|Year : 2022 | Volume
| Issue : 2 | Page : 191-196
A camp approach of community psychiatry in India: Past, present, and the future
K Rakesh Chander1, Sydney Moirangthem1, Rahul Patley1, Sharad Philip1, Prateek Varshney1, Vinay Basavaraju1, Rajani Parthasarathy2, P V Mohan Krishna3, Narayana Manjunatha1, Naveen Kumar Channaveerachari1, Suresh Bada Math1
1 Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2 Department of Mental Health, Government of Karnataka, Bengaluru, Karnataka, India
3 Department of Nursing, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
|Date of Submission||08-Sep-2021|
|Date of Acceptance||26-Oct-2021|
|Date of Web Publication||08-Aug-2022|
Dr. Naveen Kumar Channaveerachari
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Camps are a popular approach to deliver medical care in India. While it is usually a one-off event for physical ailments, it is a long-term affair in Psychiatry. One of the first camps in psychiatry was rolled out as early as in 1967 at Mandar, Ranchi, followed by Raipur Rani (Haryana) in 1976 and at Gunjur, Karnataka in 1977. This camp approach became extremely popular and got expanded across India as they were thought to be synonymous with community-based outreach for mental illnesses. In the past 5 years, however, newer models of community care have emerged, necessitating a relook at this traditional approach. In this paper, the authors trace the origin, utility and future directions of these camps, taking data from community psychiatry camps conducted by the National Institute of Mental Health and Neurosciences, Bengaluru, a premier neuropsychiatric tertiary care institute in India. Data have been collated from the annual reports of the Institute, database from the District Mental health Program, Government of Karnataka, India, and compared with published literature on the same field. While camps remain as one of the important avenues to reach the unreached, there is a need to change the approach of their functioning by incorporating training (primary care providers) aspects and collaborative care. The latter may make the initiative more meaningful and sustainable.
Keywords: Community mental health, community psychiatry, mental health camps, psychiatry camps
|How to cite this article:|
Chander K R, Moirangthem S, Patley R, Philip S, Varshney P, Basavaraju V, Parthasarathy R, Krishna P V, Manjunatha N, Channaveerachari NK, Math SB. A camp approach of community psychiatry in India: Past, present, and the future. Ind Psychiatry J 2022;31:191-6
|How to cite this URL:|
Chander K R, Moirangthem S, Patley R, Philip S, Varshney P, Basavaraju V, Parthasarathy R, Krishna P V, Manjunatha N, Channaveerachari NK, Math SB. A camp approach of community psychiatry in India: Past, present, and the future. Ind Psychiatry J [serial online] 2022 [cited 2022 Nov 30];31:191-6. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/2/191/353553
A local name for extension/outreach/satellite clinic is termed as “camps” in India. “Camp-approach” in community psychiatry means reaching out of specialist/s to peripheral destinations to provide services for persons with psychiatric disorders nearer to their doorsteps. “Camps” are quite popular in India for a variety of physical ailments including cancer screening, ophthalmologic disorders, family planning, school health, and immunization.,, Same is true for psychiatric disorders too. A notable difference between camps for psychiatric disorders and other medical disorders is that the latter are one-off events with a specific aim (such as screening for cataract, cancer, etc.). In contrast, the former is generally a recurring event as most of the neuropsychiatric disorders are chronic and demand continuity of care. For psychiatric disorders, the camp approach was a natural extension of the deinstitutionalization, decentralization, de-professionalization, and community-based treatment movements. This resulted in the advent of psychotropics in the early 1950s, after which a large number of patients were freed from the erstwhile mental asylums in the west. Camp approach was thought to have better community participation as locally available resources are utilized. They were also thought to increase mental health literacy among the residents, reduce stigma, have the better co-operation of local health-care providers who could follow up noncomplicated cases on liaison with specialist. Another movement driving the initiative was the “health for all” declaration at the Alma Ata by the WHO in 1976. Although these camps are part and parcel of many psychiatry teams across the country, their purpose, utility, pros, and cons have not been critically evaluated. They are essential from a broader perspective of reaching care to every needy person. Questions to be asked are what is the role of camp approach toward reducing the treatment gap of psychiatric disorders? Does the approach need a relook to suit the modern community-based approaches? How does this merge with the concept of the “stepped care model” that includes self-help, peer support, networking across communities such as traditional and religious healers, collaboration with Nongovernmental Organizations, and specialists? Finally, can the camp framework participate and contribute toward identification and training volunteers in the community for delivering low-level psychiatric first aid and support (task shifting), targeted interventions at workplace, and educational institutions for stress reduction and mental well-being in addition to programs supporting community-based rehabilitation.
The aim of this paper is to examine the above aspects by chronicling their origin, their growth and sustenance, their present status and utility, and end with discussion on future directions by critically evaluating their advantages and disadvantages. While doing so, we rely on the published literature on the most part and analysis of the camp data that were available with the community psychiatry team of the National Institute of Mental Health and Neurosciences (NIMHANS). Data available with NIMHANS was then compared with the District Mental Health Program (DMHP) data.
| Origins of the Camp Approach of Community Psychiatry in India: The Past|| |
Continuing on the lines of therapeutic community wherein family members stayed with inpatients by tenting camps which was initiated by Prof. Vidyasagar in the 1950s, the camp approach moved to concept of “satellite” or “extension” clinics where a team of mental health professionals would visit specific sites and cater a targeted population. This type of teams emerged as a dedicated unit at specific sites, named as the “Community Psychiatry Unit,” especially at major Mental Health Establishments across the country., Central Institute of Psychiatry, Ranchi, ran out extension clinics as early as in 1967 at Mandar near Ranchi. It later extended to Ghatotand town in West Bokaro district and Hazaribagh city and Chandankiyari village situated in Bokaro district as a part of their rural mental health program. The clinics had outpatient services, promotional and preventive programs for women, children, and adolescents held at schools and community gatherings. Similarly, the Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) began outreach clinics in 1999 at Jonha village in Ranchi. The services were further extended in 2003-3 nearby villages-Khunti, Sariakella – Kharsawan, and Hazaribagh. The teams usually consisted of a Psychiatrist, Clinical Psychologist, Psychiatric Social Worker, and Nurse who aid in early diagnosis, treatment, and management of psychiatric disorders including liaison with other stakeholders. These stakeholders were General Physicians and Specialists for comprehensive health care and nongovernment organizations for creating community awareness and scope for rehabilitation.,
Further, two other parallel initiatives did blossom in India during the late 1970s. First was a place called Raipur Rani, belonging to Ambala district of the northern state of India. A weekly clinic was started in June 1976 in a primary health center (PHC) wherein a psychiatrist and two social workers visited and provided services. After the initial management by the psychiatrist, patients were followed up by the social workers under the supervision of the psychiatrist. The clinic become quite popular as patients from adjoining areas too started consulting here. A variety of cases including schizophrenia, affective disorders, epilepsy, mental retardation, and anxiety disorders were taken care of with psychotropic medications and counseling. Wig et al. summarize the experience thus it is feasible to provide care in peripheral areas making the use of local and nonspecialist resources.
The next one was from NIMHANS, Bengaluru, which started a clinic on March 6th, 1977 at Gunjur, a village, 25 km away from NIMHANS. The purpose was to identify and treat locally prevalent neuropsychiatric disorders, provide regular follow-ups to patients, and to involve local medical doctors in the management of these cases. Clinic started with a frequency of once a month with specialist team consisting of a neurosurgeon, psychiatrist, and psychiatric social worker visiting the clinic to provide services. Here too, persons with a variety of psychiatric disorders (schizophrenia, affective disorders, anxiety disorders including obsessive–compulsive disorders, mental retardation, etc.) were cared for during the ensuing years. The authors conclude that the clinic had good acceptance by the local communities including the nonspecialist doctors. Furthermore, they purport that such outreach clinics can reduce the burden on the outpatient load of bigger mental health institutes.
| Growth and Current Status of the Camp Approach: The Present|| |
After their initiation, the approach caught on the momentum, and numerous organizations (both governmental and nongovernmental) started conducting such camps across many parts of the country. Unfortunately, the assertion remains anecdotal as the academic writing on their utility is conspicuously absent. However, a couple of institutes have documented the utility of these approaches, and they are mentioned below.
NIMHANS, through its Community Psychiatry Unit (functional since 1975), after learning from the Gunjur experience, expanded the concept to several other places, and by 1981, the following places saw the operationalization of similar services: Kanakapura, Gauribidanur, Maddur, Madhugiri, Anekal, Jigani, Sakalawara, and Marsur. These places (all were block level hospitals barring the last three) belonged to five neighboring districts. The Unit used to conduct monthly camps (with a multidisciplinary team of psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses, and trainees belonging to all the abovementioned disciplines). [Figure 1] illustrates a steady rise in service utilization over the years till early 2000's. After that, the graph shows a dip in cases coinciding with the expansion of the DMHP into the same/contiguous districts. [Figure 2] illustrates this point even further. The rise in DMHP footfalls coincides with the drop in attendance to NIMHANS camps. DMHP is the operational arm of the centrally funded vertical program (National Mental Health Program; NMHP), wherein essential mental health services are made available at the district level free of cost (assessment, first line of management including psychotropic medications and basic counseling, ideally by a team of specialists). In fact, post 2015, NIMHANS specialists stopped attending camps one after the other, and by the end of 2016, all camps were integrated with local DMHP teams of Karnataka. During this transition period, local primary care doctors (PCDs) were handheld with live consultation of new patients and marked the origin of an innovative training method called as “on-consultation training (OCT).” It may be noted that, post 2016, Karnataka did evidence phenomenal growth of DMHP services by expansion to all her districts.
|Figure 1: Comparison of National Institute of Mental Health and Neurosciences Camp versus Corresponding Camp sites' District Mental Health Program statistics over the last 3 decades|
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|Figure 2: Comparison of National Institute of Mental Health and Neurosciences camps versus Corresponding Camp sites' District Mental Health Program data since 2015–2016 (This Figure 2 is an extended version of 2015–2016 data from Figure 1)|
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As part of the DMHP, specialist teams took over the “Manochaitanya” clinics (super Tuesday clinics at peripheral places, akin to camps; provision of outpatient services at block level hospitals, community health centers, and PHCs on a regular basis)., Manochaitanya started as a public–private partnership model wherein honorarium and travel allowances were provided to voluntary private practitioners (psychiatrists who were members of the professional society; Karnataka chapter of the Indian Psychiatric Society) who provided services in these peripheral destinations., However, when DMHP got expanded, the private partnership ended, after complete takeover of these camps by the latter. As of today, these camps do occur regularly throughout the state. Each DMHP draws up its own timetable for the coming month and covers several peripheral destinations including taluk/block level hospitals, community health centers, and in some places, they cover PHCs too. The camps by RINPAS found an increase in the detection of cases and thereby reduction in the prevalence of untreated psychosis with minimal resource utility in their catchment areas.
However, in contrast to the camps for general psychiatric disorders, the ones for the management of substance use disorders have a different trajectory. Notably, inpatient treatment was provided in group settings. It had been advocated as one of the treatment models for community-dwelling persons with substance use disorders, particularly for those in rural communities who may have several barriers to reach out to secondary and tertiary care treatment centers., A specific geographic area based on the magnitude of problems is selected, and community leaders were contacted to spread the word across the area about the conduction of camps at a particular site on a given date. Infrastructure support also would be provided by the community leaders (accommodation in a hospital, boarding, and other logistic support for about 25 patients: for about 10–15 days). After examining all patients, the focus will be on detoxification and psychosocial interventions. Individual as well as group sessions targeting psychoeducation, brief interventions, relapse prevention strategies including motivation enhancement techniques, relaxation and yoga, prayer and education sessions, sessions for family members, and self-help group activities are provided. Round-the-clock supervision is provided by the relevant specialists. These short-term treatment strategies are shown to be fairly successful by way of cohesiveness as a group, negligible disciplinary problems, and compliance to the treatment regimen., A small proportion of patients may require detoxification beyond the camp duration, and they are referred to higher centers. Proponents of this model suppose that the success could be due to lesser stigma, increased awareness about the addiction, and the need for treatment and provision of better therapeutic alliance in a milieu nearer to their homes. Most hearteningly, both the short-term where three-fourth of attendees being abstinent at 3 months of follow-up and the 1-year follow-up data which showed 82.8% of them maintained sobriety demonstrated a high degree of success.,, It may also be noted that a couple of other southeast Asian countries have adopted this camp approach for managing substance use disorders with a fair amount of success.,
| Camp Approach in Community Psychiatry: The Future|| |
The future of “camp approach” in psychiatry can only be speculation, and the desirable one at that based on the critical evaluation of the road traveled thus far and predicting its future in the context of contemporary developments in the field of community psychiatry. As mentioned earlier, the camp approach was a product of the new thinking of taking treatment to the doorsteps of patients, and it had traveled a very far distance to date. While it had been successful in playing its part toward making treatment available nearer to doorsteps of patients, we need to pause a bit and think what was lacking and what else can it do. Furthermore, we need to ponder about what adaptations this approach needs to undertake in order to meet the contemporary challenges and concepts of community psychiatry.
The unquestionable positive aspect of camp approach is that it has taken psychiatry beyond the walls of mental hospitals and to date remains an extremely popular and convenient method of delivering outreach psychiatry services. Although documented literature is not available (to the best of our knowledge), it was extremely a commonplace to find psychiatrists/organizations (both public and private) from the length and breadth of the country to periodically and regularly visit peripheral destinations to provide services. Most of these efforts were voluntary and hence free of cost to patients/families. These were convenient to patients too as free services were available nearer to their doorsteps. Another positive was that the approach had contributed to the development of NMHP.,
However, the question that needs to be asked is whether these are enough to quench the thirst of such a huge population (1.3 billion and counting)? Early critique of this approach was that while it had addressed the magnitude of mental disorders in the community, it had turned detrimental to the successful integration of primary health care into the general health-care delivery. Other criticisms were (a) monthly visits were not enough with observed trend of increasing footfalls to camps that included both newer and follow-up cases, (b) nonavailability of adequate resources (both financial for transport and other logistic while visiting camps and workforce, i.e., mental Health Professionals) to run additional camps, and (c) the teams' visits on fixed days of the month aided in identifying and treating newer cases in addition to reviewing older cases. Patients who possibly required psychiatric care on other days had continued to contribute to the absolute and functional treatment gap due to inadequate training/mentoring of medical officers at PHCs in dealing with common psychiatric disorders. This is because attending psychiatrists directly provided care to patients at camp without involving the local PHC doctors.
The continued presence of specialists can potentially become a barrier for successful integration of mental health care into general health care. The Sakalwara Community Mental Health Centre setup by NIMHANS was aimed to cater for such needs. The Centre held training programs for PHC medical officers and staffs to identify and manage mental disorders by the visiting camp teams (at nearby districts including Anekal, Malur, etc.) as mentioned above. The PCD attended each camp with the aim of learning skills to identify and treat psychiatric disorders. Specialists from the center mentored them during the visits; however, they were unaided during the interval period. These camps thus emerged as excellent avenues for task shifting, a contemporary approach to bridge the enormous treatment gap. Moreover, camps fulfill the ideal setup for training PCDs in real practice scenario such as OCT. They offer them real world setup for learning. Plenty of practical material is readily available, making the learning here and now (as opposed to the top-down approach present in the classroom training in tertiary care centres). Andragogical methods can be employed effectively as opposed to the theory-driven traditional methods. Finally, pragmatic training curriculum should be used keeping in mind the practical and ground-level difficulties of PCDs. Once a PCD attains satisfactory level of skill, patients can be referred to them, allowing them to follow-up in their nearest health centers (further periphery). Support from the specialist (by way of audio or video calling) can however be made available easily.,, These kinds of collaborative efforts have been shown to be both feasible and effective. Collaborative care is one way to move forward as advocated by Lake and Turner, 2017. Hence, there is an urgent need for these camps to take on an additional responsibility of educating PCDs in psychiatry.
On another note, task shifting, while being talked of as an important way to bridge the gap, is in itself an onerous and enormous task in India. The scarcity of specialist human resources is so huge that it requires at least a couple of decades time to have an acceptable number of specialists to be able to cater to all persons with mental illness. Sustained efforts from multiple stakeholders including academicians, health ministries and departments of governments, policymakers, financial support, and PCDs themselves. Even if these are made available, individual and personal factors pertaining to PCDs need to be overcome. A silver lining though is the advent of simple digital technology, which can be harnessed easily to train and mentor PCDs and other health-care workers such as Tele-OCT. In the past 5 years, several initiatives have shown the success of these capacity-building initiatives., These digitally driven capacity-building initiatives can be taken up by specialists working in mental health institutes and departments of psychiatry across the country. Each institute/Department can adopt a given geographical area to cater to the training needs. Sustained collaborative care too will become feasible with this arrangement using digital technology (Live CVC: Collaborative Video Consultation). Policy framework and collaborations between Government department and mental health institutes/medical colleges can be a way to achieve this synergy.
As regard substance use disorders, the camp approach seems to be standing on firmer ground when viewed from the prism of community outreach treatment method. Available evidence shows that to be one of the models, that is, essential to successfully reach out to patients. Considering the complex needs of this group and the need for inputs from multiple disciplines, this approach may offer a cost-effective way of providing care in least restrictive environment nearer to patients' communities. Rigorous prospective evaluations are the need of the hour though.
| Conclusion|| |
Camp approach for reaching out to persons with mental illness in India has a glorious past and continues to be a popular method of outreach. There is no doubt that it is playing its role in bridging the treatment gap. However, the future has to incorporate contemporary models of community-based approaches and adapt itself to the emerging needs. Converting these camps into robust education centers for PCDs by embracing technology will not only facilitate this but also pave the way for better collaborative care.
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Conflicts of interest
There are no conflicts of interest
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