Byline: Nimesh. Desai
The development of community mental health from clinical psychiatry has often been described as a process independent of the larger process of the development of the field of community health,, and as if the movement towards the community was specific to psychiatry or mental health. The contributing factors and determinants of this movement have generally been identified as (i) institutional care being expensive and/or harmful in terms of 'institutionalization' syndrome, (ii) inadequacy of human resource or qualified professionals, (iii) and that the general health workers and paraprofessionals can be trained to deliver these services in their own settings for majority of patients. The fact that the movement occurred significantly as a part of the larger movement of community medicine or community health is also often overlooked. The Bhore Committee Report of 1946, which laid the foundation for the community health movement in India, not only combined the 'top down' and the 'bottom up' approaches but also included substantive emphasis on issues of mental health, albeit within the limitations of that period, much before some of the noted western movements of community mental health.
The 'top down' approach of building three apex institutions, viz. All India Institute of Medical Sciences (AIIMS), New Delhi; All India Institute of Hygiene and Public Health, Kolkata and All India Institute of Mental Health, Bangalore (later to become NIMHANS), along with the 'bottom up' approach of providing primary health care, and 'community orientation to medical services and medical education', also recognized psychiatry and mental health as integral parts. It is a different matter that the entire movement of the preventive and social medicine, including the development of the academic departments, have had a mixed impact, but the larger movement of community medicine or community health, as many progressive academic departments christened themselves later, has had significant impact in different spheres. The major guiding principle and the strategy had been of 'reaching the unreached' with a sense of paternalism if not charity, and was also governed by the socialist ideology in the socio-political atmosphere of the post-Independence period in India, as in many developing countries after the second world war. Psychiatry followed medicine in this approach, without realizing the need for a different and larger conceptual framework for mental health. Indeed, the field of community medicine had in the meanwhile, evolved to the larger concept of health, beyond the medical model, and recognized the need for working across sectors. The community psychiatry initiatives in the 1960s and 1970s culminated in the National Mental Health Programme (NMHP) in India, one of the earliest in the world with inadequate emphasis on the conceptual issues of community mental health. Some merits and benefits of these programmes as well as the experiences in implementation have been discussed., The limited success of the NMHP, and the community mental health movement has to be recognized and accepted.
Although the community-oriented health models have significant improvements over the clinical models, their limita-tions are often not appreciated. Some important limitations are: (i) the paternalistic, charitable strategy of reaching the unreached, (ii) carrying the clinics to the community with no emphasis on prevention or promotion, (iii) being limited to treatment, (iv) limited scope in target conditions and interventions identified, and most importantly, (v) continued use of the dyadic paradigm borrowed from the medical and clinical models, of one 'patient' and one 'provider'. On the other hand, the public health, and as such the public mental health models have the advantages of (i) being larger on scope beyond treatment, including prevention of promotion, (ii) being intersectoral and cutting across sectors that impact health, (iii) population paradigm, focusing on millions and not individuals, (iv) policy leading to programmes, (v) expertise of basic sciences of epidemiology and biostatistics, (vi) inclusion of applied sciences such as health economics, and (vii) inputs from public participation through advocacy and activism. …