Внебольничные службы психиатрической помощи в Индии: текущее состояние и перспективы на будущее

По оценкам, в Индии 197,3 миллиона человек страдают психическими расстройствами, при этом большинство населения страны или вовсе не имеет возможности обратиться к службам психиатрической помощи, либо его доступ к ним ограничен. Таким образом, в стране прослеживается колоссальное бремя психических заболеваний при наличии существенной разницы между общим числом случаев возникновения рассматриваемых расстройств и количеством людей, получающих необходимое лечение. Меры профилактики психических заболеваний среди широких масс населения стали приоритетным направлением развития, ввиду чего в данной области можно ожидать долгосрочных успехов. В 1982 году была запущена Национальная программа психического здоровья (НППЗ) – важный шаг вперед в области развития служб психиатрической помощи Индии, который, однако, лишь отчасти смог достичь желаемых результатов в соответствующей области. Несмотря на все усилия по ускорению и оперативному расширению программы, прогресс в развитии внебольничных служб психиатрической помощи в Индии оказался недостаточным, а желаемые результаты не были достигнуты. Меры общественного здравоохранения, наряду с внедрением служб психиатрической помощи в систему первичной медико-санитарной помощи, предлагают наиболее устойчивую и эффективную модель с учетом ограниченных ресурсов специализированной психиатрической службы. Основным препятствием на пути такого внедрения является перегруженность центров первичной медико-санитарной помощи (ПМСП) и следующие проблемы, с которыми сталкиваются данные центры: ограниченное число персонала, чрезмерно широкий спектр задач, большое количество пациентов, единовременное проведение ряда различных программ, отсутствие профессионально подготовленных медицинских специалистов, надзорных и справочных служб и нехватка психотропных препаратов в системе первичной медико-санитарной помощи. Таким образом, существует острая необходимость в новом подходе к реализации НППЗ с фокусировкой на как можно более быстрое улучшение ситуации.

1. WHO. The World health report : 2001 : Mental health : new understanding, new hope. Geneva: WHO; 2001. Accessed August 18, 2021. https://www.who.int/whr/2001/en/whr01_en.pdf
2. WHO. mhGAP: Mental Health Gap Action Programme: scaling up care for mental, neurological and substance use disorders. Geneva: WHO; 2008. Accessed August 18, 2021. https://www.who.int/mental_health/mhgap_final_english.pdf
3. Lancet Global Mental Health Group: Chisholm D, Flisher AJ et al. Scale up services for mental disorders: a call for action. Lancet. 2007;370(9594):1241-1252. doi: 10.1016/s0140-6736(07)61242-2
4. India State-Level Disease Burden Initiative Mental Disorders C. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990-2017. Lancet Psychiatry. 2020;7(2):148-161. doi: 10.1016/S2215-0366(19)30475-4
5. Lund C, De Silva M, Plagerson S, et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet. 2011;378(9801):1502-1514. doi: 10.1016/S0140-6736(11)60754-X
6. Nizamie SH, Goyal N. History of psychiatry in India. Indian J Psychiatry. 2010;52(Suppl 1):S7-S12. doi: 10.4103/0019-5545.69195
7. Chadda RK. Six decades of community psychiatry in India. Int Psychiatry. 2012;9(2):45-47. PMC6735056
8. Murthy RS. Mental health initiatives in India (1947-2010). Natl Med J India. 2011;24(2):98-107.
9. National Mental Health Programme. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Accessed August 18, 2021. https://dghs.gov.in/content/1350_3_NationalMentalHealthProgramme.aspx
10. Singh OP. District Mental Health Program - Need to look into strategies in the era of Mental Health Care Act, 2017 and moving beyond Bellary Model. Indian J Psychiatry. 2018;60(2):163-164. doi: 10.4103/psychiatry.IndianJPsychiatry_304_18
11. Goel DS. Why mental health services in low- and middle-income countries are under-resourced, underperforming: an indian perspective. Natl Med J India. 2011;24(2):94-97.
12. District Census 2011. Accessed August 18, 2021. https://www.census2011.co.in/district.php
13. Do India’s newly added districts yield desired governance results? Accessed August 18, 2021. https://economictimes.indiatimes.com/news/politics-and-nation/do-indias-newly-added districts yield-desired-governance-results/articleshow/70516246.cms?from=mdr
14. Gautham MS, Gururaj G, Varghese M, et al. The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity. Int J Soc Psychiatry. 2020;66(4):361-372. doi: 10.1177/0020764020907941
15. WHO. Improving health systems and services for mental health. Geneva: World Health Organization; 2009. Accessed August 18, 2021. https://apps.who.int/iris/bitstream/handle/10665/44219/9789241598774_eng.pdf
16. New Pathways New Hope. National Mental Health Policy of India, Ministry of Health and Family Welfare, Government of India, 2014. Accessed August 18, 2021. http://nhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf
17. WHO. Mental health atlas 2011. Geneva: World Health Organisation; 2011. Accessed August 18, 2021. https://apps.who.int/iris/bitstream/handle/10665/119996/emropub_2013_ 1578.pdf
18. United Nations Convention on the rights of Persons with disabilities, 2006. Accessed August 18, 2021. https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html
19. Math SB, Basavaraju V, Harihara SN, et al. Mental Healthcare Act 2017 - Aspiration to action. Indian J Psychiatry. 2019;61(Suppl 4): S660-S666. doi: 10.4103/psychiatry.IndianJPsychiatry_91_19
20. Rights of Persons with disabilities Act, 2016. Department of Empowerment of Persons with Disabilities (Divyangjan), Ministry of Social Justice and Empowerment, Government of India. Accessed August 18, 2021. http://disabilityaffairs.gov.in/content/page/acts.php
21. Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res. 2007;126(3):183-192. PMID: 18037711
22. Petersen I, Marais D, Abdulmalik J, et al. Strengthening mental health system governance in six low- and middle-income countries in Africa and South Asia: challenges, needs and potential strategies. Health Policy Plan. 2017;32(5):699-709. doi: 10.1093/heapol/czx014
23. Mugisha J, Abdulmalik J, Hanlon C, et al. Health systems context(s) for integrating mental health into primary health care in six Emerald countries: a situation analysis. Int J Ment Health Syst. 2017;11:7. doi: 10.1186/s13033-016-0114-2
24. Shidhaye R, Raja A, Shrivastava S, et al. Challenges for Transformation: A Situational Analysis of Mental Health Care Services in Sehore District, Madhya Pradesh. Community Ment Health J. 2015;51(8):903-912. doi: 10.1007/s10597-015-9893-1
25. Kaur R, Pathak RK. Treatment gap in mental health: reflections from policy and research. Econ Polit Wkly 2017;52:34–40.
26. Arvind BA, Gururaj G, Loganathan S, et al. Prevalence and socioeconomic impact of depressive disorders in India: multisite population-based cross-sectional study. BMJ Open. 2019;9(6):e027250. doi: 10.1136/bmjopen-2018-027250
27. Jacob KS, Sharan P, Mirza I, et al. Mental health systems in countries: where are we now? Lancet. 2007;370(9592):1061-1077. doi: 10.1016/S0140-6736(07)61241-0
28. Goel DS. The National Mental Health Program: Problems, perspectives, possibilities. In: Public mental health: An evolving field. Ministry of Health, Government of India; 2011.
29. India’s budget for mental health leaves a lot to be desired. Only INR 400 million for National Mental Health Programme. Accessed August 18, 2021. https://mediaindia.eu/society/mental-health-budget-2021/
30. Mental Health, not a priority, fiscally. Accessed August 18, 2021. https://www.ha-asia.com/mental-health-not-a-priority-fiscally/.
31. Sharan P, Sivakumar T. Roadmap for the Future: What is Needed in the Region? In: Trivedi J, Tripathi A, eds. Mental Health in South Asia: Ethics, Resources, Programs and Legislation. International Library of Ethics, Law, and the New Medicine. Springer, Dordrecht;2015;263-277. doi: 10.1007/978-94-017-9017-8_15.
32. Saraceno B, van Ommeren M, Batniji R, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet. 2007;370(9593):1164-1174. doi: 10.1016/S0140-6736(07)61263-X
33. Wig N. Vision 2020: Roadmap for the future-II. Mainstreaming mental health. In: Mental Health: An Indian Perspective, 1946–2003. Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India;2004:341-343.
34. WHO. Mental Health Atlas 2017. Geneva: World Health Organization, 2017. Accessed August 18, 2021. https://www.who.int/publications/i/item/9789241514019
35. Kakuma R, Minas H, van Ginneken N, et al. Human resources for mental health care: current situation and strategies for action. Lancet. 2011;378(9803):1654-1663. doi: 10.1016/S0140-6736(11)61093-3
36. Trivedi JK, Jilani AQ. Pathway of psychiatric care. Indian J Psychiatry. 2011;53(2):97-98. doi: 10.4103/0019-5545.82530
37. Thornicroft G, Alem A, Antunes Dos Santos R, et al. WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care. World Psychiatry. 2010;9(2):67-77. doi: 10.1002/j.2051-5545.2010.tb00276.x
38. Jacob KS. Repackaging mental health programs in low- and middle-income countries. Indian J Psychiatry. 2011;53(3):195-198. doi: 10.4103/0019-5545.86798
39. Eaton J, McCay L, Semrau M, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011;378(9802):1592-1603. doi: 10.1016/S0140-6736(11)60891-X
40. Saxena S, Sharan P, Saraceno B. Research for Change: the role of scientific journals publishing mental health research. World Psychiatry. 2004;3(2):66-72. PMC1414672
41. Saxena S, Paraje G, Sharan P, Karam G, Sadana R. The 10/90 divide in mental health research: trends over a 10-year period. Br J Psychiatry. 2006;188:81-82. doi: 10.1192/bjp.bp.105.011221
42. Saxena S, Sharan P. Research for change: supporting mental health research in India. Natl Med J India. 2003;16(3):122-125.
43. Saxena S, Sharan P. Enhancing mental health research publication from low and middle-income countries. Indian J Psychiatry. 2004;46(1):72-78. PMC2912681
44. Sharan P, Gallo C, Gureje O, et al. Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean. Br J Psychiatry. 2009;195(4):354-363. doi: 10.1192/bjp.bp.108.050187
45. Goel D, Agarwal S, Ichhpujani R, Shrivastava S. Mental health 2003: The Indian scene. In: Mental health: An Indian perspective (1946–2003). Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India/ Elsevier;2004:3-24. Accessed August 18, 2021. https://mhpolicy.files.wordpress.com/2011/05/mental-health-e-book_published10oct20041.pdf