Community psychiatry in India: Where we stand?

Ajeet Sidana

doi:10.4103/jmhhb.jmhhb_63_17

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Year : 2018 | Volume : 23 | Issue : 1 | Page : 4-11

Community psychiatry in India: Where we stand?

Ajeet Sidana
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication

2-Nov-2018

Correspondence Address:
Ajeet Sidana
Department of Psychiatry, Government Medical College and Hospital, Level-V, Block-D, Sector-32, Chandigarh - 160 030
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmhhb.jmhhb_63_17

How to cite this article:
Sidana A. Community psychiatry in India: Where we stand?. J Mental Health Hum Behav 2018;23:4-11

How to cite this URL:
Sidana A. Community psychiatry in India: Where we stand?. J Mental Health Hum Behav [serial online] 2018 [cited 2023 Jun 4];23:4-11. Available from: https://www.jmhhb.org/text.asp?2018/23/1/4/244922

I bow my head to Almighty who bestowed His kind blessings upon me to enable me to reach this position. I am grateful to my respected teachers for inculcating best professional values to treat the ailing humanity. I am indebted to my parents for teaching me the social and family values to help the economically weaker and needy in the society. I am thankful to my wife and son for regular encouragement and support. I am sincerely thankful to all the fellow members of the society to entrust upon me to serve as President of the society. Indeed, it's a great honor for me.

I am working at a place where community psychiatry has been given an important place in delivery of psychiatry services as well as training and research. Hence, I decided to talk upon “Community Psychiatry in India: Where we stand?”

Magnitude of Problem

More than 70% of population of India lives in villages. The services and infrastructure for mental health care in the public sector is not only inadequate but also confined to bigger cities and hospitals.

Various epidemiological studies from India have estimated the prevalence of mental disorders between 5.82% and 7.3%^[1],[2] and the resources available to manage the huge burden of these disorders are insufficient, inequitably distributed, and used inadequately which lead to treatment gap in the tune of more than 75%.^[3]

The National Mental Health Survey of India-2016 conducted on a nationally representative sample of 34802 individuals, which were sampled from 12 states of India. The results show the prevalence rate for any mental disorder is 10.6% and nearly 150 million Indians are in need of active interventions.^[4]

Similarly, India has an estimation of 62.5 million alcohol users, 8.7 million cannabis users, and 2 million opiate users, of whom 17%–26% are dependent users.^[5] There are only 124 deaddiction centers run by the MOH and FW in addition to 401 Treatment cum Rehabilitation Centers and 41 drug awareness and counseling centers supported by MoSJE (MSJE, 2008). Majority of these centers lack infrastructure, trained workforce, and insufficient funds. Moreover, many people do not seek treatment due to lack of motivation, perceived stigma, need of treatment not felt, time-consuming process, lack of awareness, etc.^[6]

The World Health Survey (2006)^[7] reported the prevalence of psychosis and depression at the community level from six states (Assam, Karnataka, Maharashtra, Rajasthan, Uttar Pradesh, and West Bengal) of India is a unique source of information as shown in [Table 1].

Table 1: Prevalence of depression and psychosis and treatment status in the six states

Click here to view

Reasons for not Seeking Treatment

Studies that have assessed factors that influence access to mental health care have emphasized the following barriers: Stigma and discrimination, inherent belief that nothing could help, seeking help being a sign of weakness, denial, embarrassment to seek help, poor awareness, economic policies, lack of resources, unequal distribution of resources, insufficient facilities, poor allocation of funds, lack of availability and accessibility of treatment, lower socioeconomic status, low education, poorly developed services, and beliefs in supernatural powers. A study by Reddy et al.^[8] have found out various reasons for not seeking help, which were further grouped under the following factors: Lack of awareness about the illness, religious beliefs, lack of family support, financial constraints, family dynamics, family's tolerance about symptoms, lack of insight about illness, families resilience, community beliefs regarding mental illnesses, and others. In each patient, a complex interplay of several of these factors prevents the family from seeking psychiatric treatment.

How to Reach to Unreached?

To address this issue and bridge this gap, the policy planners and mental health professionals must work on a following strategies: (a) to create awareness about mental health issue through Information, Education and Communication (IEC) and promotion of mental well-being by mental health promotion and prevention of mental illnesses; and (b) is to develop community mental health services, which reach out to the community to the doorsteps of consumers. These services should be capable of delivering at least the basic minimum level of services for neuropsychiatric conditions to everyone, everywhere. In addition to the location of services close to the community, affordable and appropriate medications should be made available in the public mental health facilities located in the community. Finally, the model of community mental health services should address psychosocial issues such as stigma and rehabilitation. Hence, there is need to develop a unique model for community psychiatry services in India.

What is Community Psychiatry?

Community psychiatry means providing community mental health services to the persons and families with mental illness within the community using community resources. The community settings may be any religious place, that is, Dharamsala, Gurudwara, persons own house or any other place in community.

Community psychiatry in India is almost 6 decades old. It was started as an effort to involve families of mentally ill persons in the care of persons admitted to Amritsar Mental Hospital in the 1950s. Today, the integration of mental health care in to general health service covers almost all the districts of India under District Mental Health Programme (DMHP) in 12^th five year plan along with wide variety of community-level facilities and initiatives to address the areas of mental health promotion, prevention, and treatment of mental disorders in community. From a situation of almost no community care in the 1^st half of 20^th century to current situation of mental health care in community, private sector and voluntary sectors is a sign of satisfaction and achievement.^[9]

What is Community Mental Health Model?

The purpose of community mental health model is to provide all mental health and well-being needs of the community within the community, using community resources and the primary health-care system. It goes “beyond the hospital-based care and treatment” and includes:

Programs for mental health promotion, prevention, and treatment of mental disorders
Inclusion of psychosocial support available in the community (religious groups, self-help groups, faith healers, local bodies, etc.)
Rehabilitation plans for persons with significant disability due to intellectual disability and recovering substance abusers and chronically mentally ill patients
Prevention of harm from alcohol and substance use
Developing linkages with primary health-care system and tertiary care hospitals.
Plans for stigma removal
Protection of the human rights of mentally ill persons.
To enhance the status of mental health within public health.

For effective implementations of these services, there is a need of paradigm shift from exclusion to inclusion. The community services should give preference to the biopsychosocial approach rather than the biomedical model, thus taking psychiatric care from the hospital bed to a family setting, from hospital to community, from short-term to long-term care, that is, rehabilitation, from individual work to teamwork, thus finally bridging the (WHO, 2006) span from treatment to service.

For the purpose to assess the effectiveness of a program, regular monitoring and review of community mental health services should be inbuilt component of the services from the time of inception. Although each service can design its own monitoring mechanism, the following impact indicators can be used to assess the impact of the services in meeting the mental health needs of the community.^[10]

Knowledge and awareness about the mental health delivery services in the community
Acceptability of services
Reduction in the treatment gap
Reduction of stigma
Patient satisfaction with treatment and continuity of treatment
Reduction of violence in the community and schools due to mental health issues.

What are the Various Hurdles in Providing Community Mental Health Services?

In spite of having community outreach services in various cities and states, still people do not prefer to visit these centers. There could be various reasons for not seeking help from these centers. It could be:

Inadequate participation of community
Lack of integration of mental health into general health care
Lack of ideal model of mental health delivery
Weak link between mental health and social development
Nonavailability of services in certain areas
No regular monitoring and evaluation.

What are the Various Existing Community Mental Health Models?

Integration of mental health into primary health care

There are various reasons for integrating mental health into primary health care:^[11]

Mental disorders create a substantial personal burden for affected individuals and their families and cause significant economic and social hardships that affect society as a whole. Hence, mental and physical health problems are interwoven and can be taken at same time
Many people suffer from both physical and mental disorders. Integrating primary care services ensure that people are treated in a holistic manner, meeting the mental health needs of people with physical disorders, as well as the physical health needs of people with mental disorders
When mental health is integrated into primary care, people can access mental health services closer to their homes, thus keeping their families together and maintaining their daily activities
Primary care for mental health also facilitates community outreach services and mental health promotion through IEC, as well as long-term monitoring and management of affected individuals
Mental health services delivered in primary care setting minimize stigma and discrimination. It also removes the risk of human rights violations that can occur in psychiatric hospitals. Primary care for mental health issues is affordable and cost-effective
Primary care services for mental health are less expensive than psychiatric hospitals. In addition, patients and families avoid indirect costs of travelling to city-based hospital, registration, etc.
The treatment outcome is likely to be better in patients treated at primary care setting, particularly when linked to a network of services at secondary level and in the community.

Initiation and early experience – The two landmark studies conducted at two different places in India demonstrated that mental health can be integrated with primary health care.^[12],[13] The positive results associated with these efforts resulted in the formulation of the National Mental Health Programme (NMHP) in 1982. The goal of the NMHP was to integrate mental health services into primary care. One direct result of the NMHP was the establishment of the Bellary DMHP, and the success of this model led to conceptualization of the DMHP which is currently implemented in 123 districts, and there is a plan to extend it to all the districts in the 12^th Five-Year Plan
The mental health services through the DMHP are developed to cater to the needs of persons with psychosis, depression, neurosis, mental retardation and childhood mental health problems, substance use disorders, and epilepsy. The medical officers after training are expected to provide a range of essential drugs (antipsychotics, both oral and parenteral, antidepressants, anticonvulsants, and minor tranquilizers) for the management of persons with mental disorders

Linkages with community – Although there is a provision for the training of community leaders under the DMHP, community participation in the program is minimal. There is a need for linkages with the community through the training of anganwadi workers, ASHA and PHC level paramedical staff for the purpose of creating awareness, identification of mental health issues, and involvement of family members and community in the treatment process. The services at Subcentre, PHC, and CHC level also need to be strengthened and made more accessible to the patients.

Critique of the District Mental Health Programme

The drawbacks of the DMHP have been highlighted by different experts/researchers since inceptions and which can be summarized as:

There is inadequate and inconsistent leadership at central, state, and district levels and irregular flow of funds
Improper implementation (including poor training of staff and motivation and retention of staff)
Extra work is allotted to already overburden PHC doctors
Too much emphasis on pharmacological treatment and lack of psychotherapeutic and family intervention
Poor networking with tertiary care centers and other treatment interventions in the community
Poor or nonexistence of linkages with other sectors (social welfare, employment, etc.)
Poor family and community involvement in treatment and rehabilitation plan
System weaknesses (lack of indicators, lack of scope for corrective action, and lack of accountability
Low rates of mental illness recognition (20%–40%) by PHC doctors
Training manuals too complex and inadequate coverage of stress and positive Mental health (Report of the technical committee on Mental Health).

But at the end,

Despite all these drawbacks, the benefits of the DMHP were realized and one recommendation of the ICMR research report was “that implementation of DMHP has resulted in availability of basic mental health services at district/subdistrict level. As such, it is recommended to expand this program to other districts of the country.” The general perception is that where the DMHP has been effectively run, there have been good results. However, the progress is slow, and the positive changes eclipsed by the numerous systemic and administrative problems. Various experts have observed that the program has ensured wider availability of essential psychotropic medication. The DMHP is now accepted as a relative low-cost, high-yield public health intervention which is doable, as shown in states such as Kerala and Gujarat.”^[14]

The community mental health development project

To further build the DMHP and increase the accessibility of minimum and essential mental health services, the MoHFW and its public health institutes have collaborated with Asia Australia Mental Health (AAMH) on innovative community mental health development project. The project was began in 2011 with the aims to develop locally sustainable best possible community mental health models and which can be practiced at local district, state, and national level. Four pilot sites were identified for this project and activities were focused on developing local capacity to prevent, treat, and rehabilitate people with mental disorders through integrating mental health care into public health. The project collaborates with international partners under a formal agreement with technical expertise provided by The University of Melbourne (AAMH).^[15]

Satellite clinics (or community outreach clinics)

Need of community outreach clinics

Considering the point prevalence of mental disorders to be 58.2/1000 population^[1] and the huge treatment gap.^[16] The need for such services cannot be underestimated. It is expected that if the services are brought close the doorstep of patients, the utilization of the services will be better. Keeping the need of service in the background, some teaching hospitals in India have established outpatient treatment services to reach patients who cannot reach hospital-based facilities. Such services are provided by professionals from the teaching hospitals who have the additional responsibility of teaching, clinical care of patients in the hospitals and research.

Team composition

Since there is no separate staff to run these services, and hence, these services are pulled out of the teaching/tertiary care hospitals and the composition of team is variable depending on the availability of resources which can be spared for a limited period. In general, the team consists of a psychiatrist/senior resident, a clinical psychologist/MPhil student a social worker/PSW student and a nurse.

Location, timing, and frequency

In general, the satellite clinics are set after the assessment of prevalence of mental disorder in that village and willingness of community leaders to start these services on regular basis. There is no permanent location of satellite clinics and it depends on the availability of space in the community. At many places, the location keeps on shifting depending on the need in the community. Most of the satellite clinics function once a week for 3–4 h in the morning. Ideally, for a satellite clinic to be successful, it must be (a) located in health setup (a dispensary is preferable to a community hall) if possible where other health facilities and routine investigations facilities are available or at or near religious place which is often visited by the villagers; (b) referral arrangements to tertiary centers must be available for severe cases and psychiatric emergencies; (c) the community need to be informed whom and where to seek help after clinic hours and also in case of emergency situation; and (d) linkages should be developed with other health-care facilities in the community.^[17]

Scope of services

In addition to early diagnosis and treatment of common mental disorders in the community, the other advantage is that patients who are stable can be seen in satellite clinics after discharge from the tertiary care hospital facilities, thus reducing the workload on the tertiary hospitals at the same time benefiting the client in terms of reduced travel expenses and reduced wait period for consultation. A closely knit community also helps to provide reliable information on the prevalent social and cultural beliefs which are relevant for the diagnosis and management of mental health problems. Such clinics also provide a framework for primary prevention of mental disorders. There is also an opportunity to understand the reasons for the treatment gap and how to handle such disorders.

Experience of community outreach clinics at Government Medical College and Hospital

The Department of Psychiatry, Government Medical College and Hospital (GMCH), Chandigarh is running the Community Outreach Clinics (COCs) in the adjoining villages of Chandigarh on weekly basis since 1996 as shown in [Figure 1]. Initially, these clinics were predominated with patients of alcohol and drug abuse and which constitutes around 60%–70% of total patients registered at these clinics. Gradually, these clinics also attracted the patients with mental health issues, and currently, there are almost equal proportion of patients with SUDs and mental health issues including patients with SMI.

Figure 1: Source: Department of Psychiatry, Government Medical College & Hospital, Chandigarh

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These clinics are based at dispensary and religious places in the villages. The team consists of senior resident and junior resident, MPhil (CP), MPhil (PSW)/MSW, and nursing staff visit these clinics on weekly basis from 9.30 am to 1.00 pm. The community team gets the medicines issued from the hospital dispensary for community clinics. In case, if any medicine is not available with the team, then team also arranged the samples for the same.

COCs are very convenient for patients; as they do not have to spend more than half an hour to see the doctor against 3–4 h in busy city-based hospitals. In case, if any patient requires hospitalization and he does not have any means and supports to reach the hospital, the community team brings the patient to the hospital and get him admitted in psychiatry ward.

Few patients after discharged from hospital would prefer to visit these COCs for follow-up visits as these clinics are close to their houses and less time-consuming.

Over all these COCs are acceptable to the community, useful, cost-effective and hence sustainable.

Community de-addiction camps

Camp approach has been a popular method in India and other developing countries to reach out to patients in the community. Camp-based detoxification for opium users was organized in Jodhpur in 1979. Chennai-based NGO; TTK group applied the camp-based approach for alcohol users. Chandigarh group has organized first de-addiction camp at village Palsora in 1999.^[18]

The Department of Psychiatry, GMCH, Chandigarh is organizing these 10 days indoor community de-addiction camps for patients of alcohol and drug abuse since 1999. A total of 270 patients have been treated in these camps.

Chandigarh group carried out 10-years outcome of patients of substance use disorders, who were admitted from 1999 to 2010 in the 10 days indoor community camps, organized by Department of Psychiatry, GMCH, Chandigarh and found that more than 52% of patients could maintain abstinence after 10 years and more than 42% of patients could maintain abstinence between 2 and 10 years. The study concluded that community camps for the treatment of substance abuse are cheaper, less stigmatizing, no or minimal disciplinary issues, good retention rate, and patient maintains higher rates of abstinence with lower rates of relapse.^[19]

However, similar to COCs, community camps; despite the evidence of their acceptability, cost-effectiveness, and better outcome; are being organized sporadically by certain public institutions, NGOs, and private clinicians as there is no regular support by the government.

Apart from the COCs and indoor camps, the department is also organizing 1-day OPD camps at least once in a month in different villages of Chandigarh with the purpose to create awareness, enrollment in treatment, and subsequent follow-ups.

Home-based detoxification

In spite of regular COCs and annual community de-addiction camps and 1-day OPD camps by the department, a substantial number of patients do not seek services from these places after the initial assessment and enrolment.

To target this population, a pilot project on home-based detoxification was carried out. A home-based team comprising of a psychiatric social worker, a psychiatric nurse, and psychiatrist established contact with community leaders and with their help, identified substance users in the locality. After identification, the patient was assessed by the psychiatrist and was subsequently visited at home by the community team on alternate day for next 2 weeks and medicines were dispensed. Family members were advised not to allow patients to go out of home for initial 3–4 days. After 2 weeks, patients and family members advised to visit clinic for follow-up. During follow-up, 75.6% of sample was maintaining abstinent from primary drug at 1 month, 54.05% at 2 months, and 48.6% at 3 months.^[20]

In the absence of separate workforce and funds, it is difficult to sustain the community outreach service for longer period. Hence, it is pertinent to keep medical college/institute as nodal center for the purpose of improvising the quality of service as well as sustaining the service as shown in [Figure 2].

Figure 2: Model of service delivery, Department of Psychiatry, GMCH

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The Department of Psychiatry, GMCH, Chandigarh is following this model with the purpose to identify patients of mental illnesses and alcohol and drug abuse in the community at early stage by holding OPD camps and providing treatment in the community by running the COCs and 10 days indoor community de-addiction camps and to minimize the dropout rate. The model works on close networking with other health and social services available in Chandigarh.

Parainstitutional care (half-way homes and daycare centers)

A half-way home (HWH) is a rehabilitation facility for individuals, such as patients with mental illness or substance abuse, who no longer require the hospitalization but at the same time not fit to return to society. HWHs assist persons who have left highly structured institutions to adjust to society to re-enter it and live within its accepted norms. The HWH provides intervention to regain social, vocational, and cognitive skills. In India, there are numerous HWHs, all established by NGOs. Some of the well-known ones are Richmond Fellowship India (Delhi and Bengaluru), Roshni (Guwahati), Paripurnata (Kolkata), Banyan (Chennai), and many others.

Unlike physical disabilities, rehabilitative processes are considered quite late in psychiatry when the patient is free of positive symptoms, a phenomenon that may require considerable time. Moreover, the center's for rehabilitation are sparse, most run by nongovernmental institutions and sadly not affordable to many. The result of the absence of rehabilitation services leads the individuals with chronic mental illness to remain confines to their homes, usually as unproductive members. With the growing number of nuclear families, the parents of those with mental illness often wonder, “What will happen to my child after me?” Unfortunately, this issue has not been well-addressed.

School mental health

Child and Adolescent Psychiatry have gradually developed in the last two decades in India. However, this specialized service is offered by few centers in the country, and all those are located in cities. Not all medical colleges in India provide adequate facilities for the treatment of common psychiatric problems in children and adolescents. With 47% of the population of the country below 19 years of age and an estimated prevalence of 15% of psychiatric issues in this population, the treatment gap is huge for psychiatric services.^[21]

NIMHANS, Bengaluru developed the School Mental Health Programme to overcome these service provision deficits. The program included:

Teachers' orientation program – Wherein teachers are provided the skill to identify psychological problems and handle them effectively
Skills training for teachers – A voluntary program that improves the counseling skills of teachers
Student enrichment program – Empowers students with issues such as effective study methods, preparing for examinations, reasons for failing in examinations, taking care of one's health, principles of mental health, understanding the self and others, interpersonal relations, the student–teacher relationship and planning for the future, and
Life skills education program – Which was developed based on the 10 generic life skills published by the WHO in 1995.

The model is an integrated one, using resources already available in the schools. Teachers are trained as Master Trainers, who further conduct training for other teachers to be Life Skills Teachers. The classes are mainly through activities among students facilitated by the Life Skills Teacher. It is a participative program focusing on experiential and peer learning. The activities are based on various developmental themes of nutrition, hygiene, academics, interpersonal relationships, substance use, gender issues, career, and social responsibility.^[22]

Other institutions have also conducted programs for school mental health. The Department of Psychiatry, BYL Nair Hospital, Mumbai, conducted student enrichment programs and also has a school mental health clinic where a multidisciplinary team provides inputs to teachers and parents of children. TTK, Chennai conducts programs in schools on substance abuse while the Tata Institute of Social Sciences conducts programs for out-of-school adolescents and young women on sexual health and lifestyle skills. Another extensive program on life skills is conducted by “Expressions,” an NGO in Delhi that collaborates with the NCERT and the Ministry of Human Resources, GOI.

Apart from these expansive programs, many NGOs also provide school counselors. School counselors help identify common psychological problems in children such as learning disabilities, hyperactive disorders, and emotional problems in children and further provide necessary remedial measures and counseling to the best of their ability. Under orders of most State Education Departments, schools are required to enroll school counselors. Although many universities have started postgraduate courses in school counseling, the pan-India presence of school counseling services is unlikely in the near future.

Research in community psychiatry

In spite of rendering community outreach services by the public and NGO sectors in different places of India, the documentation and publications of research are very limited.

Two major epidemiological studies^[1],[2] established the magnitude of mental health problem in the community.

The two landmark studies of Raipur Rani experience and Sakalwara experience conducted at two different places in India opened the doors for the need as well as feasibility of effective community outreach services in the country.

Chatterjee et al.^[23] found community-based rehabilitation for people with chronic schizophrenia are more efficacious than routine outpatient care.

Murthy et al. (2005)^[24] concluded that efforts to organize community-based care such as outreach services for people with schizophrenia living in more remote areas of resource-constrained countries can bring substantial benefits to patients and families.

Chatterjee et al. (2009)^[25] have conducted a longitudinal study of patients with psychotic disorders and concluded that community-based rehabilitation is a feasible and acceptable intervention with beneficial impact on disability for the majority of patients with psychotic disorders in low resource countries.

Thirthalli et al.^[26] assessed 215 patients with schizophrenia in South Indian population. It was observed that proportion of patients classified as disabled declined significantly in the treated group but remained the same in the untreated group.

Initial camp approach for mentally ill from Maharashtra and Karnataka was reported in 1970 and for substance use disorders from Jodhpur, Rajasthan in 1979 and TTK group in Chennai. Later on, usefulness and cost-effectiveness of camp-based approach for substance use disorders was reported from Chandigarh. Subsequently, abstinence and retention rate up to 10 years in de-addiction camps were reported from Chandigarh.^[18],[19]

Training in community psychiatry

Community psychiatry is one of the important components of 3 years MD training in psychiatry. A recent article by Patel RR^[27] did mention about 3 months community based psychiatry training, but there is no detailed about the scope and learning objectives during this posting.

The Department of Psychiatry, GMCH, Chandigarh has inbuilt posting schedule of 2 months posting in community psychiatry with well define objectives and few of them are:

Understanding about the concept of community psychiatry and knowledge about various community mental health models; Indian and Western
In-depth knowledge about various community surveys regarding the prevalence of various mental disorders in India and cost of burden of untreated mental disorders on community and families
Various initiatives taken by government to strengthen community mental health services
Knowledge about measuring the cost-effectiveness of community mental health services
Knowledge about Public Mental Health System
Gaining of knowledge about role of community and family in the perpetuation, prevention and treatment of mental illnesses, and alcohol and drug abuse; culture, family, and social dynamics
Efforts to bring the untreated mentally ill patients living in the community including homeless, living on streets, into treatment, and rehabilitate them
Gaining the skills to explore the community and family structure, beliefs, and understanding the concept of mental illnesses and translate it into scientific way to help the community and families
Skills to explore that how the community and families were handing these issues at their own level before coming for treatment
Detailed workup of all new cases including the family assessment and get it verify in the log book from Community Senior Resident
Taking psychoeducational sessions with group of families and patients to generate awareness about the need and treatment of mental and substance use disorders and at the same time to remove the misconception of community and families
Understanding the pathway to care and reasons for delay in seeking the treatment and at the same time the reasons of dropout from treatment
Formulating the ways to rehabilitate the person back in the community after recovery including patients with substance use disorder
Learn the concept of community-based research.

Summary and Future Suggestions

No doubt that we are placed better than what we had during the 1^st half of 20^th century in regard to community psychiatry services, but we still have a significant distance to travel
The outreach services for geriatric population is very limited except few schemes such as National Policy for Older Persons in 1999, The Integrated Program for Older Persons, and other Central Government Health Schemes
The Chandigarh Administration has come up with an innovative plan to carry out child protection services in collaboration with professionals, NGO, and other groups. The plan has all the components of child care in the community, that is, promotive and preventative care, early identification, and treatment
There is no unique model(s) of community psychiatry services across all the zones/states of India
There is no sanctioned workforce and budgetary provision to provide the uninterrupted community psychiatry services
Inadequate training and scarcity of research in community psychiatry
Hence, there is strong need to integrate existing health-care services with various other services such as helpline, crisis services in the community domiciliary care with the medical colleges and institutions
Development of models with “minimal standards of care”: Models are developed with purpose that must be achievable and realistic. However, just developing a model that looks great on paper is not good enough
Participation of local community including users and carers is crucial for acceptability and accessibility
Better documentation of effectiveness of services and publication of research
Minimum 2 months training in community psychiatry with well-defined learning objectives during 3 years MD Psychiatry training course.

I slept and dreamt that life was joy. I awoke and saw that life was service. I acted and behold, service was joy.

Rabindranath Tagore

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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