers have to contend with misconceptions about mental disorders and the stigma attached to them. The increasing number of mental health professionals, the availability of most newer drugs, access to information and the presence of a few centres of excellence augur a bright future for the

CHAPTER 1

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mental health scene. The Indian government provides several levels of medical services at nominal or no cost; these are essential in a country where much of the population is impoverished and there is no viable health insurance system. The National Mental Health Programme (NMHP) was developed with the objective of ensuring availability and accessibility of basic mental health care for all sections of the population. The Governments current 5-year plan has allocated a substantial amount to the implementation of the NMHP in all Indian states through the District Mental Health Programme. Despite this, medical services in the costly private sector flourish. Thus, links need to be established between governmental mental health services and various NGOs and community agencies at the local level so that appropriate housing, income support, disability benefits, employment, and other social service supports are mobilized on behalf of patients and in order that prevention and rehabilitation strategies can be more effectively implemented. (Thara, R., et. al., 2004) The past two decades have witnessed a surge in the voluntary mental health movement in India. Self-help and support groups consisting largely of the families of people with mental illness are also making their presence felt on the national mental health scene. Bangalore City is considered as the mental health capital of India. (Patel & Thara, 2003). The relationship between the public and private sectors has seldom been addressed by research or policy planners. Understanding how patients and families use each is critical. This chapter has been written in order to demonstrate the global burden of mental disorders and briefly outline the Indian scenario. The chapter also

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describes the concepts of Chronic Mental illness and puts in to perspective the need for psycho-social rehabilitation. The chapter goes on to describe briefly the existing knowledge of the work of various NGOs in the field of PsychoSocial Rehabilitation.

Global Scenario

The WHO defines health as Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (Official Records of the World Health Organization, No. 2, p. 100.) Mental health is as important as physical health to the overall well-being of individuals, societies and countries. Chronic disease (cardiovascular disease, cancer, chronic respiratory diseases) and poor mental health are the leading causes of death and disability globally. 60% of all deaths, 80% of which occur in low- and middle-income countries, are related to chronic diseases. Yet only a small minority of the 450 million people suffering from a mental or behavioural disorder are receiving treatment. Poor mental health affects one in four people over their lifetime, and depression alone is the third leading cause of disability, responsible for 4.3% of years lived with disability globally. (WHO, 2001) Worldwide, community-based epidemiological studies have estimated that lifetime prevalence rates of mental disorders in adults are 12.248.6%, and 12month prevalence rates are 8.429.1%. 14% of the global burden of disease, measured in disability-adjusted life years (DALYs), can be attributed to Mental, neurological, and substance use (MNS) disorders. About 30% of the total

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burden of non-communicable diseases is due to these disorders. Almost three quarters of the global burden of neuropsychiatric disorders is in countries with low and lower middle incomes. The stigma and violations of human rights directed towards people with these disorders compounds the problem, increasing their vulnerability; accelerating and reinforcing their decline into poverty; and hindering care and rehabilitation. Restoration of mental health is not only essential for individual well-being, but is also necessary for economic growth and reduction of poverty in societies and countries. (WHO, 2008) Major depression is now the leading cause of disability globally and ranks fourth in the ten leading causes of the global burden of disease. If projections are correct, within the next 20 years, depression will have the dubious distinction of becoming the second cause of the global disease burden. Globally, 100 million people have alcohol dependence. Approximately 50 million have epilepsy; another 45 million have schizophrenia. One million people commit suicide every year. Between 10 and 20 million people attempt it. (WHO, 2008) A large multi-country survey supported by WHO showed that 3550% of serious cases in developed countries and 7685% in less-developed countries had received no treatment in the previous 12 months. A review of the world literature found treatment gaps to be 32% for schizophrenia, 56% for depression, and as much as 78% for alcohol use disorders. Rare is the family that is free from an encounter with mental disorders. The social and economic burden of mental illness is enormous. Between 20052015, income loss estimates (in international dollars) related to chronic disease

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rise to $558 billion in China, $237 billion in India, $303 billion in Russia, $33 billion in the UK, $49 million in Brazil. Costs associated with poor mental health account for 2-3% of GDP, with most costs related to absenteeism and presenteeism. (WHO, 2001) Mental, neurological, and substance use (MNS) disorders are prevalent in all regions of the world and are major contributors to morbidity and premature mortality. 14% of the global burden of disease, measured in disability-adjusted life years (DALYs), can be attributed to MNS disorders. The stigma and violations of human rights directed towards people with these disorders compounds the problem. The resources that have been provided to tackle the huge burden of MNS disorders are insufficient, inequitably distributed, and inefficiently used, which leads to a treatment gap of more than 75% in many countries with low and lower middle incomes. (WHO, 2002) On 9th October, 2008, WHO has launched its action programme in Geneva, the mental health Gap Action Programme (mhGAP) which aims at scaling up services for mental, neurological and substance use disorders for countries especially with low- and middle-income. The programme asserts that with proper care, psychosocial assistance and medication, tens of millions could be treated for depression, schizophrenia, and epilepsy, prevented from suicide and begin to lead normal lives even where resources are scarce. (WHO, 2002)

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INTRODUCTION

Role of Governments

Governments are as responsible for the mental health as for the physical health of their citizens. One of the key messages to governments is that mental asylums, where they still exist, must be closed down and replaced with wellorganized community-based care and psychiatric beds in general hospitals. The days of locking up people with mental or behavioural disorders in grim prisonlike psychiatric institutions must end. As the ultimate stewards of any health system, governments must take the responsibility for ensuring that mental health policies are developed and implemented. (WHO, 2001) Mental and behavioural disorders are estimated to account for 12% of the global burden of disease, yet the mental health budgets of the majority of countries constitute less than 1% of their total health expenditures. The relationship between disease burden and disease spending is clearly disproportionate. More than 40% of countries have no mental health policy and over 30% have no mental health programme. Over 90% of countries have no mental health policy that includes children and adolescents. Moreover, health plans frequently do not cover mental and behavioural disorders at the same level as other illnesses, creating significant economic difficulties for patients and their families. And so the suffering continues, and the difficulties grow. (WHO, 2001) The mhGAP programme initiated by the WHO in 2002 urges the governments to scale up their efforts to provide mental health care at the community level. (WHO, 2002)

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It also goes on to state that the success in implementation of the programme rests, first and foremost, on achievement of political commitment at the highest level, and acquisition of the necessary human and financial resources. The programme will need inputs from psychiatric, neurological, and primary care health professionals; social scientists; health economists; key multilateral and bilateral partners; and nongovernmental organizations (NGOs). Service users are also important stakeholders and their inputs will be essential. In 2008, the WHO in collaboration with the World Association of family doctors brought out a detailed document on how to integrate Mental Health into the Primary Health Care Systems. They highlighted 10 broad principles by which this could be attained. (WHO, 2008) The WHO also periodically comes out with service and guidance packages to help governments make necessary changes in order to integrate mental health into the primary health care systems.

The Indian Scenario

India is a country with a population of over 1 billion, and immense diversity in the languages spoken, levels of literacy, and social and cultural practices. Organising mental health services for this predominantly rural population is indeed a daunting task. Compounding this problem are low budgetary resources, the presence of competing and conflicting healing systems, scarcity of mental health personnel, brain drain, and the stigma of seeking help for problems related to the mind. (Thara, R., et. al., 2004)

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Evidence in Ancient India

The medical compendia of ancient India are replete with references to mental health covering a spectrum of diagnoses, classification and treatment methods. A description of insanity unmada (oonma-tha) dating back to 1500 BC exists in the Atharva Veda, the most ancient authentic Indian medical scripture. Descriptions of conditions similar to schizophrenia and bipolar disorder appear in the Vedic texts; these texts differentiated doctors practising magical medicine from scientific physicians and surgeons, who lived and practised in cottages surrounded by medicinal plants. An ancient textbook of Ayurvedic medicine, Therapeutics and Surgical Practice by Charaka and Susrutha, has a vivid description of schizophrenia. It states clearly that only an expert in the field of mental health should treat people with this illness. Other traditional medical systems, such as Siddha, which recognises various types of mental disorder, flourished in southern India. The great epics such as the Ramayana and the Mahabharata made several references to disordered states of mind and means of coping with them. The Bhagavad Gita is a classical example of crisis intervention psychotherapy (Trivedi, 2000).

Epidemiology
Obviously, in a vast country like India, the threat posed by the psychiatric and behavioural disorders is just inexplicable. A meta-analysis of 13 epidemiological studies consisting of 33,572 persons reported a total morbidity of 58.2 per 1000. Another meta-analysis of 15 epidemiological studies reported a total morbidity of 73 per 1000. The saddest aspect is that the bulk of the affected falls in the 15 to 45 year age group. The existing facilities in the country fall

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short of the required norms, which makes the situation still worse. The number of psychiatric beds in the country is only about 0.2 per 1, 00,000 population and there are only two psychiatrists per 10 lakh population. The major share of psychiatric facilities lies with the government sector (especially mental hospitals), which is centred on certain areas of particular states. The psychiatric services have not yet been integrated into the primary health care system and this leaves large populations in dire need of such facilities, with no hope of effective treatment. (Gururaj, G., et al., 2005) Several policy-making bodies in India have arrived at an estimate of mental disorders of their own, the precise basis of which is not clearly known. As early as 1911, Overbeck and Wright estimated the prevalence to be 2628/1000 for the Indian population. Subsequently, the mental health advisory committee of India estimated the prevalence to be 2% of the total population (Chandrashekar and Isaac 1999). Following the path-breaking effort by Dube in Agra, the majority of the classical Indian psychiatric epidemiology studies in the past four decades focused on general psychiatric morbidity in small-tomedium populations. The population samples were more often convenient samples. Chandrashekar and Isaac (1999) reviewing these studies reveal the wide variation in prevalence rates; ranging from 10370/1000population in different parts of the country. Two recent studies have attempted to generate all-India prevalence rates. Reddy and Chandrashekar (1998) in a meta-analysis reported the total prevalence to be 58/1000 (confidence interval [CI] 55.7 60.7) with 48.9/1000 for the rural population and 80.6/1000 for the urban population. Ganguli (2000), reviewing major Indian studies, computed the total rate to be 73/1000 (range: 18207). In summary, the range of prevalence rates

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for major mental disorders from the available epidemiological literature is very wide. While extrapolating from one good study is inappropriate for deriving national estimates, pooling from a few incomparable studies is also incorrect. Hence, for purposes of estimating the number of persons with any mental and behavioural disorder in India, a median conservative estimate of 65/1000 population has been utilized. (Gururaj, G., et al. 2005)

India is a multicultural, multi-ethnic, pluralistic society with enormous socioeconomic disparities. This variety on the one hand is exciting, stimulating much research into behaviour and mental health; on the other hand, it is a daunting task to provide affordable and effective mental health care, especially to the remote rural corners of the country. The low budget accorded to health and the unenviably low priority of mental health does not make this task any easier. The spending in terms of the countrys mental health budget does not exceed 1% of the total health expenditure. (Gururaj, G., et al. 2004)

Current Treatment Trends

Alternative healing practices, especially religious healing, are still the first resort for many. Health care workers have to contend with misconceptions about mental disorders and the stigma attached to them. The brain drain is another unfortunate aspect of the Indian mental health scene. Therefore, they seek help from the private sector and there are no clear policies regarding treatment of the mentally ill in the private sector. A significant population in India cannot afford private hospital care and the insurance system in the country is in its

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infancy. The rehabilitation of psychiatric patients is also given little importance in the existing mental health framework. (Thara, R., et al. 2004) The increasing number of mental health professionals, the availability of most newer drugs, access to information and the presence of a few centres of excellence augur a bright future for the mental health scene in India. The National Mental Health Programme (NMHP) was developed with the objective of ensuring availability and accessibility of basic mental health care for all sections of the population. This programme has been operating since 1984 in a few states, but many other states have yet to adopt it in even a rudimentary fashion. The NMHP recognized that services need to be planned for a minimum population of 1 crore who suffer from a serious mental disorder. It classified the burden as acute mental disorders, chronic or frequently recurring mental illnesses, emotional illness, and alcohol abuse and drug dependence. It specified service components with three subprogrammes treatment, rehabilitation and preventionto be implemented through primary health care. The different levels identified were the village/sub-centre, primary health centre, district hospital, mental hospitals and teaching psychiatric units. Emphasizing equally on mental health training, it set out an outline plan of action with a set of targets and of detailed activities. (Patel & Thara. 2003)

Public Health Initiatives

The District Mental Health Programme (DMHP) came to be recognized as a strategy to implement the NMHP. In a major review in 2002 undertaken prior

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to the expansion under the Tenth Plan, it was found that there was considerable scope for improvement in many areas of the NMHP (Goel, et al. 2004). The specific areas that needed strengthening included examination of issues related to duration of actual implementation of the Programme, inappropriate pilot districts being chosen for implementation, problems in recruiting appropriate personnel, lack of on-the-job or periodical refresher training programmes, inadequate monitoring (no standard reporting formats, need for simple recording and reporting systems), differential (and thus ineffective) IEC materials. No centre had undertaken community surveys of mental disorders as they were very much preoccupied in setting up service components of the scheme. Where functioning was better, it was observed that the District Mental Health Clinic, inpatient facility at the district hospital and community outreach and liaison with primary health centres were relatively better organized (NIMHANS 2004). However, a major bottleneck was timely release of funds by both the Central and State Governments. In many instances, these factors seriously impacted the service delivery component. A specific instance has been the decrease in the number of patients seeking care (DMHP, Thiruvananthapuram, Kerala 2004).

In this context, ambitious attempts made to restructure and restrategize the NMHP proposing an outlay of Rs 190 crore during the Tenth Plan period, the five major domains being addressed are modernization of mental hospitals, strengthening of medical college departments of psychiatry, IEC and training, research and an ambulating DMHP (Agarwal et al. 2004) has been partially implemented. An all-India action plan with a Vision for 2020 has been

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proposed and the focus is on the efforts that need to be undertaken under the umbrella of the district health care system (Goel et al. 2004).

The Indian government provides several levels of medical services at nominal or no cost; these are essential in a country where much of the population is impoverished and there is no viable health insurance system. Despite this, medical services in the costly private sector flourish. The relationship between the public and private sectors has seldom been addressed by research or policy planners. Understanding how patients and families use each is critical.

Chronic Mental Illness

The term Chronic Mental Illness is often used in literature. However, there is no uniform understanding about this term. In the USA, a federal law passed in 1986 required states to develop service plans incorporating each state's own definition of chronic mental illness. One study considered whether the state definitions can be used to identify comparable populations of chronic mentally ill patients and to obtain a meaningful national estimate of the number of such patients. The study applied definitions of chronic mental illness used in ten states to a representative sample of patients receiving public mental health services in West Philadelphia over a two-year period. The prevalence estimates of patients defined as chronically mentally ill ranged from 38 percent using the Hawaii definition to 72 percent using the Ohio definition. The National

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Institute of Mental Health definition, used as a reference point, produced a prevalence estimate of 55 percent. The authors conclude that the considerable variance among the states in prevalence estimates renders the sum of state counts of chronic mentally ill patients of limited use. (Schinnar et al, 1990) According to Robins, E. (2005) a psychiatric illness would be considered chronic if the symptoms persist for a period of at least 5 years if there is no symptom free interval for at least 6 months. A psychiatric illness that leads to death as a result of the illness would be considered chronic irrespective of the duration eg. Suicide due to affective disorders. Chronicity is further

differentiated into four different kinds of chronicity based on the outcomes of the illness. Chronicdeath: - those psychiatric illnesses that lead to death Chronicself-limited: - those psychiatric illnesses that remain limited to the persons self Chronicremission: - Those psychiatric illnesses in which majority of the symptoms may go leaving behind a few debilitating residual symptoms. Chronicrecurrent: - those psychiatric illnesses that have a waxing and waning course. In the early 1980s, classificatory systems began to place more emphasis on the treatment of individuals who suffer from a major mental illness. To begin to monitor the movement of these individuals through the system and to identify services provided to this population, the governments of various states in the USA developed criteria to define this target population as individuals with a

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"chronic mental illness." This definition focused on diagnosis, functioning and duration of illness. The duration of the illness had to be at least two years to meet the target population definition. (Robins, E., 2005) Beginning in 1991, the definition was changed somewhat; less emphasis was placed on diagnosis and more emphasis placed on functional impairment. Many of the components of the Federal definition were incorporated into the definition. As a result, the definition was broadened to include more

individuals and the title was changed to "severe and persistent mental illness." In 1995, with the advent of managed care, one particular state again revised the target population definition. The title was changed to "serious mental illness." There was little change in diagnostic criteria. Less emphasis was placed on duration of illness, and the functional impairment criteria were revised. In addition, a functional assessment tool was developed to make the identification of this target population more objective. "Serious Mental Illness" (Adult with a Serious Mental Illness) means an individual 18 years of age or older who meets the following criteria: Currently or at any time during the past year have had a diagnosable mental, behavioural or emotional disorder of sufficient duration to meet criteria specified within DSM-IV with the exception of "V" codes, substance use disorders, and developmental disorders, unless they co-occur with another diagnosable serious mental illness; Has at least (a) moderate impairment in at least four, (b) severe impairment in two or (c) extreme impairment in one of the following areas:

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Feeling, Mood, and Affect:

Uncontrolled emotion is clearly

disruptive in its effects on other aspects of a person's life. Marked change in mood. Depression and/or anxiety incapacitates person. Emotional responses are inappropriate to the situation. Thinking: Severe impairment in concentration, persistence, and pace. Frequent or consistent interference with daily life due to impaired thinking. Presence of delusions and/or hallucinations. Frequent substitution of fantasy for reality. Family: Disruption of family relationships. Family does not

function as a unit and experiences frequent turbulence. Relationships that exist are psychologically devastating. Interpersonal: Severe inability to establish or maintain a personal social support system. Lacks close friends or group affiliations. Socially isolated. Role Performance: Frequent disruption of role performance and individual is unable to meet usual expectations. Unable to obtain or maintain employment and/or conduct daily living chores such as care of immediate living environment. Socio-legal: others. Inability to maintain conduct within the limits to property. Involvement with law

prescribed by law, rules, and strong mores. Disregard for safety of Destructive enforcement. Self Care/Basic Needs: Disruption in the ability to provide for his/her own needs such as food, clothing, shelter, and transportation. prepare food. Has a duration of illness of at least one year Assistance required in obtaining housing, food and/or clothing. Unable to maintain hygiene, diet, clothing, and

And (a) At least moderate impairment in two, or (b) Severe impairment in one of the following areas:

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Feeling, Mood, and Affect:

Uncontrolled emotion is clearly

disruptive in its effects on other aspects of a person's life. Marked change in mood. Depression and/or anxiety incapacitates person. Emotional responses are inappropriate to the situation. Thinking: Severe impairment in concentration, persistence and

pace. Frequent or consistent interference with daily life due to impaired thinking. Presence of delusions and/or hallucinations. Frequent substitution of fantasy for reality. Family: Disruption of family relationships. Family does not

function as a unit and experiences frequent turbulence. Relationships that exist are psychologically devastating. Interpersonal: Severe inability to establish or maintain a personal social support system. Lacks close friends or group affiliations. Socially isolated. Role Performance: Frequent disruption of role performance and individual is unable to meet usual expectations. Unable to obtain or maintain employment and/or conduct daily living chores such as, care of immediate living environment. Socio-legal: others. Inability to maintain conduct within the limits Destructive to property. Involvement with law

prescribed by law, rules, and strong mores. Disregard for safety of enforcement. Self Care/Basic Needs: Disruption in the ability to provide for his/her own needs such as food, clothing, shelter and transportation. prepare food. Assistance required in obtaining housing, food and/or clothing. Unable to maintain hygiene, diet, clothing, and

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NOTE: - Individuals with a primary diagnosis of substance abuse or developmental disorder are excluded from this definition. (Oklahoma Government) Therefore, diagnoses that encompass the term chronic mental illness are Schizophrenia, Bipolar Affective Disorder, Recurrent depressive disorder, Cyclothymia, Dysthymia. Some anxiety spectrum disorders are also covered under this depending on the severity, response to treatment and duration of illness like Obsessive Compulsive Disorder, Generalized Anxiety Disorder and Social Phobia. Individuals with chronic mental illness face enormous challenges getting the care they need. Not only do they have to cope with their illness, but they and their families must also try to arrange services from two complex and often unreceptive systems of care: the medical system and the social service system. Following the movement of patients from state mental hospitals to community settings, the problems faced by people with chronic mental illness became more visible to the public. (Goldman, 2000) Policy analysts and historians have described four cycles of reform. The first cycle, during the early nineteenth century, championed "moral treatment" in asylums; the second, almost a century later, advanced scientific "mental hygiene," to be practiced in psychopathic hospitals and clinics. The first two reform cycles expanded a variety of public and private institutions for treating people with mental illness. Before World War II, most services were delivered in large state and county asylums, and in a smaller number of private hospitals and clinics. (Goldman, 2000)

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After World War II, a third cycle of reform, financed largely by the US federal government and state mental health authorities, shifted the focus to community-based care in private offices and community mental health centers. Outpatient services expanded greatly during this period, employing new treatments, including antipsychotic and antidepressant medications. These changes ushered in the era of deinstitutionalization, in which the resident populations of state and county mental hospitals were reduced dramatically-from a high of about 560,000 in 1955 to well below 100,000 by the 1990s. Inpatient and long-term residential services in other settings, especially general hospitals and nursing homes, substituted for much of this dramatic decline. Mental health care policies and resources associated with deinstitutionalization, however, were not accompanied by commensurate changes in social welfare policies and resources--in income support and housing subsidies, for example-to accommodate the shift to community care. Individuals with mental illness, particularly those with severe and chronic mental disorders such as schizophrenia and manic-depressive illness, were not as well integrated into their communities as the reformers had expected. (Goldman, 2000) Each of these reform movements proposed a new way of treating mental illness in a new setting. Each theorized that early intervention in acute cases would prevent the problems posed by chronic mental illness. For 150 years, pursuing these strategies resulted in the continuing neglect of people with severe mental illness. Then, in the 1970s, a fourth cycle of reform proposed a program of community support to address the problems of chronic mental illness. Instead

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of placing continued hope in early intervention, the community support movement re-characterized the problem of chronic mental illness in social welfare as well as psychiatric terms. This approach broadened the scope of policy to include issues of employment, income support, transportation, and housing. In doing so, the movement revealed the fragmentation of the system of services needed by those with chronic mental illness. (Goldman, 2000)

Bio-Psycho-Social Approach

Today, it is known that most illnesses, mental and physical, are influenced by a combination of biological, psychological, and social factors. Understanding of the relationship between mental and physical health is rapidly increasing. It is known that mental disorders are the outcome of many factors and have a physical basis in the brain, that they can affect anyone anywhere, and that, more often than not, they can be treated effectively. Genetic research has produced intriguing biological insights into mental illness, showing that particular gene variations predispose some individuals to conditions such as depression and schizophrenia. Now, thanks to a growing union of epidemiology and molecular biology, the role of the environment in the etiology of mental illness has become clearer. "Some of the greatest advancements in twentieth-century medicine were achieved by identifying and preventing infectious diseases through vaccination,

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improved sanitary measures, improved nutrition, and diminished hazards of environmental contaminants," adds Alan Brown, an associate professor of clinical psychiatry and epidemiology at Columbia University Medical Center. "If environmental risk factors for [mental illness] can be validated and confirmed, there is every reason to expect they will point to preventive measures that lower their risks and morbidity." (Schmidt, 2007)

Scientists define "environment" in the realm of mental illness broadly, some going so far as to suggest it encompasses everything that isn't an inherited gene. That's a departure from traditional thinking in environmental health, however, which has historically viewed environmental threats in the context of infectious agents, pollutants, and other exogenous factors that influence the individual's physical surroundings. Environmental threats to mental health include these traditional parametersalong with pharmaceutical and illicit drugs, injuries, and nutritional deficienciesbut also consist of psychosocial conditions that relate to the individual's perceptions of the social and physical world.

Any number of circumstancesfor instance, sexual abuse, falling victim to crime, or the breakup of a relationshipcan produce psychosocial stress. But experts assume each of these circumstances triggers more primal reactions, such as feelings of loss or danger, which serve to push victims toward a particular mental state explains Ronald Kessler, a professor of health care

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policy at Harvard Medical School. Either alone or in combination, psychosocial and physiological stressors can interact with genetic vulnerability to alter brain chemistry and thus alter the individual's mental health. Several lines of evidence point to an environmental role in psychiatric disease. Among identical twins, if one becomes schizophrenic, the risk to the other is on average less than 50%, suggesting that environmental influences must somehow be involved. Similar findings have been observed with depression and other mental disorders. (Schmidt, 2007) Researchers and clinicians base psychiatric diagnoses on behavioral symptoms described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, a handbook published by the American Psychiatric Association in 1994. However, many of the handbook's 297 listed conditions share similar features, and patients typically show up with co-morbidities that obscure links to underlying risk factors. Schizophrenia, for example, is frequently accompanied by depression. Without being able to link exposures and outcomes more clearly, scientists have heretofore been unable to determine how environmental factors trigger psychiatric conditions, or why. Moreover, some environmental exposures might be strong enough to trigger mental illness regardless of the individual's genetic makeup. Interestingly, environment-based interventions in mental illness could produce health benefits extending far beyond psychiatry. Studies consistently show that mental disorders elevate risks for a host of other health problems. Depression, for instance, increases health risks for heart failure patients, possibly by promoting the development of blood vessel plaques; according to research in the February

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(Stewart, J. 2007) Another recent study linked excessive anger and hostility in childrenevident among those with antisocial personality disordersto compromised lung function (Jackson. 2007) Throughout history mentally ill patients have been shunted to the sidelines in medicine, the most severely among them institutionalized, while others struggle to survive in society. And because their ailments haven't been linked to any obvious biological problems, patients have often been blamed for their conditions. (Levinson, 2007) But now, that stigma appears to be on the decline, especially as physiological biomarkers for mental illnessfor instance, changes in brain structurebegin to emerge. Ideally, growing recognition of mental illness as a biological phenomenon will fuel efforts to meet ongoing needs for adequate treatment, and as importantly, for environmental interventions that might serve to costeffectively prevent large numbers of cases. Chronic Mental illnesses require psychosocial solutions. Thus links need to be established between mental health services and various NGOs and community agencies at the local level so that appropriate housing, income support, disability benefits, employment, and other social service supports are mobilized on behalf of patients and in order that prevention and rehabilitation strategies can be more effectively implemented. (WHO, 2001)

Psycho-Social Rehabilitation

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As declared by a consensus statement published by the WHO Division of Mental Health and Prevention of Substance Abuse in 1996, Psychosocial rehabilitation is a process that facilitates the opportunity for individuals who are impaired, disabled or handicapped by a mental disorder to reach their optimal level of independent functioning in the community. It implies both improving individual competencies and introducing environmental changes. Because of the complexity of the psychosocial rehabilitation mission, its strategies vary according to consumers needs, the setting in which rehabilitation is provided (hospital vs. community), and cultural and socioeconomic conditions of the country where it is undertaken. Housing, vocational rehabilitation and employment, and the social support network are different aspects of a psychosocial rehabilitation strategy whose main objectives are improvement of individual social competence, creation of a long-term system of social support, consumers empowerment, and reduction of discrimination and stigma; thus, psychosocial rehabilitation is not a technique but a comprehensive approach.

Community residential rehabilitation facilities for severely mentally ill persons have been set up in many countries of Europe and in Canada, the United States, and Australia. In China, an important movement for psychosocial rehabilitation is influencing mental health policy and psychiatric service organization. In addition, among countries such as India, Pakistan, Malaysia, South Africa, Botswana, Mali, Senegal, Iran, Tunisia, Spain, Greece, Brazil, and Mexico, the most interesting developments in the field of psychosocial

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rehabilitation are taking place. In these countries, the approach is mostly oriented to vocational activities and community social support. Often, psychosocial rehabilitation does not deal with housing because it has not provided for the most severe patients, who need a residential alternative to institutionalization; in addition, housing strategy is often too expensive for developing countries. (WHO, 2008)

The involvement of consumers and family is closely related to both community-based psychiatry and psychosocial rehabilitation. Consumer and family associations have emerged as a major force in creating reciprocal social networks between mentally ill persons. Psychological support and appropriate information for patients and their families have proved effective in reducing individual suffering, clinical relapses, and family burden. Support and involvement should also include information about patient and family rights and the availability of psychosocial resources. Consumer and family movements have a long and important tradition in the United States and Europe, and recently similar movements have emerged in Latin America (Brazil especially), Asia, and the Western Pacific regions. This movement implies a democratic environment because it advocates for rights and needs that are often neglected by the mental health care system itself. The seven basic principles have influenced the mental health care system around the world. Nevertheless, too many people are still without any mental health care or receive insufficient care or even inhumane treatments. (WHO, 2002)

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NGOs in Mental Health in India

Non-Governmental Organisations (NGOs) are recognised by governments as non-profit or welfare-oriented organisations, which play a key role as advocates, service providers, activists and researchers on a range of issues pertaining to human and social development. Historically, they have played a critical role in promoting and facilitating health and educational activities in India. Prior to independence, religious bodies set up a number of educational institutions, health facilities and other charities. These movements were often led by charismatic individuals, driven by a sense of missionary zeal. Many NGOs were born in response to major disasters and crises with the aim of providing emergency relief and rehabilitation. Since independence, there has been a meteoric rise in the profile, breadth and range of NGOs in India. There were three key changes that occurred in the evolution of NGOs: First, the greater degree of professionalization of NGO activities; Second, the widening of sources of funds for NGO activities to include major national and international donor agencies; and Third, the secular origins of NGOs.

In the 1960s, several NGOs began to focus on health issues. These NGOs increasingly filled gaps in providing healthcare, focusing primarily on underserved populations. Some of these NGOs have now become large institutions

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in their own right, providing primary care services and strengthening community action for change. The activities of internationally acclaimed NGOs, such as the Self-Employed Womens Association (SEWA) and the Child in Need Institute (CINI), have become models for wider adoption by the government in its own programme development. Much has already been written and documented on the work of NGOs in a variety of sectors of community development issues, including health. However, there was no such initiative in the specific area of mental health. (Patel & Thara, 2003) The past two decades have witnessed a surge in the voluntary mental health movement in India. There are several non-governmental organisations (NGOs), many of them in the southern part of the country, for example those offering specialised care to people with chronic mental illness (the Schizophrenia Research Foundation, Chennai, and the Richmond Fellowship Society, Bangalore and Delhi), those with suicidal ideation (Sneha, in Chennai), elderly people (the Alzheimers and Related Disorders Society of India (ARDSI) in Kerala, with chapters in several other states), children, (Sangath, Goa) and substance misusers (T. T. Ranaganathan Research Foundation, Chennai). Self-help and support groups consisting largely of the families of people with mental illness are also making their presence felt on the national mental health scene. Bangalore City is considered as the mental health capital of India. (Patel & Thara, 2003). Despite considerable diversity in the range of objectives and activities of various MHNGOs, there are several common features shared by many of them. The perceived need of the community appears to have been a major

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catalysing factor for the sustainability of all these organizations. In some cases, personal tragedies and first-hand experiences have been inspirational factors. Skepticism and cynicism, especially of the medical community, noncooperation and lack of sensitivity of government officials have been similar experiences especially in the founding years. (Patel & Varghese, 2005) Not unexpectedly, a high premium is placed on the involvement of families and other stakeholders in the activities and programmes of all the MHNGOs. For many of them, government funding support is minimal, and most are dependent on the general public or donor agencies for financial resources. A few have been able to mobilise research funds, by virtue of having established research credentials. Many MHNGOs charge fees for services. Many MHNGOs provide services for specific mental disorders. The Research Society in Mumbai even provides for laboratory facilities for genetic tests for the diagnosis of genetic syndromes associated with childhood mental disabilities. Some MHNGOs provide facilities for in-patient care, in particular for the management of severe mental disorders. Virtually all of them provide some type of out-patient clinic. The clinical interventions provided reflect the diverse strategies available for the management of mental disorders. These include medical (i.e. drug) treatment and psychological treatment, including individual counselling, marital and family therapies and group therapies. Many people require long-term care to minimize the disability associated with some mental disorders. Typically, about one-third of patients with schizophrenia will show signs of long-term disability associated with a variety of factors, such as chronic symptoms, stigma and the side effects of medication. Most MHNGOs

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working in this area have comprehensive services focusing both on the control of symptoms of the acute phase of the illness as well as rehabilitation to ensure optimal functioning in the long term. Providing vocational training in skilled professions, such as carpentry and printing, social skills training and family therapy, are some examples of the kind of activities undertaken. MHNGOs provide linkages with potential employment by sensitizing employers to the needs of those suffering from chronic mental disorders. Unlike hospital-oriented health service providers, MHNGOs have a strong commitment to extending care into the community. This can be seen in virtually all their activities. Indeed, by their very location within noninstitutional structures in the community, MHNGOs essentially provide community-based services. The nature of some community outreach programmes focus on prevention. Examples of primary preventive programmes run by MHNGOs include: the telephone help lines for immediate access to counselling and advice for anyone in distress, early intervention for babies born at risk for developmental delay, and education programmes in schools and workplaces for prevention of substance abuse. Secondary prevention focuses on minimizing the handicaps associated with existing mental disorders. Examples of such programmes include community-based rehabilitation for childhood and adult mental disabilities. As part of the broad perspective on healthcare, many MHNGOs are adopting methods to enhance the effectiveness of treatments provided to individuals. Support groups are widely used as a way to ensure that people recovering from substance abuse can remain sober. The globally recognized organization,

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Alcoholics Anonymous, is an example of the kind of support group philosophy which becomes the core to the process of treatment of alcohol dependence. Support groups are also evident in the residential and daycare facilities geared to those with severe mental disorders. Some MHNGOs run support groups not for those actually affected by a particular disorder, but for their families. Here, families of elders with Alzheimers disease, adults with schizophrenia and children with autism meet regularly to discuss common problems, support each other and provide practical solutions to everyday difficulties. (Patel & Varghese, 2005) Many of the MHNGOs actively invest in the development of skills of their staff. Participation in workshops, conferences and seminars, and formal training in courses such as rehabilitation are often offered as opportunities for career development. Most of the MHNGOs provide opportunities for training other professionals and health workers in specific areas of mental health, such as counselling skills. Many colleges, for example, send their students to MHNGOs for field placements. Workshops with health workers, teachers and other key groups are a standard feature of the activities of many MHNGOs. Many of these organizations regularly organize local, national or international conferences, seminars, workshops or symposia to discuss current issues in the field. (Patel & Varghese, 2005) Advocating for the needs of the under-served and underprivileged sections of the population has been the reason for existence for most MHNGOs. At present, there is very low awareness of the considerable advances in our knowledge of the causes and treatment of mental disorders in India. This low

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awareness, coupled with the enormous stigma attached to mental illness, means that the needs and rights of the mentally ill are largely ignored. MHNGOs have raised the awareness in different sectors of the community, such as health workers, teachers and lay persons, a priority area. The documentation and dissemination of relevant facts and research, and lobbying policy makers for changes in the law are vital instruments for improving mental healthcare. Prominent examples of the success of the efforts of MHNGOs are the inclusion of mental disabilities in the disability legislation of India. Many of the MHNGOs publish their work in annual reports and souvenirs. Others publish regular newsletters and host websites, marking the close affinity of MHNGOs with contemporary technological advances. (Patel & Varghese, 2005)

Until relatively recently, MHNGOs were primarily concerned with service provision and advocacy-related activities. Research was considered an academic exercise, best reserved for the ivory towers of universities and teaching hospitals. This has changed so much in recent years that today; MHNGOs are at the forefront of ground-breaking research in India. Major research programmes in health areas as diverse as infectious diseases to nutrition are now conducted under the aegis of MHNGOs. The SCARF studies on schizophrenia are the most widely cited research on the subject from any developing countries. All three published studies of dementia in the community in India are from work done by MHNGOs. Sangaths studies on the treatment of depression are amongst the largest such studies from India. Ashagrams community programme for schizophrenia has generated the first scientific evidence of the use of the community based rehabilitation approach

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for rehabilitation of a mental disorder. These are just some examples of innovative, action-oriented research emanating from MHNGOs. All the MHNGOs are strongly committed to collaboration and inter-sectoral partnerships. Networks are established between MHNGOs, with government organisations and with academic institutions. Paripurnata is, for example, a member of the Forum for Mental Health, an umbrella organisation of more than a dozen MHNGOs that are located in West Bengal. Sneha has actively supported the development of similar organisations in other parts of India. Partnerships with government are also a notable feature in some MHNGOs. Sangath currently runs a womans health clinic in a government primary health centre, as part of a larger research project on womens mental health. Partnerships with academic institutions are encouraged by many MHNGOs, particularly those with a key interest in research. (Patel & Varghese, 2005)

Need for the Current Study

Newer methods of dealing with various mental disorders are widely researched and entire journals are devoted to specific schools of thought in dealing with specific mental disorders are being published. However the implementations of these are rather diminished. It is in this context that we need to look at NGOs in the field of Mental Health. Although their existence has been known since the 1980s, very little is known about who works there, the training that is

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required for the same, the resources necessary for it and the interventions they provide.

Some of the research and literature in his field has been in order to develop directories of services offered by various NGOs. Many NGOs submit their reports to their respective funding organizations which are used for their monitoring and evaluation purposes which are driven by numbers and specific case and success stories. The ground reality indicates that the picture is not as rosy as it appears to be. Not much literature has been compiled to review the work of all the NGOs in the Psycho-Social Rehabilitation sector. The current study attempts to review the profile of various Psycho-Social Rehabilitation NGOs in Bangalore City. It attempts to compile qualitative aspects of their work and present their strengths, weaknesses, opportunities and threats.

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