[Image by Utkarsha A Singh]
“I was a medical scribe in the emergency department with intentions of eventually becoming a physician assistant or a social worker. While I never constructed any plans to end my own life, I spent an alarming amount of time thinking about death and suicide itself. I was afraid of the fact that if my depression got any worse, I knew exactly how death was medically and physiologically accomplished. I never allowed anyone to suspect that I was in trouble because I needed to appear infallible and competent.”
–– Dr. Kevin Pho, in My double life: Mental illness in health care
Like him, many of us try to close our eyes towards negative thoughts by putting up a brave face to the world. Yet, the demon of mental illnesses stays put. Although the need for efficient policies is imperative, why should the government create policies for a non-communicable disease that might not manifest physically?
This question stems from a 2008–2013 WHO report on non-communicable diseases that included cardiovascular disease, diabetes, respiratory illness, and cancers. Mental illness found its position in a footnote that stated, “Mental health disorders are not included here despite the heavy burden of disease that they impose, as they do not share the same risk factors (other than the harmful use of alcohol), and because they require different intervention strategies.” However, research shows that non-communicable diseases have intertwining mental health issues. For example, about 50% of cancer patients suffer from depression and anxiety, which, when treated, can prolong the life of the individual. In an inverse scenario, patients with depression have a higher risk of developing cardiovascular diseases. Also, the treatment of depression in patients who have had a heart attack reduces the possibility of re-hospitalisation. The presence of depression makes patients vulnerable to type 2 diabetes.
Thus mental illnesses are not only isolated diseases but also act as comorbidities with other disorders. About 42.3% of corporate employees suffer from anxiety and depression, which may cause losses worth 1.03 trillion dollars to the Indian economy. These losses might result from absenteeism or a lack of productivity during working hours. In the face of such a staggering loss, India spent 1.3% of its gross domestic product (GDP) in 2015-16 on healthcare with around 0.06% of this healthcare budget on mental health. These are one of the lowest values in the world with countries like Bangladesh spending 0.44% of their health budget on mental health, whereas developed countries spend close to 5% of their health budget. The Indian government has promised to increase expenditure on healthcare from 1.3% to 2.5% by 2025. However, what percentage of it will be spent on mental health remains to be seen.
Infrastructure for mental healthcare
To estimate the cost of the services required for mental healthcare, policymakers need to have a clear idea of the extent of infrastructure and human resources required. A parliamentary questionnaire in 2019 revealed that India has only 43 government mental hospitals spread across 21 states. Among the union territories, only Delhi has a solitary mental hospital, while smaller states like Uttarakhand have none. The country houses ten centres of excellence in mental health and three central mental health institutions.
The mental health atlas put forth by WHO in 2017 stated that India has 0.29 psychiatrists for every one lakh individual. The number is worse for psychologists, with only 0.15 psychologists available for every one lakh individual. In all, 1.93 mental health workers are available per lakh population. Surprisingly only 49 child psychologists serve the entire country. In a single year, 11.1 visits per lakh individuals were conducted by healthcare workers in a community-based outpatient facility. The atlas also reports that the government provided school-based and anti-stigma awareness plans. However, there was no strategy for suicide prevention.
Recently, in a letter written to the Indian Journal of Psychiatry, researchers from NIMHANS point out that per lakh individuals, there are only 0.75 psychiatrists in India as of 2019. Although this number has risen since 2017, it does not come close to developed countries where there are three psychiatrists per lakh individuals. Going by this number, India requires about 2700 new psychiatrists per year to match up this deficit by 2029. Apart from the lack of doctors, the letter also points to the faulty monitoring system, which makes it very difficult to estimate the number of healthcare professionals within the country.
The Emerald countries
India falls within the low- and middle-income countries (LMICs) of the world. Rampant poverty and illiteracy make the residents of such countries vulnerable to mental health disorders. To combat these challenges, six countries –– India, Nepal, South Africa, Ethiopia, Nigeria, and Uganda –– volunteered for the Emerging mental health systems in LMICs’ (Emerald) program from 2012 to 2017. The program aimed to identify the mental healthcare problems faced by low- and middle-income countries and find solutions. It estimated the need for mental health facilities within the six participating countries with the view of economic sustainability. It also created a network between Ministries of Health and Finance, policymakers and planners, national and international development agencies, non-governmental organisations, researchers, patients and providers, and caregivers. Communication within different groups and assessments of the program by surveys and in-depth interviews was vital in generating a robust mental health policy. A massive policy change followed as a result of the Emerald program. For the first time since 1982, India revamped the mental healthcare plan, and introduced the Mental Healthcare Act, in 2017.
[Taken from Semrau et. al. (2015).]
Intervention by the government: mental health policies
The Government of India implemented the National Mental Health Plan (NMHP) in 1982. This plan aimed to provide minimum mental healthcare to all. It directed that knowledge about mental health must be applied in general healthcare, and the community must contribute towards the improvement of mental health within the country. The District Mental Health Program (DMHP) in 1996–97 followed the NMHP. This program further included points that would ease travel difficulties for patients, reduce stigma about mental health in society, and rehabilitate patients back into their regular life. A 2005 study on NMHP and DMHP revealed that there was a lack of enthusiasm within district heads to implement these programs. Even if the plans were implemented, there was a lack of health care staff and amenities.
The outcome of these plans manifested in the National Mental Health Survey of India 2015–16. It revealed that 10.6% or 150 million Indians suffer from mental distress and need active help. The burden of the disease is higher in the urban metropolitan areas than in rural areas. The majority of mental illnesses fall in the category of common mental disorders which affect 10% of the population. Lifetime depression affects 5% of the population, whereas substance abuse and alcoholism have a grip on 22% of the population.
With a growing population suffering from mental disorders, the government rescinded NMHP and introduced the Mental Healthcare Act of 2017. This new act laid the definition of mental illness. It recognised the rights of mentally sick patients to choose how they were to be treated, and decriminalised suicide. Commenting on the guidelines proposed by the new act, Dr. Abhishek Mishra and Dr. Abhiruchi Gahlotra from the Department of Community and Family Medicine, All India Institute of Medical Sciences, write,
“The new Mental Healthcare Act 2017 is supposed to change the fundamental approach on mental health issues including sensible patient-centric health care, instead of a criminal-centric one, in India, the second-most populous country and one of the fastest economies in the world. The guidelines need to be reviewed on aspects such as primary prevention, reintegration, and rehabilitation because without such strengthening, its implementation would be incomplete and the issue of former mental health patients will continue to exist.”
Apart from international and national mental health programs, multiple small-scale community-based schemes run in different parts of the country. The Vidarbha Stress and Health Program (VISHRAM), which began in 2011, aims at increasing mental health literacy within rural Vidarbha, Maharashtra. A survey conducted in 2013–15 showed an increase in awareness and a better knowledge of depression in rural Vidarbha, resulting in a larger number of people wanting to visit hospitals for mental health issues. UNARV was a district level mental health program directed at adolescents in Kerala from 2007 to 2012. This program addressed substance abuse and reduced suspension of students with conduct disorders.
The Atmiyata program targeted common mental disorders such as depression and anxiety in rural Maharashtra from 2013 to 2015. The project realised the lack of service for mental illnesses and the overburdening of public health workers. Thus a community-based approach was used where ayurvedic doctors and social workers provided necessary counselling and therapy sessions. This program also set up the Atmiyata mobile application (app) on an Android platform. The app has a list of films that individuals had to watch and answer a set of questions. The app provided information about the answers to the questionnaire to an atmiyata mitra (friends of Atmiyata), a pre-selected group of volunteers who were given preliminary training in identifying distress in people. The atmiyata mitra would then pass on this information to trained professionals for further evaluation. Overall, the program showcased the success of a community effort.
An enthused government effort in the form of the Mental Healthcare Act 2017 and a diverse set of mental health programs with their individual successes indicate our capability to improve. However, coordination and farsight can prevent these from merely being experiments conducted on a small segment of the population. Recently, India has promised to partner with the USA to exchange information in combating the mental health crisis. Via the agreement, signed in February 2020, the USA has agreed to share its mental health research with India, while it gains access to traditional Indian medicine and therapy to counter mental illnesses.
Dr. Bharat Vatvani, a leading psychologist and winner of the Ramon Magsaysay award, aptly commented on India, “There is hope, concern, and compassion for the mentally ill [but it is] misdirected.” There is a positive change in mental healthcare in India with an improvement of government policies and increased awareness through public outreach programs. Now, we need thorough research on the impact of these policies on mental health issues in India. In the last and final part of the series on Research Matters, we will cover the status of research on mental health in India.