5.11 Mental health care

5.11 Mental health care

The Directorate of Mental Health is the national-level focal point responsible for the National Mental Health Programme within the MoH, Sri Lanka. The Directorate is responsible for policy development and strategic planning, coordination, supporting implementation and monitoring and evaluation of mental health services in the country. A Mental Health Act has been under deliberation since 2005. After years of multiple drafts and competing interests, a diverse task force consisting of representatives from the MoH, WHO, Sri Lanka College of Psychiatrists, NGOs and other stakeholders have compiled a draft act, and this is being reviewed currently prior to finalization. The Act will replace the present Mental Diseases Ordinance of 1956.

The National Mental Health Advisory Council (NMHAC) was established in 2007 to advise the Director Mental Health. The Secretary of Health was appointed as the Chair with the DGHS as the convener, and consisted of a diverse, interdisciplinary team with both technical and administrative expertise. Within a couple of years, it was reconfigured as the National Committee on Mental Health, chaired by the DGHS and convened by the Director Mental Health.

The mental health sector provides its services through a multidisciplinary team consisting of consultant psychiatrists, MOs of mental health, psychologists, counsellors, occupational therapists, speech therapists, physiotherapists, psychiatric social workers and community workers. Over the past 15 years, there have been major gains in HR development for mental health across all cadres to support the growing demands on services.

At the district level, an MO Mental Health is the focal point. The MO assists the Regional Director of Health Services and coordinates all mental health services within the district, having a close linkage with the national level, district health team and all other relevant departments and community groups. Within a district, services are provided through a network of medical institutions and health units.

A major shift has occurred in the level of organization of services, from institutionalized mental health-care delivery to care in smaller facilities and outpatient care closer to people’s homes. In 2007, the main mental hospital located at Angoda was restructured into the National Institute of Mental Health.

There are seven tertiary-care hospitals in Sri Lanka with facilities for acute psychiatric inpatient care. In addition, acute inpatient units are currently available in 23 of the 26 districts and in few regionally managed institutions.

Presently, there are 61 adult inpatient units, three child inpatient units and one forensic unit in the country.

Medium-stay units were available in only five districts in 2004, which has now expanded to 15 districts. Outreach clinics currently exist in almost all MOH areas. In addition, community support centres are being set up at district level to serve as hubs for the promotion of mental well-being.

Outpatient care is provided through specialist, divisional and outreach clinics. Mental outreach clinics provide close-to-home services that enable better care and follow up of clients, and reduce the treatment gap. These clinics support continuity of care, assessment, treatment and home visits. They are conducted by the MO Mental Health or MO Mental Health Focal Point or Consultant Psychiatrist. Home visits are mainly for tracing defaulters and providing assistance to their carers. Home visits are done by a team consisting of an MO, nursing officer and psychiatry social worker.

The main hospitals that specialize in child care, Lady Ridgeway Hospital in Colombo and the Sirimavo Bandaranayke Specialized Children’s Hospital in Kandy, address child mental health needs. In addition to the regular outpatient clinics and inpatient services, the Lady Ridgeway Hospital for Children and the Colombo North Teaching Hospital conduct specialized programmes to address specific learning disabilities (SLDs), attention deficit hyperactivity disorder (ADHD), early intervention for autism spectrum disorder (ASD) and family support for children with behavioural disorders. To make child care services available at the district level, the Directorate of Mental Health has promoted child psychiatry outpatient clinics in all DHs. Currently, there are four child and adolescent psychiatrists working in four districts, addressing promotive, preventive, clinical and rehabilitative care for children and adolescents.

The number of mental health rehabilitation centres in Sri Lanka has grown from one in 2000 to 22 in 2017. These include medium-stay (6 months) and long-stay (1 year-plus) rehabilitation centres. Medium-stay units provide services to individuals who do not require intensive medical interventions but need further treatment and support to develop life competencies to live productively in society. An important part of rehabilitation is occupational therapy that builds life and vocational skills. The rehabilitation centres focus on the client’s learning of daily life skills such as self-care, cooking and cleaning. Most of these centres are hospital based and their management may differ from one district to another. In addition to these government rehabilitation centres, NGOs such as Nest and Sahanaya have their own facilities.

The mental health programme also addresses the issue of gender-based violence (GBV). GBV desks and mithuru piyasa centres have been set up and are being managed in tertiary-care institutions in selected districts. They collaborate with other relevant services such as the police, social services, child protection, probation, legal/justice, education and NGOs.

Deaddiction rehabilitation units (alcohol rehabilitation centres) are another initiative to combat the increasing use of alcohol. There are seven centres, located in Gampaha, Kandy, Jaffna, Batticaloa, Kurunegala, Badulla and Killinochchi. The client-centred model of rehabilitation provided in these centres requires voluntary admission; however, they may be encouraged and motivated to enrol by community workers and mental health professionals. Rehabilitation activities include play therapy, group therapy, counselling, gardening, religious programmes and family interventions.

Responding to mental health needs during emergency situations is another area that has evolved satisfactorily over the past few years. Mental health teams, other community officers and volunteer groups provide psychosocial support for victims of natural disasters and in emergency situations. The Directorate of Mental Health has trained teams of master trainers and established them in all vulnerable districts. During disasters, the Directorate of Mental Health mobilizes these teams to train the staff of affected areas and take action to provide psychosocial support to the community.

“Consumer and care groups” is a nationally widespread concept. There are about 70 groups representing most districts. Ten of them are registered as non-profit entities. The Consumer Action Network Mental Health Sri Lanka (CANMH Lanka), which operates from the National Institute of Mental Health, is one such successful organization. The Network was established for the collaboration of people affected by mental health issues and their carers to advocate for a secure mental health system.

District review meetings act as a platform for the Mental Health Directorate to monitor and guide service provision. These meetings review district mental health services (gaps and challenges), outreach clinics, school programmes and other initiatives carried out in the district. Further, mental health-related guidelines that are developed at the national level are customized and implemented at the local district level through this platform.