Karnataka is struggling to consolidate a robust and uniform mental health management structure across the state to enable affordable and easy access for common people. This is despite mental issues increasing especially due to Covid-19 pandemic-induced impacts on society across age groups and social strata. As per government records, over 10 lakh people annually seek mental health care in public institutions in Karnataka. Common mental disorders like depression and general anxiety disorders constituted 34% of the cases while severe mental disorders (like schizophrenia, bipolar disorder) and alcohol and substance abuse constituted 18.4% and 11.2% of the cases, respectively.
Through the pandemic and its impacts, the situation has worsened. Compromised education, lockdown effects on elders, adverse impact on interpersonal relationships, effects on job security and economic fallouts have compounded the mental health situation in the state, as much as across India which has just 0.75 psychiatrists per 1 lakh population against the required 3 per 1 lakh population. This is well below the 6 per-1 lakh population in some developed countries.
Moreover, pre-pandemic figures indicate a mere 0.37% of Karnataka’s budget health expenditure was allocated to mental health. Here too, only 74.4% of the funds allocated to District Mental Health Programme (DMHP) were utilised. There are districts which have exhibited public-private initiatives in an effort to consolidate mental health management programmes. But more inclusive steps involving stakeholders’ are needed.
The Indian Constitution and the Supreme Court point to rights of individuals to mental health. But the reality is far from that.
THE ON-GROUND STATUS
There is a severe scarcity of psychiatrists in the twin districts of Chitradurga and Davanagere. Except two psychiatrists and two counsellors who are working on contract basis, there is no regular recruitment.
In Davanagere, the district has one psychiatrist and one counsellor at District Government Hospital. Along with this, there is a district mental health programme officer at Davanagere, who is recruited on a contract basis and every year his or her appointment is renewed as he or her is recruited under the National Health Mission programme.
The number of patients in private and general hospitals varies from 100 each day to 3000 each month.
In Chitradurga, except a district level mental health programme officer and a counsellor, there are no specialised sanctioned posts at taluk and public health centre (PHC) level. Every month there are about 1,500-2000 cases that are screened at the district hospital.
The Madikeri District Hospital has just one counsellor and a psychiatrist appointed to handle mental illness cases. “There are no appointments of counsellors at PHCs. The team from the district hospital conducts surveillance frequently and visits the taluk and rural health centers for consultation,” says District Health Officer Dr Venkatesh.
The number of private counselling centers is less than a handful. Residents rely on hospitals and clinics in Mysuru or Mangaluru to address mental health issues. Online support is also sought by many. There are no psychiatrists or counsellors appointed in the government taluk hospitals and PHCs in Belagavi. Only one psychiatrist works at the District Hospital.
Senior psychiatrist Dr Bheemsen Takkalaki says, “Mental health problems are huge as per the recent National Mental Health Survey by NIMHANS. The government has brought improvements by appointing psychiatrists in district hospitals but a lot more needs to be done. Awareness needs to be created among people — especially in rural areas — that there are reasons for mental health problems. There are wrong beliefs among people that mental illness is caused by black magic, and about side effects of medicines for mental disorders.”
Despite the introduction of the National Mental Health Programme (NMHP) , public health services for mental patients in Dakshina Kannada have not improved. Except for a ward in Wenlock District Hospital, there are no government facilities in the district for mentally ill patients. A clinical psychiatrist with five decades of experience in the field says incidents of families abandoning persons with mental illness is on the rise.
In most cases, affected men reach the beggars rehabilitation home in Pachanady, while women find their way to facilities run by NGOs and missionaries. “Taking care of mentally-ill patients is difficult. But it is the responsibility of families. If they are treated with love and care, they will improve,” says Prof Hilda Rayappa, a social activist.
UDUPI SETS A PPP EXAMPLE
Udupi has better facilities for mental health treatment due to public-private partnership. Psychiatrists from Kasturba Hospital, Manipal and Dr AV Baliga Memorial Hospital, Doddanagudde, have been roped in to conduct screening camps and counselling sessions across Udupi district. Sources say private doctors under this PPP method offer free consultations and issue appropriate medicines.
Psychiatrists from Kasturba Hospital and Dr AV Baliga Memorial Hospital visit various places in the neighbouring regions each month for consultation and treatment.
This ensures psychiatrists are available in all PHCs, CHCs in the district at least once a month.
Parivartana Psycho-Social Rehabilitation Centre in Kota conducts a free screening camp for mental health issues on the first Wednesday of every month. Periodic one-week training is given to doctors at PHCs and CHCs. Even nurses, ASHAs are trained in the district to identify and refer to the mental health issues among the people in the community at the grass root level. Minor issues are managed at the PHC level by doctors trained in counselling skills, while patients with severe mental illness are referred to the district hospital.
There are several mental health private practitioners in the district. Dr Ravindra Munoli, Associate Professor, Department of Psychiatry, KMC, Manipal says substance abuse cases are common of late. There has been an increase in cases pertaining to anxiety and depression and attention deficit hyperactivity disorder (ADHD). ‘‘They come for treatment quite early due to awareness’’ he says.
STATE GEARING UP
The concept of Mano Chetana clinics at PHCs was started in 2019 and MoUs were signed with Nimhans for assistance and case references. Randeep D, Commissioner, Health Department, says Mano Chetana clinics are held every Tuesday at PHCs, where trained doctors counsel those seeking help and prescribe medicines.
Since some psychiatric medicines are costly, and fearing this, those seeking help do not approach doctors. Randeep says e-consultation platforms have been created, wherein assistance from experts in Nimhans is being taken. As a pilot, the centres for brain health are being set up in Chikkaballapur, Jayanagar (in Bengaluru) and Kolar.
On whether doctors in PHCs are adequately qualified to prescribe medicines and explain the situation to patients, Dr Rajini P, Deputy Director Public Instructions (Mental Health), Karnataka health department, says doctors are MBBS and trained. “You do not need a psychiatrist for common psychological problems. Mostly, a person just needs someone to talk to. If you do not treat a patient at the PHC, then the burden on institutes like NIMHANS increases. With this being the aim, the NMHP was launched. Karnataka is the first state to have an integrated mental health centre.”
She says counselling and observation are done over two weeks, after which if the person is not improving then signs of biological problems become visible and Mano Chetana centres help.
Dr KV Trilokchandra, Special Commissioner, Health, Bruhat Bengaluru Mahanagara Palike (BBMP), says the brain health initiative was taken up by NIMHANS to identify people with mental health needs.
Doctors in the PHCs have been sensitised to identify those needing help when they come for health issues. A protocol on how to handle patients has also been laid out. There are many psychosomatic and hypochondriasis cases. So far one batch of doctors in Bengaluru, in the south zone, has been trained by NIMHANS to address such cases. The training is now being extended to other zones and PHCs.
THE SHIVAMOGGA EXAMPLE FOR IMPROVEMENT
Shivamogga has had more number of psychiatrists over the past several decades. Late Dr Ashok Pai was instrumental in setting up Karnataka State Mental Health Task Force in 2013. As per that, two programmes — Manochaitanya and Manasadhara — were implemented. The district has 22 psychiatrists, including six in government hospitals and four in Shivamogga Institute of Medical Sciences. District Health and Family Welfare Officer Dr Rajesh Suragihalli says, “Every Tuesday is termed ‘Super Tuesday’ when two government psychiatrists visit two taluk headquarters every week to provide medical help for both neurotic and psychotic disorders.” The district has 20 counsellors and social workers who visit schools, colleges, workplaces like garments and other such places where more number of women work to listen to their problems and extend counselling services. The counsellors have been regularly visiting the Central jail, juvenile homes, industries and factories, says the DHO. All PHC medical officers have been imparted training for initial medical diagnosis and to provide medical help for neurotic problems.Shivamogga has made significant contributions in mental health from early 1980s. Because of a robust set-up, Shivamogga gets cases from lesser equipped neighbouring districts of Chikkamagaluru, Davanagere, Haveri, Ballari, Chitradurga, and Dharwad.
Inputs from: Bosky Khanna, Bengaluru; Divya Cutinho, Mangaluru; Prakash Samaga, Udupi; G Subhash Chandra, Chitradurga/Davangere; Prajna G, Madikeri; Sunil Patil, Belagavi; Ramachandra V Gunari, Shivamogga
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