The doctor at the Primary Health Centre in the small town was listening to Asha's mother narrating her case history. A chronic stomachache patient since seven, Asha now suffers from incessant cold and cough, and body pain. TB tests are negative but the doctor is unable to identify the reasons for her “sitting and staring” through the day. The mother asks the doctor whether he can do something before her marriage, due in a couple of months.
Ground-zero realities like Asha's must have influenced the 2010 theme for the World Mental Health Day, which falls on October 10. Devoid of the usual rhetoric with slogans, the two leading players — the World Health Organisation, Geneva, and the WFMH, U.S. — have identified the Mental Health Gap Action Programme (mhGAP) and Integrative Care as their respective contributions. The former targets scaling up services encompassing mental, neurological and substance use disorders that account for 14 per cent of the global disease burden. The WFMH's campaign is for the Great Push for Mental Health that underlines “the intimate and bi-directional relationship between mental illnesses and chronic physical illnesses including diabetes, cancer, heart disease, respiratory diseases, and obesity.”
Physical and mental illnesses do not necessarily coincide. However, going by WFMH data, cardiovascular, diabetes, cancer and respiratory illnesses account for 60 per cent of the world's deaths, of which 80 per cent are happening in the poorest countries. The risk of patients with a chronic physical illness suffering from depression is 25 per cent to 30 per cent more than for the rest.
Depression is present in one of five out patients with coronary heart disease and in one of three out patients with congestive heart failure. Global prevalence estimates in 2000 show that 43 million people with diabetes have symptoms of depression. “Depression is a disabling illness that affects about 15 per cent to 25 per cent of cancer patients,” reports the fact file on cancer.
The association between obesity and serious chronic illnesses such as coronary heart disease, stroke and osteoarthritis marked by depression and anxiety seems to be a growing challenge for medics and health workers. “Individuals with current depression or chronic depression are 60 per cent more likely to be obese than those with no history of depression.” Unfortunately, the flavour of India's National Mental Health Programme is isolation and not integration.
The isolationist approach is evident from the latest NMHP data given by the Ministry of Health. For an estimated prevalence of 9.6 per cent of mental disorders in India, the treatment gap is an astounding 50 per cent for SMDs (severe mental disorders) and 90 per cent for CMDs (common mental disorders). However, co-morbidity of major and minor mental disorders has assumed diagnostic significance recently in the clinical practice of psychiatry. Perhaps, semantic dialogues are not uncommon even now among the specialists as to whether treatment of SMDs takes care of CMDs or not.
Such divergent views must be resolved in a national programme through standardisation of the diagnostic package for the medics at the PHC level who are not specialists in psychiatry. At another level, until the recent emergence of palliative care as a special field, many physicians would dismiss patients complaining of depression as irrelevant. The convergence of mind-body approach will benefit millions in India, besides ensuring cost-effective public health care.
The Health Ministry believes that the present two-pronged approach to ease manpower crisis in mental health will take care of underutilisation of funds allocated for the district programmes. Under the 11th Plan, more than 1,500 qualified mental health professionals would be produced from the proposed Centres of Excellence and PG Institutes. However, this does not still cater for the integrationist approach advocated by the WHO and the WMHF, which is more than a mere horizontal integration of mental health into physical ailments at the PHC level.
True integration lies in designing longitudinal support models for chronic patients — mental and/or physical — providing lifetime care, management of risk through collaborative diagnostic models and enhancing QOL. The NMHP needs a policy-level overhaul before structural changes are made at PHCs. As on March, 2008, 23,458 PHCs are functioning in the country with only 13 per cent of the PHCs without a doctor. It is not clear from the NMHP data how many of these PHCs have trained doctors who are sensitised to mind-body level diagnosis.
Another major flaw in the isolationist approach is that it restricts the scope for non-medical interventions like disability and human rights issues. The NMHP has ignored these as alien protocols because these areas officially belong to the Ministry of Social Justice and Empowerment and perhaps the Ministry of Law. However for the consumers, a single-window policy is the most efficient and effective way of overcoming the bureaucratic maze. The prevailing scenario is one of truncated services divided among the two or three Ministries, one each for mental illness, rehabilitation, social justice and rights-based civil society equality. In order to provide a single-window integrationist system, the Vision Plan for mental health must work towards setting up a National Mental Health Organisation, a nodal agency similar to the dedicated NACO for HIV/AIDS.
Until then, for patients like Asha, marriage will seem an easier solution than getting treated for chronic depression.
(The writer is Director, Action for Mental Illness, Bangalore. Her email is acmiindia@gmail.com)
