From care to cure

The treatment and rehabilitation of mentally ill patients is at the heart of Udaan, a unique endeavour with multiple dimensions

Iwish I can have a normal life, wear good clothes, maybe get a small job and live independently like others.” Asha Meghe’s* backstory makes that yearning seem forlorn. Or perhaps not.

Life can be hard, and harder still without luck. Ms Meghe has had too much of one and precious little of the other. Home for her is the Regional Mental Hospital in Nagpur (RMHN), and it has been so for 38 long years. She got admitted to the place when she was about 12, two summers after being separated from her family, she says. The in-between period, Ms Meghe adds, was what made her lose her mental equilibrium.

“I used to roam the streets; nobody gave me food and I was too exhausted,” says Ms Meghe of the time leading up to her ailment. “I approached a house one day, begging for something to eat. The people there fed me and allowed me to work there. But they used to abuse me verbally and physically. That’s when I became mentally unstable.”

Helping Ms Meghe and people like her regain their sanity — and their dignity — is the intent driving Udaan, a Tata Trusts programme that has set new standards in the care and treatment of India’s mentally disabled. Initiated in 2016 and now in its second phase, this is a collaborative effort with the Maharashtra government that takes in institutional reform, community-based mental health services, technical support and individual patient care of the kind that may yet bring Ms Meghe the ‘normal life’ she craves.

Udaan began with a comprehensive initiative that has transformed RMHN, a colonial-era relic then in dire need of an overhaul. The programme has played the role of enabler in effecting just that. With patient welfare and recovery as the focus, the institution has come through an inclusive and broad-ranging process of remodelling and modernisation. The objective was to turn RMHN into a centre of excellence and learning.

Refurbished wards, day-care centre and half-way home, automated data management for patient tracking and treatment, an emphasis on cleanliness and personal hygiene, televisions and phones in the wards, movie club, library and meditation room, gym equipment, open spaces, dance therapy and art sessions, hair salon and beauty parlour, a buffet system for meals, in-house farming, coloured clothing instead of drab uniforms, competitions and even fashion shows — RMHN has gone the distance and beyond with its recasting agenda.

Embedding empathy

Crucial here has been the embedding of empathy in the way patients are cared for and treated. This could not have happened without the committed participation of the hospital’s staffers, ward attendants as much as nurses, in the exercise. Training, based on revised care protocols, and capacity building have been important in the context. Included in the reforms package was a cleaning up of patient records, which are now organised and archived properly.

The ‘district mental health programme’ (DMHP) in Udaan is wider in scope and with the potential for greater impact than what has been attempted at the hospital. Launched in early 2018 and deployed in seven subdivisions of Nagpur district, DMHP is a community-based module through which more than 300,000 people have been screened for mental ailments. Conducted door-to-door, the idea is to fuel awareness of mental health issues in rural communities, detect those who need help and provide treatment close to the patient’s home.

DMHP is cast in a mould that makes it implementable in the rest of Maharashtra and across the country. The programme’s delivery mechanism depends on the state’s public health system at the district level. With local government hospitals tapped to offer treatment and medicines, a mental health helpline, day-care centres and half-way homes, data management, and psychiatrists who also function as trainers and mentors, the programme has a host of elements to extract the best outcomes.

Udaan also has a ‘technical support unit’, including training packages for health workers and data analytics, to aid the government in crafting an integrated mental health package that improves the availability and quality of care for the state as a whole. This component has gained in traction but not satisfactorily enough. Its promise is not in doubt, though.

What has flowered, particularly over the past year, is the individual care package for patients at RMHN. Need based and intensive in nature, the approach here is holistic. Patients receive pinpointed attention to reduce disability and promote independence in thought and movement. The end goal is the psychosocial rehabilitation of randomly selected sufferers and their reintegration into society.

Employing established principles of case management, the package is designed for those who have been living in a mental institution for long. The concept is simple: enable individual patients to develop their abilities and renegotiate their space in a hospital environment.

Well-trained case managers are of the essence to make the method work. Among the elements involved are accommodation, safety and food, social relations, symptom management, connecting with family, occupational and financial inclusion, emotional and physical wellbeing, leisure activities and life skills.

Debris of disconnect

This may all sound straightforward enough, but wresting success with those whose minds are filled with the debris of disconnect is demanding in the extreme. The work is punishing and returns are uncertain even when every protocol of therapy is followed. “Individual case management is one of the toughest assignments I have done as a professional,” says Archana Lade, a case manager with Udaan. “It is hard work but you can see the difference in the patient. And that can be huge.”

More than 100 patients at RMHN have benefitted from the individual care package. The basis for their recovery and healing is the relationships they have formed with their case manager. Building such relationships can be exacting, given the convoluted trajectories of severe mental illness and the experiences and vulnerabilities of those who have to live with it, not least poverty, social disadvantage and, frequently, abuse.

Udaan has come a long way, but there are many miles left to be covered before the slated end of its timeline in December 2022. As with much of the world, the Covid-19 pandemic has slowed everything down. “Ours has been a steady upward journey,” says Tasneem Raja, who leads the programme. “We have almost completed all the clinical processes and the structural reform. The patient half-way home at RMHN is up and running, as is the family ward. And we are on the verge of adding a bakery and a day-care centre.”

What remains is the integration into the community of long-stay patients. That’s part of the individual care package and far from easy to pull off in a jiffy. “For patients with severe mental illness, you need a one-on-one interface,” explains Ms Raja. “This was very, very difficult and challenging at the start. But then the changes [in patient behaviour] began happening and our team experienced some extremely emotional moments.”

Ms Raja is more than hopeful that the lessons and voices emerging from Udaan will be heeded, and not merely in Maharashtra. With close to 200 million of its citizens suffering from some form of mental illness — depression accounts for about a quarter of cases — India as a whole can benefit too, from implementing what is a unique and proven endeavour that has produced tangible results.

“There is no reason why Udaan should not spread,” says Ms Raja. “The time is opportune because, very clearly, mental ill-health is a fallout of the coronavirus outbreak. It also helps that a lot of resources are flowing into the mental health sector from philanthropies and the like.”

An Udaan team member (left) on a home visit in Sukali village in Nagpur