Dr. K.V. Kishore Kumar Dr. C.R. Chandrashekar

Dr. B.N. Gangadhar Dr. B. M. Suresh

Dr. P.T. Shiva Kumar Dr. Jagadisha

Dr. Om Prakash Dr. B.V. Karur

Information Education and Communication Manual for Health Workers Implementation of DMHP

2008

NIMHANS

Information Education and Communication Manual for DMHP

FIRST DRAFT

Information Education and Communication manual for health workers and the community

For Implementation of DMHP

Prepared by Dr.K.V.Kishore Kumar Dr. C.R.Chandrashekar Dr.B.N.Gangadhar Dr.B.M.Suresh Dr.P.T.Shiva Kumar Dr.Jagadisha Dr.Om Prakash Dr.B.V.Karur

Department of psychiatry

National Institute of Mental Health and Neuro-Sciences NIMHANS- Bangalore –560029

IEC material for DMHP IEC for patients

Edition: First, May 2008

Copyright NIMHANS , Bangalore

For further details contact Dr.B.N.Gagadhar Professor and Head Department of psychiatry NIMHANS Bangalore – 560029 Phone 080- 26995260 ( O) 080- 2699 5250( DO ) 09448062040 (M)

This IEC material may be freely adapted, reproduced or translated in parts or in whole, purely on a non-profit basis. We welcome receiving information on its adaptation or use. The opinion, analysis and recommendations suggested in this document are solely responsibility of the authors

CONTENT

1. What is DMHP 2. Components of DMHP 3. Mental health problems covered under DMHP 4. Psychotic disorders 4.1 What do families do when a member develops psychotic illness? 4.2 What should the families know about psychotic disorders 4.3 Common misconceptions about psychosis 4.4 Key messages about psychosis 5. Depressive Disorders 5.1 What do families do when a member develops psychotic illness? 5.2 What should the families know about psychotic disorders 5.3 Common misconceptions about psychosis 5.4 Key messages about psychosis 6. Neurotic and stress related disorders 6.1 What do families do when a member develops psychotic illness? 6.2 What should the families know about psychotic disorders 6.3 Common misconceptions about psychosis 6.4 Key messages about psychosis 7 Substance Use Disorders 7.1What do families do when a member develops substance use problems? 7.2 What should the families know about substance use disorders 7.3 Common misconceptions about substance use disorders 7.4 Key messages about Substance use disorders 8 Mental Retardation 8.1What do families do when a member has MR ? 8.2 What should the families know about MR 8.3 Common misconceptions about MR 8.4 Key messages about MR 9.Epilepsy 9.1What do families do when a member develops psychotic illness? 9.2 What should the families know about psychotic disorders 9.3 Common misconceptions about psychosis 9.4 Key messages about psychosis 10 Whom should you contact in case you have problems accessing services from the DMHP 11. DMHP services 12. Flow charts

FOREWORD Information, education and communication are very important components of any health care activity in the community. The more medical professionals attempt to educate the community- ill persons and their carers, better is the ability of the community to understand the ill person, support him and utilize the available services in the community. Health workers, ANMs, Asha workers, volunteers and the anagawadi teachers should take the message to the community that mental disorders are treatable and that person with mental illness can lead normal life like any one of us with appropriate treatment, rehabilitation and follow up. The present IEC manual is an attempt to provide basic and simple facts to the community through the paramedical workers. The manual covers various aspects of the DMHP- what is DMHP, Whom is DMHP for, components of DMHP, disorders covered under DMHP, details of the each disorder, what the ill person and family should do and lastly misconceptions about each of the disorder. This information is presented in simple manner so that paramedical workers can educate the community continuously. The mental health program for India has registered new growth in the last five years. This is primarily due to the commitment of the Government of India to take mental health to the farthest of villages in the country as well the impoverished urban slums. Realization of this commitment of the Government is possible only by rejuvenated effort of the professionals , administrators and planners as well a the collective action of the community. The current effort is to ensure that education and sensitization about DMHP occurs uniformly all the country using one set of material. The program officers can make necessary modification depending on the local culture to add pictures and other relevant material rather generating one set of material all over again. It is note worthy that the present IEC manual has content to educate the community about whom they should contact if they have problems accessing care a part of the DMHP. Taking into consideration all the aspects of the manual, I am optimistic that this simple IEC manual can go a long way in taking the message of mental health problems and treatment available to far off villages in the country. Dr.D.Nagaraja Director/Vice –Chancellor NIMHANS, Bangalore – 560029

PREFACE Educating the community is an important responsibility of the medical team in primary care settings. Often times, many pubic health care programs do not optimal benefits to the community because of lack of education about the program. Experience has suggested that in the past, awareness in the community about mental health problems and the program in the community like the DMHP has been poor because of inadequate effort to educate the community. Many technological advances have taken place in the mental health scenario in the past two decades but the benefits of these advances have not reached the community because of lack of education and inability to follow a uniform education module. The present Information, education and communication module serves that purpose to a great extent. It is very crucial to educate the community about mental disorders, early treatment, its benefits, rehabilitation, stigma and discrimination and so on. It is important to recognize that the family is able to identify abnormalities in their relatives as early as possible, and they take some action to redeem distress. This means that they are able to identify changes in speech, biological functions and behavior as soon as it’s occur. Ironically, the families do not get the right kind of information s to whom to contact for help and this often delays contact with appropriate medical agency. The DMHP program envisages that the primary health centre doctors and their team can handle most of these problems very efficiently. However, the task in front of them is to see that patients needing mental health care should seek help from them so that they can treat. Health workers, ANMs, Anganawadi teachers and Asha workers should proactively educate the community on a continuous basis so that benefits of the DMHP reaches all the needy in the community.

Dr.B.N.Gangadhar Prof and Head Department of psychiatry NIMHANS, Bangalore – 560029

IEC material for DMHP

Introduction. Mental disorders are universal and uniformly distributed in the community across rural, urban and tribal locations. . Persons suffering from mental health problems do not access care because of several factors. One of the most important issues is lack of awareness about mental disorders in the community and lack of avenues for early treatment. It is impossible to expect change in people affected by mental health problems to recover with the aid of intervention since mental disorders do not remit naturally. The critical issue therefore is to educate the community about the nature of mental health problems and also to set up systems to care for the persons suffering from mental disorders. The most important interface between the community and the system is the education. With the popularization of print and electronic media, enormous information is circulated every day but ironically, very little information reaches the rural masses because of limited reach of the print and electronic media to rural locations. The most certain way of educating the rural masses continues to proactive efforts on the part of medical and paramedical professionals. It is further relevant to note that the more the number of people treated for mental disorders, the more is the possibility of people recovering from the illness to lead a normal life. The present manual is an attempt to make some basic information available to the community in a uniform manner. We hope that the material developed can be translated into local vernacular and circulated extensively so that people are able to understand that behavioral abnormalities occurring on the background of mental disorders are understandable and that they are bodily dysfunctions amenable to medical intervention. The current manual also intends to educate the community about the mental health care program in the community to closer to where they live, ways to access the same and the kind of help available to them.

The IEC material for the DMHP has the following components. What is DMHP? District mental health program is a public health approach used to deliver mental health care for persons suffering from psychosis, depression, neurosis, mental retardation, substance use disorders and epilepsy. Care for each of these disorders is available in your local primary health center/ primary health unit/ taluk hospital or the District hospital. All the medical officers, specialists and other medical practitioners are trained to provide basic mental health care which enough for the ill people to recover from their illness. The services available in the DMHP district is free of cost, except that patients are expected to pay the charges such as user fee when the first register. Each of the patients registered in the PHC/PHU/Taluk hospital/General hospital and a case record should be available in the respective hospital. Each of the users will have bring a 100-page book where details of the medication will be entered. Patients are requested to bring this record to the hospital every time they come for follow up. Remember it is your responsibility to use the service provided by the Government.

Components of DMHP Urban mental health care, rural mental health care, School and out of school health promotion, College counseling program, suicide prevention and stress management are the key components of the district mental health program. The 11th plan has revitalized the DMHP to make the program a true public health program by using the resources of the public health system. As part of this a nodal officer will be appointed by the state government to over see, supervise the implementation of the DMHP.Unlike in the earlier, a program officer appointed for the DMHP will be a Medical Officer from the State Government services. He will be trained for a period of 6 months – three months each in the first two years of the DMHP. The revised 11th plan envisages coverage of all the person with severe mental disorders in the first year followed by care for other brain disorders from second year onwards. School and college mental health program, suicide prevention and stress management will also start from the second year and will be carried forward through the entire period of DMHP implementation. The revised plan has set up State and Central monitoring committee and these bodies are responsible for monitoring and reporting the progress of DMHP in all the States in the country. . District mental health program has several components such as –

• Basic mental health care • Follow up of treated patients • Information, education and communication • School mental health program • College mental health program • Suicide prevention • Stress management for personnel • Monitoring and supervision of care

Who are the people eligible to use the services? Any one with mental health problems can avail this service from their nearby Government hospital on any working from Monday to Saturday. All patients diagnosed with one or the other mental health problems will be dispensed free drugs at the hospital pharmacy for a period of one month.

Disorders covered under DMHP 1. Psychotic disorders

Psychotic disorders are categorized as severe mental disorders. They are referred to as severe mental disorders because of the dysfunction that results from such a disorder. Psychosis is characterized by changes from the person’s usual self. For example the person may show changes in sleep pattern, eating habits, socialization, work habits and ability to take usual responsibilities. His thinking is disorganized resulting in ununderstandbale speech, unusual and strange beliefs; his emotions are inappropriate or blunt so much so that he does not show any emotions and his behavior may be so disorganized that he may be either very excited or dull and withdrawn. Lastly, he is unaware that he is ill in any way. Psychotic disorders are very common and one in every hundred person is likely to be affected by this illness in ones lifetime. A. What do families do when a member develops psychotic illness? Families are at cross roads to understand the changes exhibited by the person. His unusual thinking, altered behavior, inability to follow family or the social norms, lack of emotional responses or unusual aggression makes them think that he is possessed by evil spirits or being under that influence of black magic. Hence, they consult traditional or faith healer who unfortunately does not help the person recovers from his illness. The entire experience of getting treatment from the faith and traditional healers can be so traumatic that the person feels petrified and actively resents seeking any help. It is vital not to lose the opportunity to set things right so after the onset of illness by simply consulting primary care doctor or general practitioner or mental health professionals. B. What should the families know about psychotic disorders?

• Psychosis is a disorder of brain functioning. • Psychotic individuals have disorganized thinking, strange beliefs and ideas, which

are not amenable to any logic. • Person affected by psychosis does not do any thing deliberately to annoy any one

in the family or the larger society. • His chaotic thoughts, fears about his persecutors, misinterpreting normal stimulus

can make him exhibit strange behavior. It is important to recognize that altered behavior is understandable and not mysterious or the result of supernatural influence on the individual.

• Psychotic illness can be treated very effectively with safe medication called anti-psychotics. They a cheap and available everywhere. The Government of India has launched a scheme called District Mental Health Program to ensure that all person suffering from psychotic disorders are able to access services close to where they live.

• It is important for all concerned- families, relatives, friends and significant others not to disagree or confront the person behaving in a strange manner due to psychosis. Often such an attitude complicates matters and worsens the situation.

• A person affected by psychosis can lead and productive life after symptomatic recovery, provided he is on regular treatment, but the duration treatment may be for a long time. . Prolonged treatment should not dishearten any one because most

of the physical disorders like Hypertension; Diabetes, Bronchial asthma, Arthritis and Skin disorders need long-term treatment.

• Families should supervise medication regularly; work with the person so that he/she takes responsibility to take medication on his own. He/she should be educated that medication keeps critical brain functions at a normal speed.

• The person should be encouraged to do all activities like any other person in his family or community. Denying opportunities to lead a normal life can have adverse consequences on the person.

• 7 out of every 10 person treated for psychosis can make significant recovery and lead near normal life. The rest will need evaluation and support from specialist in tertiary care facilities.

• Work is therapy for person with mental disorders. If this therapy is started early, disability, non-productivity is less often issues in such persons.

• Families should learn to handle person with psychosis. They should show concern consistently. Approach him if he is approachable; keep distance if he does not like your intrusion.

• It is wrong to think that a person with psychosis is dangerous. He could unpredictable if he is actively experiencing distressing voices or distressed with suspicions.

• Criticizing, showing hostility, tending to treat the person like a child should be avoided at any cost. Presence of such factors might contribute to deterioration in the mental health of the person.

• Nearly, 1 out of every 4 severely mentally ill person might have disability needing support and supervision for most part of the person life. This should be accepted as the truth and make can changes in the family.

• Disabled person with severe mental illness is eligible for welfare benefits from the Government, provided family’s annual income is less than 18,000 per annum.

• Disabled person is eligible for such benefits only after completing three years of continuous treatment and regular follow up.

• A person with mental illness can marry provided the partner is aware of the nature of the illness and willing to accept the possibility of relapse.

• Remember that every person with psychosis has life beyond the psychotic illness. Families, communities and significant others should help him to get integrated into active life.

Common misconceptions about psychosis 1. Person with psychosis is under the influence of evil spirit or black magic or

affected because of curse of God. Psychotic disorders are brain disorders. Behavioral abnormalities in the person suffering from psychosis are understandable. For eg, a person who is suspicious of peoples bad intentions is likely to withdraw from socializing with people; a person hearing voices abusing him is likely to feel fearful or run amok some time. The above two examples suggests that behavioral alterations are understandable in the person. Dopamine activity is high in some area of the brain, hence medication should be used to cause blockade resulting in improvement in symptoms. 2. Person with psychosis are very dangerous, hence they should be physically

restrained. As mentioned earlier, a person with psychosis is showing behavior change because of the strange experiences due to excess dopamine transmission in the brain. Attempts to restraint can worsen his fears and complicate matters. A very small proportion of psychotics could show aggression and violence and they could be related to substance use like alcohol or ganja. Most often giving a hearing and interacting with him will calm down patients. If necessary use mild restraint if all measures fail to calm down the patient. 3. Psychosis is hereditary disorders Psychotic’s disorders are not inherited. If a person is having a relative with psychosis, then the possibility of developing psychosis is marginally higher than a person with no family member affected by such a problem. It is wrong to presume that a person with psychosis will have children who will develop psychosis. 4. Once a person develops psychosis, he/she will never recover, he will remain ill for rest of his life. No it is untrue, research evidence suggests that delay in treatment can result in increased disability. However, with treatment 7 out of 10 patients will make significant progress so as to lead independent life with little support. However, 2-3 patients are likely to have severe disability but the good news is that even they can be managed but will require higher inputs from mental health professionals. 4. Can person with psychosis be given medication without his knowledge? It is quite common to encounter such situations in clinical practice. As per the mental health act 1987 and human rights convention, administration of medication with out the knowledge of the ill person is not a good practice and should be avoided. All most all psychotics are unaware that they are ill and hence refuse medication. Further, medical consultation, and prescription of medication may be seen by the person as an act of harm rather than doing good to him. Most often convincing the person is sufficient to make him take medication by gaining his confidence. If the person cannot be given medication, and risk of harm increases due to ill health, such a person should be hospitalized under the mental health act. The treatment order should be

obtained from the local jurisdictional magistrate after production of two independent medical certificates from medical officers or general practitioners.

5. A person with psychosis cannot be employed because of history of mental illness Mental illness can result in disability if treatment id delayed. Despite treatment, about a third of the mentally ill can be disabled. The disability can be in the form of lack of energy, amotivation, inability to show appropriate emotions, poor attention and concentration. But other recovered mentally ill can work, think, speak and behavior in a socially appropriate manner. These people can take responsibility like any one of the so-called normal person. Therefore, it is wrong to think that mentally ill people are unemployable. However, recovered mentally cannot be employed in certain jobs like defense and security duties which needs handling firearms. 5. Mentally ill person cannot marry. Procreation is an important bodily function. Mentally ill persons are no different from others in so far as procreation in concerned. Recovered mentally ill person can get married provided the partner is fully aware of nature of the illness, current deficits and future treatment needs. 6. Mentally person should follow specific dietary habits. There is no need to follow any specific diet when a person is mentally ill. He or she can eat anything that he/she wants.

Things to remember • Mental illness is treatable • Mental illness is due to disorder in brain functioning. • Not all mentally ill are dangerous. • Mentally ill can work like any one of us. • Mentally person can marry provided his/her partner is aware of the nature of the

problem and treatment needs. • Mental illness is an illness not personal failure • Early identification and treatment is very important for recovery • Mentally ill can be treated in a village hospital or general practitioners clinic • 9 out of 10 persons can be treated on out patient basis • 1 out of every 10 severely ill need inpatient care for brief period of time • District mental health program is a specific community based approach directed

towards helping people in rural, urban and tribal areas to seek help for their mental illness free of cost.

• Dignity, inclusion, and treatment for the mentally ill are matter of concern for all not just the family.

• Demand the service and use the facilities to the best possible extent

Depressive disorders Depression is a very common disorder in the community. About 3 out of every people are likely to develop depression in their lifetime. It is recognized that depression will be number one cause of death and disability by the year 2002. Even though depression is a common disorder, the number of patients diagnosed with disorder is far too because of several reasons. Persons who are depressed experience many problems because of the disease and they do get such an opportunity to sort their problems because of delay in diagnosis. Further people are unwilling to talk about boredom or sadness or ill health due stigma and shame. A. What do families do when a member develops depressive illness? Families may not recognize that recognize depression as an illness needing attention. They might suggest to the patient that he/she should be bold and courageous whenever he/she talks about difficulties arising in the person on the background of depression. It is possible that families might seek the help of temple priests, traditional healers, and astrologers and medical practitioners when one if affected by depression. It is a sad paradox that non-medical healers give hope to the person but medical healers might just reassure that things will be better soon. Well it is interesting to note that none of the interventions from medical and non-medical practitioners help the person to recover from the illness or shorten the course of the disease. Some times families blindly put pressure on the person to do things and they trivialize sad feelings in the person rather than understanding the current problem in the person as a morbid sadness, which is beyond the patient’s control. B. What should the families know about Depressive illness? Depression is a miserable disease, often resulting in severe problems in the persons life and these problems can be reversed by appropriate treatment and prompt recognition. Depressed mood state can make the person initiate very destructive actions against oneself, e.g., quitting job, ending relationships, giving up studies or ending life/ attempting suicide or committing suicide, hence treatment is absolutely essential to shorten the course of the illness. Depression is not a sign of personal failure or incompetence but a dysfunction of the brain due to decrease in neuro-chemical substances. This biochemical abnormality can be corrected by administration of anti-depressants. Depressed patients have can have negative thoughts and the families should spare time to make the patient talk about his/her problems; they should provide support and encouragement to doing routine things rather than like eating with the family, socializing, simple shopping, bathing, listening to news and reading new papers. Depressed patients should never be allowed to isolate themselves. The families should assign one member or more the task of talking to the person, helping him talk about his mood, feelings, joining him/her in completing the task on hand.

• Depression is a brain dysfunction due to decrease in certain neruo-chemical substances, which is reversible.

• Prolongation of misery, disability is due to non treatment

• Depressed patients may perceive ill health and feeling tired. • They are often preoccupied with bodily complaints • Depression is a treatable illness and the person can recover in short period of time • Anti-depressants medication is the key to recovery from depressive illness • Depressed patients sleep less than usual, give up things easily, lack interest and

initiative to carry out routine activities, eat less, may have thoughts of ending ones life.

• They may be tearful and look as though they have lost every thing in their life. • Discussing with the above problems with the primary care doctor/ General

practitioner is helpful to make a diagnosis. • Anti-depressant medication should be continued as per the doctor’s advice as long

as it is necessary. • Discontinuation of medication or reducing the dose of medication is the most

common reason for relapse. Family should ensure that medication is taken very regularly.

• Encouraging him to carry on with routine activities as early as possible is essential to help in recovery from depression.

• Exposure to several life events can increase the risk of developing depression. • Poor social supports and community supports can increase the vulnerability to

depressive illness. • Depression is not attention seeking behavior, neither it is personal failure nor

reaction to personal difficulties but morbid sadness in the person. In other depression is sadness amounting to sickness and disability.

• Depressed patients can lead normal life like any one of us after the depressive symptoms remit.

• Depressive disorder is the most important condition responsible for disability and death by suicide.

C. Common misconceptions about depressive disorders 1. People who develop depression are weak people Depression is a disorder of the brain functioning. It is nether weakness or lack of courage of personal failure in any way. 2. People who develop tiredness or fatiquability or sadness are lazy and they

need a good push. The above mentioned are symptoms of the disorder and they need support and encouragement to handle such a situation, since, they can give up things easily and end their life. 3. Depression runs in families, depressed patients should not marry.Well is true that depression can run in some families, but is always not true that depressed individual begets a child who develops depression. However, person who have depressive disorders should provide all information about the treatment to his / her partner.

4. Depressed individuals can get well with prayers It is untrue that prayers alone can help depressed persons to recover. Anti-depressants are essential for a person with depression to recover. The medication should be taken for a period of one year. 5. Depression is always related to life difficulties It in deed true that life difficulties make us feel depressed for brief period time of time. The chances of depression occurring in a person are related to social supports. That means that people with poor social supports are like to develop depression on the background of life events compared to people who have good social supports. Depression is not always related to life events. 6. People with depression are dull and withdrawn because they have physical

illness Depressed person is suffering due to morbid changes in the mood state. Most often, they present with multiple aches and pains, visit hospital frequently. They suffer from severe mental health problems needing urgent attention. Their symptoms are due to any physical health problems. 7. Depressed patient do not commit suicide Depressed patients can give up things easily, because they feel hopeless and worthless. This indicates the severity of their illness. Untreated depressed patients commit suicide and nearly 20% of them may end their life and this can be prevented by effective treatment.

Things to remember • Depression is a very common and serious brain disorder needing urgent attention. • A biochemical dysfunction in the brain is responsible for depressive illness • Depression is the third most common cause of death and disability based on the

evidence from global burden of disease • Depression does not need any sophisticated equipment to make a diagnosis.

Simple clinical examination is adequate to identify the disorder and initiate one on treatment.

• Anti-depressants are the drugs of choice for the treatment of depressive disorder. These drugs are very effective, safe and economical.

• Anti-depressants should to be taken for a period of one year from the point of remission of all depressive symptoms.

• Response to treatment depends on the use of medication in therapeutic doses. • Patients on treatment for depression should resume their work as early as

possible. • Patients on treatment should be actively supervised by relatives on a regular basis. • Discontinuation of medication can result in relapse of depressive symptoms. Do

not blame your doctor for getting much help for depression. • Antidepressant medication does produce minimal side effects, which are self-

limiting. • Depressed patients need support from family members, friends and relatives till

he/she feels good about one self.

Neurotic and stress related disorders Neurotic and stress related disorders are the most common mental health problems seen in any given health care settings. These patients present with multiple bodily complaints and feel that they suffer from ill health of some kind. They demand good care from doctors and often ask them for injections, tonics, and some special kind of medication. They take some medication and feel better for a very short period of time and return back to distressed state sooner or later. As time passes by, these patients are dissatisfied with the system and find faults with the system since their physical problems persists. Persons with such problems end up spending lot of money perusing care from various hospitals and get very frustrated. Though the person suffering from emotional disorder is going through some difficulty in his/her life, they are unable to understand such a relationship because of poor awareness about mind and body. Neurotic disorder should be appropriately treated in primary care settings and most often this involves simple education and sincerity in communicating the nature of the problem.

A. What do patients do with neurosis? Persons with neurosis seek help for their bodily complaints from various medical agencies like primary doctors, taluk hospitals, district hospitals and several others. They believe that their health is affected in some way and demand lot of attention from doctors. They are unable to understand that they do not have any physical health problems and get frustrated that help from doctors has not been beneficial. They often seek help from traditional healers, faith healers, soothsayers and temple priests and end up spending lot of money in carrying out rituals of several kinds to neutralize the effects bad eye or influence of evil spirits. B. What should they know? People who are affected by neurosis should understand that they have emotional disorder which is tress related. They are actually reacting to adverse event in their life but unable to recognize. They often think that stress or personal adversity is unlikely affect their health in any way. The meaning they give to an event often determines the type of distress they might have. For e.g frustration can manifest as irritability, anger and aggression if one feels let down. Let us husband did not support wife during family discussions with other family members. The person feels let down and shows irritability. The reason for irritability therefore, is the feeling that “ I am not important” , “ Feel disrespected or feel cheated”. Some people somatize psychological distress into a bodily symptom like conversion reaction- paralysis, fits, possession attacks and so on. It is therefore important for the person to understand the source of distress in ones life and recognize that experiencing distress is their legitimate right. However, their coping strategies may not be adequate and therefore learn that. Person with neurosis do not require extensive investigation or multiple medication

Misconceptions about neurosis 1. Neurosis is also madness because such people have strange behavior- break things with out reason/ get angry without reason? Neurosis is categorized under minor mental disorders and they cannot be called mad. In fact no one with mental disorders should be referred to as mad. 2. Neurosis is a long-standing illness because of poor quality of care by the doctors. Psychological distress is related to long standing life difficulty – such as alcoholic husband, disabled child, recurrent stress factors – legal battle and so on. Support and early recognition by the doctor and accepting responsibility to solve / address issues in one life determines distress resolution. 3.Person with neurosis needs extensive investigation to diagnose his illness? No, extensive investigation are not required to identify the nature of the illness. Simple clinical examination and honest discussion about ones life situation is most often enough to diagnose the disorder. 4. How is it possible for person who has multiple symptoms to recover just by talking to the doctor or attending counseling sessions? Don’t such patients need medication? A mentioned earlier, neurosis is a disturbance in feelings. They are invariable related to one or more life difficulties in ones life. Anti-depressants have no rile in the treatment of neurosis. On the other hand, minor tranquilizers may be used for a short period of time only. Benefits of talking about ones problems and attempts to solve difficulties in ones life can be very beneficial. Medication is not required beyond 4-6 weeks. 5. Can neurosis lead to psychotic disorders if not treated properly Neurosis is stress related disorder. The risk of developing psychotic disorder is the same as that of people who are not diagnosed. Seeking help for emotional distress due to unresolved conflicts early is certainly beneficial to achieve health and emotional well-being. Chronic stress due to unresolved difficulties may result in development of other physical disorders such as diabetes, hypertension and so on.

Some important things to remember

• Neurosis is a treatable mental disorder. • Counseling is an important form of medical intervention. • Identification of stress in ones life and using health coping strategies is most

often adequate to handle any adversity in ones life. • It is useless to believe that the doctor is not doing enough to help the patient and

he/she should discuss life problems with the doctor. • Psychological distress can rise to bodily symptoms. • Relaxation, breathing exercises, sharing problems with other, brain storming

with relatives and family members can be very useful to handle life difficulties. • Accepting responsibility to consider alternatives is very useful when one has to

solve problems. Thinking that one cannot solve problems is untrue. • Actively seeking support from other, taking responsibility to identify and solve

problems, acting on issues rather than feeling helpless are useful ways of coming of difficulties.

• Emotional disorders could be related to unresolved difficulties or unpleasant early childhood experiences.

• Considering helpful strategies is far more useful than unhealthy/un helpful strategies such as drug use of alcohol use to reduce worries.

• Recognize that all people can experience life difficulties is important. Life difficulties are not because of fate or sin. Accepting life difficulty as a challenge and trying to handle the same is useful.

• Medication is not very useful for neurosis because there is no correctable brain function abnormality like in psychosis or depression.

• Making an effort to clam down the aroused anxiety can be extremely useful

.

Substance use disorders Substance use and its consequences are familiar to most families in cities, towns, villages and hamlets in the country. It is the most common problem that contributes to driving families to poverty, marginalization and deprived opportunities to study and gain skills. Persons affected by drug use problems are likely to visit hospital more frequently than people who do not use drugs. Persons who visit the hospital do so for various reasons. For, e.g. frequently upper gastro-intestinal disturbances, accident proneness, unexplained injuries, deliberate self harm, emotional problems secondary to domestic violence, marital discord and so on. Substance use usually starts very early in adult life and continues well beyond it. It is well established that drug use is related to high medical expenditure due to morbidity, financial burden to families, and loss of earning members due to high mortality and early identification and management of person can prevent most, these problems in the community at the level of primary care. It is important to understand that many drugs are abused and the type of drug abused varies from one setting to the other. However, alcohol continues to be the most important drug abused. Person abusing drugs are not deviants but person who have become victims to drugs because of lack of some skills. Hence it is important to help adolescents develop skills early in their life so that they are able to handle opportunities and challenges well. It is possible the drug use can occur on the back ground of several situations such as – Social norm, peer pressure, curiosity and as a means to overcome mental distress. Therefore, prevention is an important strategy to reduce drug addiction and early identification and treatment in primary care settings for secondary prevention. A. What do families do when one or more of their kin are addicted to Drugs Families may not be aware of the drug use problems in the individual for a long period of time. There are two kinds of response from families towards person with drug abuse problems. One is to criminalize and consider the person as a deviant, anti-social and immoral and so on, and the other is to trivialize the problem. Families may involve in excessive advice, emotional black mail and so on the make the person give up the habit once they come to know about substance. Families are known to try several levels of strategies to combat drug use habits in the person such as- prevailing upon him to give up the habit by advice and suggestions, providing the person with incentives and rewards for remaining abstinent, making him to visit temples to carry out rituals, undertaking penance and owes to the God, using talisman for protection and so on. If none of these strategies work, person is made to confirm to certain norms by imposing restriction, withdrawal of incentives and so on. B. What should families know about substance use disorders? Substance use disorders and addiction is an illness like diabetes of hypertension. Persons who are addicted to drugs are not anti-social or deviant individuals but persons who have lacked skills to consider alternatives before using the drug. Person becomes dependent on the drug because his body adapts to metabolize the drug at rapid speed as the person continues to use it. While it is not possible t predict who can become addicted to drug; drug addiction can be prevented by keeping away from it or not exposing the ones body to it. Families should recognize drug addiction as a treatable medical condition and

consult doctors for the same. It is important for them to understand that ones will power can fail and therefore the person can restart using drugs and this should not be considered a failure on the part of the person. A person addicted to drugs can have several slips from the time he/she has started to live without using the drugs. Families should recognize that working in self helps groups is a powerful means to learn skills so that the person lives with out the drugs. The family and the community should actively support him in his endeavor to kick the habit. His failure to remain abstinent should not understand as poor motivation on the part of the individual. Drug addiction is treatable but that is possible only with support from the family. The person also feels guilty and sorry within him and feels that people do not understand his efforts to work towards a drug free life. He /she should be given enough support to work on this aspect so that he gains all the skills required to conquer addiction. Punishment, criticism, rejection, emotional black mail, pressure and judgmental attitude is unlikely to help him over come addiction. On the other hand, a sympathetic attitude, emotional support, positive attitude, being objective and non-judgmental attitude can help him over come the problems. All efforts should be made to help him learn from other experience of remaining abstinent by attending self-help groups. C. Misconceptions about substance use disorders 1. Person addicted to drugs cannot be helped at all. It is untrue to say that person who is addicted to drugs cannot be helped. The process of helping an addicted person is different from treating other medical disorders. It is estimated that educating people about drug use and its consequences has helped in reduction of consumption by 60%. 2. People who are addicted to drugs are from slums and poor families. Addiction can affect any person – both rich and the poor. Indeed the vulnerability of drug is high in deprived communities, slums and poverty stricken population because poverty brings new set of values- losing hope/ nothing will change/ negative attitude called as culture of poverty. 3. An addicted individual will remain an addict all his life. It is untrue to believe that an addict remains a addict all through his life. It is possible to treat him and free him of addiction. However, a combination of strategies is required to keep him abstinent from drugs. 4. There are no medicines available for treatment of drug abuse? There are drugs available to treatment addiction. This can be grouped as fallows.

a. Drugs to reduce the intensity of withdrawal symptoms after being abstinent from drugs.

b. Drugs that reduces craving. c. Drugs that can block the action of the substance used. d. Drugs that act as chemical deterrents

It is evident that a range of drugs available to treat person with drug addiction drug acute withdrawal and during the follow up period.

5. Drug addict can live like any other person. Drug addicts are know to die much earlier than people who are not addicted to drugs. This is one reason why the person who is addicted to drug/drugs needs treatment as early as possible. 6. Apart from some medication, nothing else works for an addict. Treatment of addiction is simple but many levels of treatments are available. In the first level simple education to reduce harm reduction is known to help a large number of people. People who have developed dependence on the drug can develop withdrawal symptoms need detoxification using certain drugs called benzodiazepine; this is the second level of treatment. In the third level patient might need inpatient care for both detoxification and learning skills for abstinence. In the fourth level of treatment, person needs rehabilitation, which includes learning skills for abstinence, learning vocation skills and skills for living. It is important to recognize that person with substance use problems benefit from non-drug interventions such as counseling. 7. Drug addicts do not develop HIV/AIDS Persons who are IV drug users are at risk of developing HIV/AIDS. This is because of use of unsterilized needles. 8. Drug addicts are such unreliable people that there is no point in treating them. It is best to jail them for life Drug addicts are ill people. Drug addiction is comparable to any other illness like diabetes, hypertension or cancer. Drug addiction is treatable and therefore human treatment should be offered to all persons with addiction problems. Jailing drugs addict’s amounts to in human treatment and violation of his or her rights for freedom. Currently, very effective treatment is available and all of them should be tried for patients. It is understandable that families can get frustrated supporting addicted kith and kin. Key to success in drug addiction program is early identification and treatment. No single strategy may be helpful but combinations of strategies are known to be useful. 9. Banning sale of drugs is the only way to eradicate the problem of drug addiction. It is ideal situation to think that drugs should be banned to prevent people from using them. Attempts of such a nature has not been helpful to reduce consumption totally, though there is reduction in use by legal regulations in use of drugs. However, the real solutions lie in the individual considering strategies rather than criminalizing drug use. Hence it is important to work with adolescents to help them learn strategies so that they will think of alternatives to drug use. D. Power of self helps groups in the management of drug addiction Self help groups have been known to be very helpful to support person who have quit drugs to lead a drug free life. Alcoholic anonymous, narcotic anonymous, self help for spouses and children of addicts have been found to be very useful. In this approach to community care of person with addiction, former users conduct self-help groups and they share their experience of leading a drug free life and the strategies they use to achieve it. This kind of sharing of information by ex users has been very effective and powerful to

maintain person from relapses. Self helps groups of this nature can be organized in villages, towns and cities very easily. One room in a school, or college or any other public utility facility in the local area can be used for this purpose. At least 15-20 persons can join together to a form a informal self help group and meet periodically in a month.

Things to remember about substance use disorders. • Addiction is a treatable illness • It can affect men and women as well as adolescents • It can be seen in all sections of the society though; the proportion is much higher

in low-income locations, slums and poverty stricken populations of the community.

• Addiction should be understood as a disease rather than deviance or anti-social behavior.

• Prevention of drug addiction is the key to create a society free of addictions. • Prevention of drug addiction needs psychosocial competence enhancing program

like the life skills education. These inputs should be made at the level of schools and colleges.

• Families should be involved in identification and reporting of the problem by seeing drug addiction as a faulty coping/ unhealthy practice in the person.

• Education is an important strategy to prevent people from using drugs. • Adolescents’ becoming secretive about their activities is the first sign of

indulgence in drugs. • Families should be very cautious and encourage the person to seek help as early

as possible. It is important to decriminalize indulgence in drugs. However, he/she should consider various advantages/ disadvantages before one considers use of drugs.

• Drug addiction can be treated in any hospital and each location has some limitation in care.

• Families should be supportive and development an attitude of trust with the person who was using drugs.

• Abstinence should not be the only goal in de-addiction program. • Relapses and remission is an important outcome in many people using drugs. To

get disheartened if a person relapses is not desirable. • It is possible that some people who are addicted can really test the limits of family

endurance, it is important to accept this as a fact and seek higher level of care. • Positive attitude of the family can make a person feel responsible and path to

recovery from addiction can be reasonably uneventful.

Mental retardation Mental retardation is a state of sub-average intelligence due to arrested brain development occurring before the age of 18. Mental retardation is a permanent disability needing a variety of inputs at different development phases in the individual. One in hundred person are expected to have mental retardation, Mental retardation is characterized by delay in development milestones, impaired adaptive ability, difficulty in emotional expression, impairment in language, reading, writing and other skills. Mental retardation affects both sexes and can be seen in people of all the social classes. It is important to recognize that mental retardation is often referred to as poverty related disorders. This implies that proportion of people affected by mental retardation increases as the poverty and impoverishment increases since poverty is characterized in poor access to health care, malnutrition, ignorance, illiteracy, misconceptions, unsafe delivery and poor antenatal care. Hence poverty by virtue of its several implications on people and their health is a preventable cause of mental retardation. Mental retardation cannot be cured with medication or drugs/tonics/ operation or any other form of intervention. Persons with mental retardation can have associated problems like epilepsy, psychiatric disorders such as depression or psychotic disorders and these can be treated with medication. Persons with mental retardation need long-term care and identification started as early as possible is the key to make such an interventions. Person with mental retardation is eligible for certain benefits from the state government – during schooling and after the age of 18 years. A. What do families do when one or more of their kin are mentally retardation Families are known to seek help from various facilities in the local area like neurologists, psychiatrists, non-psychiatric specialists, tradition healers, faith healers and priests. It is important to recognize that none of these intervention are likely to result in any significant change unless family members are able to start interventions as early as possible. The resistance to accept that mental retardation is incurable is very high in the early days of the child’s life. It is also true that families exhaust all their valuable resources hoping that some magical cure can be found and give up doing anything as days pass by. Professional make a very sincere attempt to see that burnout is prevented in families. Hence it is important to identify the families with one or more person with mental retardation and initiate them on treatment. The sooner the families get associated with care related activities, they get excited about the prospect of caring and working on skills to reduce disability B. What should families know about mental retardation? Families are very central to management of mental retardation. The most important aspect that the families should be aware of is that they are in no way responsible for the birth of a mental retarded child. It is not related to past sins or curse of god. Since mental retardation is a permanent disability, it is prudent that the families can act as early as possible so that attempts can be made to reduce disability. Further, it is important to recognize that issues in mental retardation keeps changing from one development phase to the other. In other words, management of mental retardation is a continuous process with change in emphasis at various points in time.

Families should be aware that they have a key role to play in the management. It is a futile exercise to keep blaming doctors, parents or significant other for the problem on hand. They should actively look for resources that help them take care of mental retarded person within their families. Misconceptions about mental retardation.

1. Mental retardation is due to past sins. Mental retardation is due to arrested brain development. Past sins or wrath of Gods has nothing to do with mental retardation. 2. Mentally retarded person remains disabled all their life. Mental retardation is a life long disability. Adaptive ability of the person with mental retardation can be increased/improved by initiating training as early as possible. It is very crucial to identify mental retardation as early as possible and initiate training to acquire various adaptive abilities 3. Mentally retarded cannot read/write. Persons with mental retardation can learn several abilities with training. Mild mentally retarded people are educable and they can read and write. Moderately retarded person can learn to read and write but much less than the mildly retarded persons.

4. Mentally retarded girls should be advised to under go hysterectomy. Mentally retarded girls need not under go hysterectomy as a routine. Ability to care for self is limited depending on the degree of retardation. Severely retarded person may have significant problems in taking care of oneself, if adequate supports are not available, hysterectomy can be recommended purely on the basis of lack of support. 5. Mentally retarded person can be very impulsive and harmful to the society. It is not true that mentally retarded are impulsive and dangerous. About a third of mentally retarded persons can have behavioral problems and such problems are invariably related to environmental situations. Problems such as attention deficit hyperactivity disorder, and others can be managed very effectively with medication. Similarly, psychotic disorders, depressive disorders can also be effectively managed using medications. 6. Mentally retarded person is known to misbehave with person of the opposite

sex. Mentally retarded persons have limited social abilities. Their ability to interact with members of the opposite sex can be faulty because of poor adaptive ability. Their sexual maturity is no different from normal people in the community but sexual expression can be different. This should not be regarded as anti-social behavior. 7. Mentally retarded non- productive members of the community, such person

should be jailed.

Mentally retarded person can be productive if adequately trained. Habilitative programs for mentally retarded should be started as early as possible. Jailing mentally retarded person or institutionalizing them is inhuman and violating rights of people. 8. Prayers, rituals, herbal drugs can be very helpful to handle mental

retardation. Mental retardation is not curable with medication. Prayers, religious rituals, herbal medicines can not cure mental retardation, neither does operation helps in rectifying the defect. Mentally retarded persons can be trained to improve their abilities. 9. Mentally retarded person cannot be employed in any sector. Mentally retarded persons can be trained in skills with which they can be employed in some sectors. Since they can be trained in some skills, employment is possible based on these skills such as office assistants, carpentry, weaving, candle making and paper cover making. 10. Mentally retarded boy should be administered medicines to suppress their

libido. Libido is physiological and sexual expression depends on ones ability. There is no need to suppress it by administration of medication.

Self-help groups in the management of mental retardation in the community. Self-help groups of carers are a vital resource for management of mental retardation in the community. Since this condition is a life long disability, there are many issues that should be handled by carers at different development phases in the person life. Most often, inability to find a solution to a particular problem or difficulty can be very frustrating to the carer. It is in this context that self-groups can be a very useful support group not only to share ones experiences about the occurrence of a particular type of problem and solutions to some of the commonly encountered problems. The self help groups can go along way to making such a support available to carers and also provide be possible solutions based on ones experience of having faced and resolved difficulties. Formation of self-help groups in the community to disseminate caring skills is a very useful and progressive strategy to empower families caring for the mentally disabled children.

Things to remember about mental retardation • Mental retardation is a condition characterized by arrested brain

development. • 1 in every 100 individuals can be affected by this condition. • Persons who are mentally retarded have life long disability. • Early identification and initiation of treatment. • Mental retardation can be due to multiple causes. The most important of

them is brain damage at childbirth. • Mental retardation is equally distributed between both sexes. • Persons with mental retardation have deficits such as poor adaptive ability. • Training a mentally retarded individual from early childhood is a very

important means to improve adaptive ability. • Mental retardation is neither contagious nor entirely hereditary. • Mildly retarded are educable, moderately retarded are trainable and

severely retarded need long term supervised care. • One in four persons with mental retardation also have epileptic seizures

needing drug treatment for long duration. • One in three persons with mental retardation can have one or the other

psychiatric disorder, which can be easily managed with medication. • Mental retarded individuals need love, care, support and encouragement

from family as well as from the community.

Epilepsy.Epilepsy is the most common brain disorder affecting children and adolescents in the community. Approximately, one in hundred persons are likely to be affected by this disorder. Epilepsy affects young people before the second decade of their life and both sexes equally. Epilepsy is a treatable brain disorder and intricately related to poverty. Higher the poverty, higher is the incidence of epilepsy. Even though epilepsy is easily treatable, large numbers of people are inadequately treated due to several factors. It is therefore very important to treat epilepsy as early as possible so that mental disabilities that is likely to occur is prevented so that young people get opportunities to participate in all life activities like any one of us. There are very effective and safe drugs for management of epilepsy in our country. These drugs are available even in a small village level pharmacy in case the government supply falls short of peoples needs. The government of India is committed to ensure that basic and essential drugs to treat brain disorders are available at the level of primary health centres on a continuous basis. Nearly, 70% of all epilepsies in the community can be treated very effectively, while the remaining 30% of epilepsies may need specialist care in due course if primary level of care falls short of patients needs. As mentioned eelier that the Government of India is very strongly committed to allocate funds to all the states and union territories in the country to ensure that every one needing basic mental health care is able avail such a care near to their residence so that gaps in treatment is reduced uniformly across the country. The 11th plan envisages that all districts in the country is able to implement integration of basic mental health care so that any one who needs care is able to access care. This remarkable development needs support from officials at levels and the larger community. We as the citizens of this country have nothing to feel proud just because funds are allocated by the government, but the critical element is the implementation if the program. In the past, the tenth five year plan did not cater to the needs of people at the grass root level because of various problems and one of them was unclear guidelines and the other was lack of commitment on the part of state governments. Since health is a state subject, the central government can have a lot f say in the matter. However, if the people demand for care, the state is obliged to do the needful. It is there fore very important for the users, carers, volunteers and significant others are aware of the Government programs and use it to the optimum extent and at the same time organize themselves to demand services if there are omissions and oversight. It is needless to emphasize that consumer participation is vital and demand for services as a matter of their fundamental right. What do families do when their kin suffer from epilepsy.Epilepsy is a very scary illness. Dramatic onset of symptoms resulting in altered sensorium; behavioral changes and bodily symptoms such as rhythmic movements of upper and lower limbs can evoke different kind of responses from the family members. While some families rush the person to the hospital or local clinic, others initiate several home remedies. Some the home remedies can be inhuman and others can be very dangerous. Home remedies include inhalation of pungent odor of burning chillies, making the patient inhaling smashed onions, inhaling fumes of burning leather or administration of onion juice intranasally. Intranasal administration of any herb or medication to the unconscious individual can be disasterous. Many had died during such interventions at home which goes unnoticed. Some families believe that fits id due to evil

eye or black magic or possession by ghosts and therefore seek help from traditional healers/ faith healers or temple priests. None of the above practices cures seizures in any way and they should be avoided at any cost. It is important to remember that some of these interventions are carried out in a helpless manner since there are no alternatives. Some families try to feed the person some heat producing foodstuff; they believe fits are due to bad effects of cold and they try to neutralize the cold by administering hot stuff such as decoction of herbs with pepper or some other spicy herbs. What should the families know about epilepsy.Experience of working with large number of families and patients suggests that mere lack of predictable and reliable care in the communities is one important reason which derives families to use any service that is available in the vicinity rather than using the right kind of service. It is therefore, critical to ensure basic mental health care services, which is responsive to peoples needs. Attitudinal changes are likely to occur only if services are provided in parallel with continuous education art all levels. Seeing believes for most in the community, therefore, seeing ill persons getting well after regular treatment . The families should be aware of the following facts.

• Epilepsy is the name of the disorder and seizure or epileptic fit is a symptom of brain disorder.

• Epilepsy is a curable brain disorder. There are very effective, safe, and very economical drugs available for the treatment of epilepsy in India.

• All primary health centres, primary health units, GADs, taluk hospitals/CHCs and District hospital have phenobarbitone and phenytion. These drugs are available free of cost. Referral hospitals and medical college hospitals have carbamazepine in addition to basic anti-epileptics.

• Epilepsy is not due to evil spirits/black magic/bad eye, wrath of gods, past sins or exorcism.

• General practioner or PHC medical officer is trained to manage this disorder very safely in his or her own settings. It important for ill persons and family members to talk to the health workers, ASHAS, or any other health care functionary to organize care as soon as possible.

• Epilepsy can be controlled in a very short period of time- 3-6 months in nearly 70% of cases. Regular intake if medication and taking the dose as prescribed by the doctors is crucial.

• Patients should report any problems that may arise after intake of medication to the health workers or doctors. Discontinuation of no solution to the problem of side effects.

• Side effects are very common with most drugs but they are brief lasting and harmless.

• Drowsiness, slow mental activity, dullness, gingival hyperplasic and anemia are commonly seen with anti-epileptic drugs.

• It is important to see the doctor in case of following problems- Persistent headaches, vomiting, visual disturbance, difficulties in balance or walking, coordination problems and increase in frequency of seizures. These problems need immediate attention from the doctors and consultation should not be postponed for any reason. Delays can lead to fatalities.

• Epilepsy is not a contagious illness. • A person with epilepsy can lead a normal life after seizures are controlled for a

period of two years. It is untrue to believe that epileptics need treatment and support for all their life.

• Person with epilepsy can marry and nothing prevents him/her from doing so after control of fits. He/she should openly discuss about the past treatment and current status with all concerned

• Person with epilepsy should refrain from driving motor vehicles, working at higher altitude, swimming, handling machinery and fire arms till seizures are well controlled.

• He can resume work as soon as possible provided some caution is exhibited always.

• There is no need for any specific dietary restrictions of any kind. However care should be taken that meat is well cooked; cleaning raw vegetables and greens is very much essential in a country like ours because of potential contamination.

• Epileptics do not beget epileptics and it is wrong to presume that illness is heredity. Only a small proportion of seizure disorders are inherited.

Misconceptions about epilepsy1. Epilepsy is not treatable illness Epilepsy is a brain disorder and treatable with very simple anti-epileptic drugs. 2. Epileptic patients are unfit to do any work. Persons suffering from epilepsy can do any work after control of seizures. However, they should take medication for 2 years after which are they are eligible to do any work, they legally entitled to drive and swim as well. 3. Epileptics should follow a strict dietary regime. Epileptic seizures are unrelated to diet. There is no evidence scientifically at the present time that certain kind of foodstuff is responsible for aggravation of seizures. 4. Persons with epilepsy are under the influence of ghost/evil spirits Epilepsy is a disorder of the brain. These patients have epileptic attacks because excessive electrical discharges. Tonic-clonic movements or clonic movements or episodic behavioral disturbances and altered sensorium is related to electrical discharges. 5. Epileptics are very short tempered and aggressive people and they should be imprisoned. About 1 in every 6 epileptic patients are known to have poor control of seizures. Such patients are likely to have brain damage and as a consequence may have personality change or even psychotic episodes. Aggression and violence cannot be generalized to all persons with epilepsy. 6. Persons suffering from epilepsy are likely to get more frequent attacks when they are near water or fire. Hence they are forbidden from doing any work at home.

Fire or water has nothing to do precipitation of epileptic attacks. Once seizures are controlled, the person can do any work. However minimal caution is required to prevent problems that might come up any time. 7. Brandishing children with iron rods, burning the skin red-hot glass bangles on the fore is a very effective remedy for epilepsy Brandishing with hot iron or heated bungles is not remedy for epilepsy. Perhaps this could have been a procedure used to wake up patient in altered sensorium, which has continued even after availability of treatment. 8. Using iron rods or keys during an epileptic attack is very effective remedy to control epileptic seizures. Aborting seizure with iron rods or keys is impossible. Since seizure is a self-limiting activity, Fit will remit on its own whether or not any thing is done. There is no need to consult a doctor every time the person has fits. 9. Pregnant mothers should not take anti-epileptic medication during pregnancy. Pregnancy is a very critical period for women with epilepsy. They should take medication regularly as prescribed by the doctor. Pregnancy can decrease seizure threshold there by increasing the risk of frequent attacks. It is important to take medication. 10. Lactating mothers cannot breast feed the infant if she is taking anti-convulsant medication. It is fact that anti-convulsants are secreted in the breast milk and the child is likely to remain drowsy. If the mother has enough supports to manage external feeds without risking the child’s health, external feeds can be considered. It is best to discuss with the doctor about this issue. 11,Epileptic patients do not commit suicide. Patients with epilepsy can have several psychosocial problems. Self-injurious behavior can occur

Things to remember • Epilepsy is a disorder of the brain. Epileptic fits are due to excessive electrical

discharges for various reasons. • Anti-epileptic drugs are very inexpensive and effective remedies in the

management of epilepsy. • Regular medication, adequate rest, regular food intake and minimizing emotional

stress is very important for good seizure control. • There are many seizure types and each one them is treatable, though control of

seizures can vary. • Epilepsy is not a communicable disease and epileptic should no be

discriminated. • Majority of epileptics can be treated very effectively in primary care settings;

though about a quarter of epileptics can be resistant to treatment needing specialist care.

• Persons with episodic abnormal behavior lasting for brief period of should be understood as epilepsy.

• Some persons can develop altered sensorium after hot water bath in some geographical areas in our country. Such a change should be understood as epilepsy.

• Duration of treatment for epilepsy is for a period of two years. Medication can be gradually tapered over several months.

• Persons taking medication for epilepsy should avoid alcohol use because of risk of poor control of seizures.

• Epileptics can marry and lead normal life like any one of us. • They can do any kind of work once seizures are controlled. • Persons suffering from epilepsy are not eligible for disability allowance from the

government. • Untreated epilepsy can result in mental retardation in persons3.

Whom should you contact in case you have problems with DMHP DMHP is a public health program primarily directed towards providing basic mental health care through the primary health care system. Each district will have a program officer who is primarily responsible for implementation of the program. The State should appoint nodal officer who will oversee the implementation of the program in the state. The DMHP program is funded by the Govt of India for all the components of DMHP in the district. In case of problems, please contact either the program officer, or the DHO/DMHO or the District health society. DMHP services? District mental health programs a public health approach to mental health care in the community. As a part of this program, every person in the district is entitled for free mental health care in the Government facility in his /her vicinity (PHU, PHC, CHC/Taluk hospital and the district hospital) in the designated DMHP district. As part of the first year plan, the DMHP officials will conduct mental health camps in all the taluks of the DMHP district in the first year of DMHP. The identified cases with mental health problems will be referred to their respective primary health care institutions so that they can avail follow up care from them. Each of the registered person with mental health problem will be issues a registration number and this number is used for future consultation and retrieval of the mental health record in the respective institution. All the drugs like RESPERIDONE, IMIPRAMINE/AMITRYPTALINE, CHLORPROMAZINE, CARBAMAZEPINE, and INJ FLUPHENAZINE, TRIHEXYPHENIDYL PHENOBARBITONE, PHENYTOIN AND DIAZEPAM or LORAZEPM will be dispensed free of cost in all the government health care institutions for a period of month till the said person requires medication. The other benefits people can avail are as follows.

1. Identification card for persons with mental retardation Persons with mental retardation should register themselves in the respective Government health care institution in the district. This registration is important for them to avail all Government schemes meant for the welfare of the mentally challenged individuals. 2. Identification card for persons with severe mental health problems- Schizophrenia, Bipolar mood disorders, other psychotic disorders and OCD Persons with above-mentioned disorders are entitled for disability welfare benefits from the Department of social welfare based on PWD Act 1995. The person with above mentioned disorders should have been ill for three years and that they should have completed at least two years of uninterrupted treatment from mental health facilities. The diagnosis, treatment record and follow up details of the service user should be maintained up to date in such facilities. In case the person has disability after two years of continuous treatment, he or she should be evaluated on IDEAS scale. If evaluation reveals more than 40% disability, he or she is entitled for certificate of disability. This certificate should contain the following details-

• Record Number • Name of the person • Name of the Husband/ Wife/ Relative • Date of issue of the certificate • Permanent address of the person • Identification marks • Diagnosis • Duration of illness • Treatment details • Brief summary of the case • Signature of the certifying psychiatrist.

On completion of the certificate, Identification booklet should be filled and signed by the appropriate authorities (Panel) and the identification book should be handed over to the patient. He/she will use this document for welfare benefits, train travel concessions, income tax exemption and several similar benefits announced by the Government from time to time. Disability mentioned in the ID is not considered permanent and life long. The disability status should be reviewed once in five years. This means that ID certificate and the ID book should be reissued every five years.

EARLY RECOGNITION OF SEVERE MENTAL ILLNESS Ten Features of Mental Disorders

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Flow Chart for Psychotic Disorders – DIAGNOSIS AND TREATMENT

Presenting complaints

Functional Psychosis

• Progressive self-neglect • Withdrawal • Disturbed sleep • Hearing voices • Suspiciousness • Excitement • Not working • Restlessness • Irritability • Extraordinary physical complaints

Organic Psychosis

No History of Fever, Seizures, Head injury, Headache, Vomiting, Visual Disturbance, Substance use or Neurological deficits

History of History of Fever, Seizures, Head injury, Headache, Vomiting, Visual Disturbance, Substance use or Neurological deficits or altered sensorium

SHORT DURATION Less than 4 weeks

LONG DURATION More than 6 months to many years

On examination Increase or Decrease PMA

Hallucinations Delusions

Disorganized Speech and lack of insight

SHORT DURATION Less than 4 weeks

LONG DURATION More than 6 months to many years

On examination Confusion/Altered sensorium

Increased PMA Visual Hallucinations

Fleeting Delusions Memory disturbance

1. Start Chlorpromazine 200 mg and increase to 400 – 600 mgs in few weeks depending on the need. OR 2. If there is no response with 400- 600mg of CPZ in 12 weeks, refer to mental health professional 3. In case of Resperidone start with 2 mg and increase to 4 or 6 mgs depending on the need. 4. If there is no change with Resperidone 6 mgs for 12 weeks, refer to mental health professional 5. In acute psychosis treat for 6 months and stop 6. In chronic psychosis, continue treatment for longer period of time

In Acute organic psychosis administer 5-10 mg Haloperidol IV and Refer to secondary care or tertiary care center immediately In Chronic organic psychosis (Dementia) refer to the nearest mental health professional for further care

Flow charts for Depressive disorders- Diagnosis and Treatment

Presenting Complaints

Multiple aches and pains, vague bodily complaints, tingling /numbness, tiredness, lack of interest, feelings of sadness, inability to work, poor appetite, decreased sleep, loss of weight

Decreased PMA, slow speech, stooped posture, sad face, non-reactive mood, preoccupied with subjective ill health, tearful, hopelessness, worthlessness, and suicidal Ideas

On examination

Above features started hours or days after life events like death, separation, failure in exams, loss of any other kind, demotion or any other traumatic event

Above features developed with or without any life events or any other psycho-social stress but depressive features present for more than 15 days

Adjustment Disorders/ Reactive Depression Major Depression

1.Physical examination and feedback 2. Reassurance 3. Link between stress and symptoms 4. Problem solving and coping strategies 5. Teach Distraction strategies 6. Encourage resumption of daily routine 7. Minor tranquilizers for a short period of time (Not more than 4-6 weeks) if necessary 8. Facilitate ventilation 9. Encourage the patients to focus on the life events or stress rather on symptoms during follow up. 10. If no change after 4 weeks – consult PO

1. Physical examination and feedback 2. Reassurance and educate the patient and the family about the nature of the problem. 3. Start Antidepressants – IMN = 75 mgs at bedtime for withdrawn depressives. OR 4. AMN = 75mgs at bed time for agitated depressives (3 and 4 for patients who young and those without any cardiac problems).5. Build up a therapeutic dose 100- 150 mgs of IMN/AMN within few weeks. 6. Chose Fluoxetine 20 mgs at break fast for elderly depressives and young people with cardiac problems since IMN/AMN is not suitable

Refer patients who have persistent suicidal ideas, depressive symptoms not improving despite adequate dose of anti-depressants, depression associated with complex psychosocial problems, depressive patients who refuse food and those who are in stupor

Flow chart for diagnosis and treatment of substance use disorders

Presenting complaint

• Physical complaints - upper gastrointestinal disturbances

• Accidents proneness - injuries • Increased susceptibility to infection • Sleep problems • Psychotic symptoms • Low mood • Acute intoxication • Aggression/violence - criminal charges • Multiple bodily complaints • Frequent requests for leave due to ill health

On examination

No Physical Health Problems. Drinking patterns suggests abuse

Physical abnormalities + / -History suggestive harmful use of alcohol

Physical abnormalities + / - History suggestive of dependence

Educate the individual about the ill effects of alcohol

Educate the individual about the ill effects of alcohol and treat physical health problems

Educate about the ill effects of alcohol and suggest out –patient detoxification if there is no evidence of serious physical health problems

Out patient detoxification Detoxification is a very simple intervention. Calculate the dose of benzodiazepines required by using the following. 1mg lorazepam OR 5mg Diazepam or 10 mgs Chlordiazepoxide for every 30 ml of alcohol consumed. If the total amount of alcohol consumed is 300 ml, then the amount of BZM required is 10mg of lorazepam OR 50 mg of diazepam or 100 mgs of chlordizepoxide. Start the total amount is divided doses on day 1 and gradually stop by day 10. Supplement plenty of vitamins

Refer 1. If the patient develops delirium tremens 2. Serious physical problems 3. Onset of neuro deficits 4. Relapse of drinking during detoxification 5. Not willing for OP detox

Flow chart for diagnosis and treatment of neurotic-stress related disorders

Presenting complaints

Multiple-bodily complaints, multiple aches and pains, worries, tiredness, fatigue, tension, fear, sleep disturbance, inability to concentrate, irritability, quarrelsome, excessive concern about ill health, episodes of unresponsiveness, possession attacks, white discharge or hysterical fits.

Short duration Long duration

No physical abnormality but psychosocial stress +

Physical Abnormality detected and psychosocial stress nil

Abnormality on physical examination and psychosocial stress +

TREAT PHYSICAL DISORDER

MSE- worries, preoccupation with life difficulties, tearfulness, preoccupation with bodily complaints, helplessness, demands a particular type of medication/injections/tonics, needs repeated reassurance

1.Physical examination and feedback 2. Reassurance 3. Link between stress and symptoms 4.Facilitate ventilation 5. Problem solving and coping strategies 6. Teach Distraction strategies 7. Encourage the patient to practice yoga, meditation and relaxation exercises 8. Minor tranquilizers for a short period of time (Not more than 4-6 weeks). 9. Encourage the patient to resume routines 10. Encourage the patients to focus on the life events or stress rather on symptoms during follow up. 11. If no change after 4 weeks – consult PO

Emergence of new symptoms or persistence of physical symptoms despite interventions. Reports psychosocial stress

Referral 1. Refer patients with

complex psychosocial issues

2. Not benefiting from counseling interventions

3. Patients who want only drugs mediated interventions

4. Those rejecting counseling

Flow chart for diagnosis and treatment of epilepsy

Presenting Complaints

Frequent episodes of fall and loss of consciousness, tonic/clonic movements, injury, tongue bite, episodes of brief lasting abnormal behavior, sudden jerks, brief lasting vacant looking spells and fits following hot water bath

Early onset - Before 20 years of age

Late onset- After 20 years of age

Establish whether seizures –GTCS/ Focal- motor, sensory/sensory motor/ complex partial/reflex seizures/febrile/afebrile seizures

Refer for further evaluation to the specialist after starting PB 60mg or DPH 100mg to identify the cause

No neurological abnormalities on examination – start anti-convulsant

Neurological deficits +, Or fresh neuro deficits emerge during follow up- refer

Phenobarbitone dose: Maximum PB per day 180 mgs 0 - 3 years = 15 mgs per day 4 – 10years = 30 mgs per day 11 years and above = 60 mgs per day *USEFUL IN GTCS, FOCAL SEIZURES AND ATYPICAL FEBRILE SEIZURES Diphenyl-hydantoin: Maximum DPH per day 400mgs Children = 50 mgs per day in divided doses Adults = 100mgs at bed time *USEFUL IN GTCS, FOCAL AS WELL AS FOCAL-GEN Carbamazepine: Maximum CBZ per day 800mgs Children = 100 mgs per day in divided dosed Adult = 200 mgs per at bed time *USEFUL IN GTCS, FOCAL AS WELL AS FOCAL-GEN

1. It is preferable use one drug; reach the maximum dose depending upon the need.

2. Add another anti-convulsant only after reaching the maximum dose of drug.

3. Explore whether the person had genuine seizures before increasing medication.

4. Depression, psychosocial stress factors, discrimination at work place or home can result in psuedo-seizures. Reassurance and counseling is essential in such situations

Refer patients to the specialist in the following situations

1. Late onset seizures 2. Sudden increase in

frequency of seizures 3. Poor control of seizures

despite use of two anti-convulsants in adequate dose.

4. Onset of fresh neurological deficits during follow up

5. Patients who have attempted suicide

6. Onset of acute excitement or acute withdrawal or depression

Single seizure No drugs

Flow chart for diagnosis and management of mental retardation

Presenting complaints 0- 6 years 7- 18 years 19 and above

Prolonged labour, delayed birth cry, feeding problems, not able to smile at mother, not able to hold the neck, not crawling, not able to sit or stand, not walking, not able to speak, not able to feed by self, no toilet control, overactive, irritable, does not play with other children

Not able to help self, poor in studies, detained in the same class because of poor performance. Cannot read/write, poor memory, overactive, destructive behavior, dull and withdrawn, disinhibited behavior, not able to do simple calculation/shopping. Above problems have occurred on the back ground of delay in developmental mile stones

Cannot do simple calculation, needs help in self acre activities, cannot follow simple instruction, does not know cooking, socially disinhibited behavior, irritable, odd behavior in presence of people, demanding and recent onset behavioral problems. The above difficulties have been present on the back the background of delayed, miles stones after birth.

Physical examination to detect-minor congenital abnormalities, hemiplegia, cranial nerve palsy, OR other CVS/RS/PA abnormalities. Interventions1. Educate the parents about the nature of the problem. 2. Listen to the reaction of the parents. 3. Clarify doubts if any 4. Early stimulation intervention- Start Sensory motor stimulation – Oil massage followed by hot water and touching, tickling, gentle bouncing, to and fro rocking movements, balloons, colorful toys, playing tunes, gentle clapping, talking to the child and building simple conversation around daily routines Getting the child to experience different tastes and odors prone positioning, supported sittings, walking, grasping reaching, holding and transferring 5. Social skills training- mother child games, imitation and showing body parts 6. Cognitive training – sorting, classifying, arranging and matching and concept of size, shape, time, distance and direction 7. Start Anti-convulsant if required 8. Link the family for support – ANMs, HWs, Anganawadi teacher, IED teacher or other agency 9. Review every month 10.Care for physical health problems 11. Certification for welfare benefits

Physical examination and behavioral observation Multi-focal congenital abnormalities, hemiplegia, cranial nerve palsy, OR other CVS/RS abnormalities. Interventions1. Educate the parents about the nature of the problem. 2. Listen to the reaction of the parents. 3. Clarify doubts if any 4. Reading /writing skills through IED teacher 5. Vocational skills with help from parents/Volunteers / out reach workers 6. Involve self-help group members 7.Start anti-consultants for epilepsy if needed. 8.Encourage formation of self-help groups in the village with support from IED teacher, ANM, HW or out reach workers of other agency 9. Review once in 2-3 months 10.Care for physical health problems. 11. Certification for welfare benefits

Physical examination and behavioral observation Multi-focal congenital abnormalities, hemiplegia, cranial nerve palsy, OR other CVS/RS abnormalities. Interventions1. Educate the parents about the nature of the problem. 2. Listen to the reaction of the parents. 3. Clarify doubts if any 4. Vocational skills with help from parents/Volunteers / out reach workers 6. Involve self-help group members 7.Start anti-consultants for epilepsy if needed or start RSPN for psychosis or IMN for depression. 8.Encourage formation of self-help groups in the village with support from IED teacher, ANM, HW or out reach workers of other agency 9. Review once in 2-3 months 10.Care for physical health problems. 11. Certification for welfare benefits

Refer to psychiatrist or discuss with program officer if there is no desirable change in the child after interventions