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Proposal for proper functioning of full-fledged Institute of Mental Health and

Neurosciences (Center of Excellence) and Drug De-addiction centre, Government
Medical College Srinagar.

Burden of Mental Illness

Globally, mental health disorders are among the leading causes of illness and disability. Mental
illness leads to decreased productivity and has a negative impact on the quality of life of affected
individuals and their families. Annually, over 450 million people worldwide experience mental health
disorders, but few seek access to services. For the past decade, the high burden of mental illness in
the Kashmir Valley has been reported by mental health practitioners and in empirical literature.
Institute of Mental Health & Neurosciences-Kashmir, in the valley’s capital, Srinagar, has
experienced an increase in outpatient presentations, from an average of 100 per week in 1980 to 1000
per week in 2017. The community center SMHS also sees a huge rush of psychiatric patients across
all ages, almost 200 patients visit this facility on daily bases. The common psychiatric diagnoses are
depression, anxiety disorders, bipolar disorders, psychotic disorders, substance dependence etc. A
literature review of different studies conducted in this direction show the following statistics.
A recent study conducted by Actionaid india indicates that 11.3% of adult population suffers from
mental illness in the valley. This prevalence is significantly higher than the Indian national average of
7.3% (Ganguli, 2000). The study finds that the prevalence of mental health disorders was more in
females (12.9%) than males (8.4%). It was also more among those who were not educated (12.7%)
than those who had attained education up to high school (12.8%) or higher levels of education
(8.7%). The prevalence was also significantly higher among those who were either divorced or
separated or widowed (14.7%) than those who were married (12.1%) or never married (8.7%). The
prevalence of mental health disorders also showed a clear class gradient, higher among those who
were poor than those who were better off. 13% of those who reported to have no land holdings at all
suffered from some mental illness, while as 11.5% of respondents who had 1 to 8 Kanals of land (1
acre) had mental illness. In contrast a significantly lower proportion of 9.1% of those who had more
than 8 Kanals of land had any mental illness. This was corroborated by findings across ration-card-
type categories with significantly higher presence of mental health disorders among AAY ration card
holders (16.3%) than BPL (10.8%) and APL ration card holders (10.2%).
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In 2005, in a cross-sectional survey of 548 individuals in the districts of Kupwara and Badgam,
De Jong et al. reported a prevalence rate of 33% for psychological distress.1 (12) In a study involving
3000 individuals from all districts in 2006, Margoob and Ahmad estimated a point prevalence of
7.3% for PTSD2 and a lifetime prevalence of 15.2%. (13) In 2009, Amin and Khan reported an
estimated prevalence rate of 55.7% for depression in a study of 2728 individuals across all districts of
the valley.3 (14) Consistent with reported high prevalence rates of mental distress in the population, a
retrospective study on suicide conducted by Shoib et al. recorded an increase of over 250% in the
number of suicide attempts between 1994 and 2012. (15) .From the hospital OPD record database it
is inferred that psychiatric patient attendance increased manifolds from 1985 to 2017.The attendance
was only few hundreds in 1985 and it has escalated to 1,30,000 in 2015(both hospitals).(Nissa
,2015).This certainly indicates a steep increase in number of psychiatric patients who sought
psychiatric services. This sudden increase in mental illnesses in the valley remains a fact and has
been corroborated from research findings from different studies

Burden of drug addiction

Drug abuse being a multidimensional problem involving social, legal, economical & medical issues is
eating on the very social fabric we are bound with, creating havoc with our rising crime rates and
becoming one of the common emergencies in hospitals. More alarming is the way it is making the
present youth nonproductive entities of the society in the long term. Loss of family is difficult to
quantify, the emotional trauma, shame, and grief resulting from and the frequent threat of violence
and subsequent separation destroys the family system. Scientific data based on community surveys
on drug related problems in Kashmir is indicative of epidemic proportion of substance use, e.g.,
estimating opoid use as high as 3.8% in adult males (Margoob et al.).Deaths have started occurring
directly (due to over dosages, convulsions, and cardiac arrests) and indirectly (road traffic accidents).
It is worthwhile to mention from epidemiological point of view that when deaths start occurring,
epidemic is on.
As is evident from extensive research, clinical experience, media reports and reports of law enforcing
agencies, there is an epidemic of drug abuse in Kashmir. Drug abuse has reached every nook and
corner of Kashmir; places where bus doesn’t go, drugs of abuse reach.
This whole scenario is compounded by absence of any scientific based facilities whatsoever
for treatment of these patients which means existence of a detoxification and de-addiction center as
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per the set guidelines and principles under the professional care of a multidisciplinary team of
psychiatrists, clinical psychologists and psychiatric social workers.
The department of psychiatry has always been at the forefront of different activities
aimed at eliminating the menace of drug abuse from our society and has been carrying out
deaddiction services amid very difficult conditions The department also runs a drug de-addiction
centre located at community general hospital unit SMHS Srinagar. The Postgraduate department of
Psychiatry of Institute of Mental Health and Neurosciences as an institute attached to Government
Medical College Srinagar has been the nodal centre for drug de-addiction treatment for last more than
one decade. The institute started in patient drug de-addiction services from 10/2004 with existing
staff, and infrastructure as per order No. PSMC/1070-74 dated:-11.10.2004. Since the inception of
drug deaddiction centre the number of drug addicts has increased manifolds and the centre is under
extreme duress because of shortage of manpower and limited infrastructure. Considering these
limitations the department has already requested for up gradation of its manpower and its
infrastructure .A detailed proposal for establishment of full-fledged drug de addiction centre was
submitted to the department of Health & Medical Education, Govt. of Jammu & Kashmir from the
office of Principal/Dean, Govt. Medical College, Srinagar vide No.MC/Plan/DDC/Staff/3366-69
dated:-3.01.2004 followed by proposal for up gradation of drug de-addiction Centre vide
No.PA/HOD/PSY/2004/605 dated:-29.11.2011 and proposal for drug de-addiction centre cum status
report furnished to the state Govt. in 2007 vide Principal/Dean, Govt. Medical College, Srinagar
No.MC/Plan/PSY/DDC/1740 dated:-24.8.2007.

Existing Infrastructure and manpower shortage

Department of Psychiatry, Govt. Medical College Srinagar has been running two hospitals;
Government Psychiatric Diseases hospital at Kathi Darwaza which is 100 bedded hospital and
Community General Hospital SMHS Srinagar with admission facility of 40 patients excluding the
emergency beds. Till now the department has been rendering both inpatient and outpatient services at
Government Psychiatric Diseases hospital and at the Community Centre located at SMHS hospital,
Srinagar. In addition to de addiction services, Community General Hospital Unit provides
Consultation & Liaison psychiatry services to associated hospitals of Government Medical college
,Srinagar. There are also specialized clinics such as child Psychiatry clinic, Women’s Mental Health
Clinic and Geriatric Clinic running at this centre. The department has 8 MCI recognized MD
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Psychiatry seats and 8 M.Phil Clinical Psychology seats recognized by MCI and RCI respectively
annually , besides that the department also trains students pursuing BSc & MSc Nursing, Masters in
social worker and Masters in Psychology from various institutes of the state. The number of patients
seen at Institute of Mental Health & Neuroscience at Kathi Darwaza and Community General
Hospital Unit during April 2014 to Dec-2017 was as under:

Patients seen at Institute of mental Health and Neuro-Sciences, Kashmir

YEAR OPD IPD
2014-15 133495 1187
2015-16 74496* 1084
2016-17 102539 1271
Total 310530** 3542**

*The decreased number is due to the continuous strikes, hartals and curfews
**Data does not include OST patients and short stay admissions

A glimpse from our hospital data base reveals the following statistics:-
Substance Abuse/Dependence Patients Seen At Institute Of Mental Health & Neuro-
Sciences, Kashmir
YEAR OPD IPD
2014-15 3114 227
2015-16 3395 245
2016-17 2157 175
Jan-2017 To Dec-2017 3000 200
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Substance Abuse/Dependence Patients seen at Community Centre, SMHS Complex

Srinagar.
YEAR OPD IPD
2014-15 694 119
2015-16 1263 203
2016-17 535 212
Jan-2017 To Dec-2017 710 408

District wise Admissions at Community Centre SMHS Complex from (Jan-2017 to Dec 2017)
District No Of Admitted Patients
Srinagar 185
Budgam 43
Pulwama 24
Shopian 15
Anantnag 39
Kulgam 11
Gandarbal 07
Bandipora 14
Baramullah 40
Kupwara 25
Jammu 04
Ladakh 01
Total 408

Pattern of Admissions at Community Centre, SMHS Complex Srinagar.

(From Oct-2017 to April-2018)
Substance No Of Admitted Patients
Multiple Addictions 76
Opioids 72
Cannabis 68
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Sedatives 42
Alcohol 22
Tobacco 15
Solvents 06

Evolution of this hospital

Our hospital which was an erstwhile asylum has now evolved in centre of excellence but what is
saddening is the fact that its manpower has remained the same without any additions .After the
hospital was gutted down ,the department mobilized different NGOs and stakeholders and new wards
were raised and basic services were started and slowly but steadily the department rose from the
ashes and applied for centre of excellence in 2007 .After repeated representations and presentatios the
centre was finally recognized as centre of excellence in 2009 among 8 other centres across India .In
2011 a separate community general hospital unit was established uner NMHP keeping in view the
WHO vision and integration of mental health services with general health services. A separate drug
deaddiction centre was established in 2011 in the same general hospital unit. The funding was used to
develop infrastructure and now we have new hospital block with different facilities. We have brain
imaging unit, neuromodulation unit, closed wards, open wards, safe rooms, auditorim ,Recreational
unit, opd block, library block, laboratory block, child psychiatry unit, drug deaddiction centre and
geriatric psychiatry unit. The department had two functional units for smooth delivery of patient care
till recently but now the department has expanded to four functional units. Out of the four units, three
units work in psychiatric diseases hospital and one unit works in deaddiction centre for exclusive
drug deaddiction services. The department delivers a lot of services at its two hospital units and in
addition to that it also delivers community outreach services in form of community outreach camps,
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awareness programmes, drug addiction camps, smoking cessation programmes. The department also
delivers psychiatric services in central jail srinagar and also childhood psychiatric services in
paediatric hospital srinagar. It also delivers consultation liaison services to other allied medical
specialities. It is pertinent to mention here that this is unparalleled centre in whole of north india as
there is no such second centre in north india which delivers such integrated services .It replicates
NIMHANS Bangalore in such an integrated service delivery but what is saddening is the fact that it is
not possible to manage these units and give such exhaustive services simultaneously with the existing
manpower .This extensive service delivery has put the department under severe duress because of
acute shortage of manpower and with ever increasing mental illness prevalence. The department
needs more mental health professionals across different positions for smooth delivery of psychiatric
services. The department has many times requested the Govt. and has sent detailed proposals for the
same but nothing substantial on ground has happened so far. We again submit that for smooth patient
care the department needs further staff which is given below in deficiency column of the below given
table.

JUSTIFICATION FOR HUMAN RESOURCE REQUIREMENT

1. As endorsed by the Honourable Chief Minister the role of Institute of Mental Health and
Neurosciences, Kashmir an Associated Hospital of Government Medical College, Srinagar as a
Nodal Agency with following mandate:-
a) Will serve as apex training Centre.
b) Coordination and linkage with all other stake holders.
c) Research & training of manpower.

i. Quality teaching of students.(pgs, ugs )etc

ii. Capacity building and human resources development by organizing different training
programme for medical professionals, academicians (Teacher, Anganwari Workers, Asha
Workers)
iii. Development of treatment protocols based on latest guidelines.
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iv. Sensitization for bureaucracy and judiciary regarding substance use.

d) Providing of round the clock helpline (manpower support from State Government)

e) Provision of Mobile De addiction Unit (manpower support from State Government)

f) Management of all complicated cases of patients having multiple medical or psychiatric

commodities.

g) Continuous liaison with other medical specialties for the same.

h) Creation of data-base on patient characteristics and patterns of different psychiatric issues

including drug abuse, presence of morbidity and new trends in drug abuse.

i) Will look after the work of different sub-centres and different people working in the field.

j) Will entertain all the referral patients from different quarters including District Hospitals
community hospitals and different NGO’s.

k) Will be in continuous two way communication with different stakeholders. It will communicate
vertically to Government officials and different Government Departments and horizontally to
different NGO’s Organizations.

2. The postgraduate department of psychiatry of Institute of Mental Health and Neurosciences as an

institute attached to Govt Medical College Srinagar has been the nodal centre for drug de-addiction
treatment for last more than one decade. The centre has facility of OST in collaboration with NACO
and is also involved in Drug Abuse Monitoring System (DAMS) in collaboration with AIIMS, New
Delhi. However, the shortage of manpower has been a prime issue in service delivery. Upon
approval of present project, this centre will be in a good position to deal with the huge rush of
addiction problem and moreover it will be centre for capacity building i.e. manpower production and
scientific research. It will also be a facilitation centre between administrative planning and service
delivery.

3. The faculty positions are guided by the MCI guidelines and bed strength. Our department being
a post graduate department in psychiatry upgraded by the central government funding to one of the
institutes of mental health and Neurosciences with a mandate to train and teach and produce
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manpower in mental health for the whole state. Currently the department is producing 8 MDs in
Psychiatry which is likely to get upgraded as per new MCI relaxation to 10 MDs per year. We also
run M Phil courses in clinical psychology producing 4 clinical psychologists every year. The
department has 150 beds in offing which means 5 MCI units with minimal requirement of four
Professors (including Professor in charge undergraduate teaching), five Associate Professors , five
Assistant professors and ten lecturers.The department needs more faculty members for smooth
delivery of psychiatric services in the hospital.

4. Clinical Psychologists might work in a number of different health facilities. This can include
hospitals, physical therapy centres, long-term care centers, drug and alcohol rehabilitation centres,
psychiatric hospitals, and mental health clinics. Psychologists belong to a scientific field of
Rehabilitation Science which focuses on the application of Psychological Knowledge and Skills on
behalf of Individuals with Disabilities, Chronic Health Conditions, Substance Abusers and Alcoholics
etc. in order to maximize health & welfare, independence & choice, functional abilities and social
roles. Psychologists are working as counsellors, therapists, researchers, policy makers and
administrators in multiple areas of Rehabilitation. Their primary duties would include counselling
and other psycho-social interventions at the outpatient and inpatient level. The role of Psychologist is
important in the rehabilitation process of different psychiatric patients including drug Addicts. They
would form the mainstay of the psycho-social interventions and would also be responsible for the
motivation of patients and their psychological rehabilitation. They are experts in Psychological
Assessments, Interventions, Advocacy & Sensitization Programs for Persons with Multiple Needs of
Rehabilitation, families, Training & Awareness Programs for Community, Professionals and other
stakeholders.

5. Social workers and outreach community workers are the very important category of staff at the
hospital particularly drug deaddiction centre. They could also be involved in making education
material including posters and leaflets. Community outreach services including service delivery,
awareness generation and motivating patients. Preventive Education and Awareness Generation
programme should address specific target groups (vulnerable and at risk groups), educational
institutions, workplace, and social welfare organizations with the purpose of sensitising the
community about different mental illnesses, addictions , and the need to take professional help to
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treat them. The programme needs to specifically focus on children and youth, in and outside
educational institutions.

6. Indian Nursing Council norms require 1 staff nurse for every 5 beds in a hospital. For a 30 bedded
unit of a hospital, this translates into 6 staff-nurses. However, at least additional 4 more staff-nurses
are required for round the clock patient cover during night in a dedicated unit. Thus, 24-hour
coverage of the ward will be done by 10 nurses. In the ward the nurses are expected to carry out
various functions including dispensing medicines, keeping a record of various patient parameters,
ensuring cleanliness and provide basic counselling. While the nurses from the general pool of nurses
at the hospital can also be posted at the DAC, it would be advisable to post them permanently once
they have receive specific training on substance use disorders.

7. For monitoring and auditing the dispensing procedure of medicines. It must be remembered that
some of the medications used for treatment possess abuse liability and risk of diversion. Only
authorised persons (pharmacist/Nurse) must be allowed to handle / dispense medicines.

8. At a minimum level all patients attending de-addiction treatment services should be registered in a
dedicated register and should receive a unique registration number. This service will be linked to
Drug Abuse Monitoring System (DAMS) of AIIMS New Delhi. As of now all the cases attending the
De-addiction unit at SMHS are linked to DAMS, although the paucity of staff is a hindrance in
delivering the services as per requirement.

9. While most hospitals are expected to have a central registration system, the same applies to our
hospital as this would be important for monitoring and evaluation purpose. A de-addiction centre
would require an exclusive record section of its own. For this, there must qualified staff in the form
of Medical Records Technician. Technician will perform tasks like: maintaining records and filing,
running the registration, accessing records and delivering them to the doctors.

10. Security guards

The above mentioned category of the staff would be required exclusively for manning the de-
addiction centre and running the centre smoothly. The exclusive duties of security staff would be
frisking of the attendants/Visitors and patients and to keep a check on the activity of drug peddlers
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around the de-addiction centre , as there is always a risk of increase in movement of drug peddlers
around the de-addiction centres.