India’s rumpled mental health crisis: Pearls and Pitfalls

Making mental health and wellbeing for all a global priority is the designated theme of the World Mental Health Day 2022. India's aspiration to achieve global mental health education, awareness, and advocacy against social stigma remains untapped. 

Representational image of a depressed person | Photo courtesy: Special arrangement

The onset of Covid-19 has paved the way for an increased global disease burden in terms of depression, anxiety, stress, and other neuropsychiatric diseases. There has been an escalating concern over India's approach towards public mental healthcare and outreach services. The general attribution often points fingers at India's rumpled mental health interventions. However, it is important to comprehend that in the microcosm, the mental health crisis in India is perplexing due to a lack of interconnectedness with the larger socio-political and ethical public policy formulation. For instance, so far, the lack of political will to allocate sufficient funding towards mental health in the country remains unresolved. 

National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru | Photo courtesy: Nimhans

According to the mental health survey (2021) conducted by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, 10.2 per cent of India's population suffers from diagnosable mental health problems. The pandemic has further widened the treatment gap in the Indian context, and there is a significant spike in the number of cases with psychological concerns. This has given rise to two broader issues in public mental health. Firstly, there are methodical concerns over how psychiatric epidemiology is conducted, and this calls for a deviation from the existing medicalisation of mental health problems. Secondly, there is a dire need for an effective and efficient mental healthcare system in a diverse country like India.

The digitalisation of mental healthcare and telepsychiatry got some needed focus as part of the union healthcare budget 2022. In this line, the central government has proposed two aspirational programs – the National Tele Mental Health Program (NTMHP) and the National Digital Health Ecosystem (NDHE). 23 tele mental health centres will be launched as part of the NTMHP, and NIMHANS, Bengaluru, will serve as the nodal centre. The tele mental centres envisage providing mental healthcare services and counselling to underserved regions, especially in rural areas where there is sporadicity of mental health infrastructure. 

These tele mental health centres could be handy in providing basic counselling for people suffering from mild forms of psychological distress and facilitate emergency care and interventions. For instance, Chinese mental health services made use of apps like WeChat, Weibo and TikTok for education and self-help interventions during the Covid-19 outbreak. The Australian government allocated additional funded services (via Medicare Benefits Schedule) for ensuring telehealth services. The program failed to provide access to wider sections of the population. Similar concerns and questions corner India's public health agenda.

National Tele-Mental Health Programme, Government of India | Photo courtesy: PIB

The union budget's emphasis on NTMHP appears as a paradigm shift in the domain of mental healthcare. It could be a timely and desirable solution to treat common mental disorders by making provisions for accessible mental healthcare services in the country. However, the announcement of NTMHP has further created a bisect amongst the professionals in the mental health fraternity for various reasons.

Financing healthcare, especially finance for mental healthcare, is crucial for India to achieve its public health agenda (especially for achieving Sustainable development goal number 3: target 4). The union budget 2022-23 has allocated a total of Rs 86,200 crores for the health sector, and there is a mere 0.2 per cent increase from last year's allocation.

The inclusion of mental healthcare with a 10 per cent increase in the health budget by 2020 has been India's unmet budgetary need. The onus of devising appropriate policy-driven mechanisms in terms of delivery and management, rationalising its systemic functions, equipping and upskilling the providers of care to achieve the mental health well-being of diverse stakeholders lies within the ambit of India's public mental health agenda.

India suffers from inadequate infrastructure, a lack of mental health professionals, a funding crunch, and insufficient cohesiveness in the planning and implementation of mental healthcare policies. A comprehensive understanding of the landscape of mental health and the status quo of the existing mechanisms, especially in terms of gaps in mental health, services, and measures, is crucial for formulating the future roadmap of mental healthcare in the country. 

The full spectrum of mental healthcare would involve the steps of identification, diagnosis, treatment, promotion, prevention, referral, and rehabilitation. For instance, most programmatic approaches in India often focus on sensitisation, identification, or treatment; but rehabilitation as a core function of mental healthcare is often neglected. Such ill-defined approaches form a significant gap in India's mental healthcare.

Certainly, some concerns must be addressed if India aspires to reach its public mental health outreach agenda. Aligning and framing systemic connections between mental health, its services, and its measures with that of the outcome is critical to have an efficient and effective mental healthcare system in India. India's health governance and administration must reassess the role and function of health institutes within its healthcare system, redefine the role and functions of auxiliary services, and make general hospitals, psychiatric hospitals, and primary care units more accountable for mental healthcare delivery.

Unfortunately, mental healthcare in India is treated in isolation, and there is a greater need for multi stakeholder involvement. For instance, higher education institutions could act as a good starting point. While the national education policy 2019 recommends holistic development of students, the decision-making bodies in the higher education sector need to stop teaching and providing standalone courses in psychology. In addition, higher education spaces should largely tackle the existing rudimentary understanding of mental health concerns and disseminate, train, and educate varied stakeholders. There is greater scope for introducing multidisciplinary approaches to such existing courses and devising appropriate pathways for practical implementations. 

Mental health well-being is often interlinked with development factors such as poverty, work, crime and violence, economic growth, peace, and justice. As a way forward, India should conceptualise a robust mental health system that ensures achieving outcomes in terms of accessible, effective, equitable and accountable care and delivery mechanisms for diverse stakeholders across India. For instance, digital integration for NTMHP could enable tools to provide equitable, accessible, and responsible (e.g., data-driven measures) mental healthcare for all sections of the population. Digital integration could surpass barriers of location (urban/rural/tribal), socioeconomic background, age, and gender. Digital integration could act as a driver to access mental healthcare and aid in addressing pre-existing systemic issues of stigma, isolation, discrimination, and violations of human rights while providing mental healthcare.

Further, if India must achieve well-being as part of its public mental health policy, it must devise or strengthen alternate mechanisms like public-private partnerships, community-based mental health services, the creation of a sustainable workforce, and support systems for NGOs and volunteers for better outreach and outcome. Such a holistic conceptualisation, assessment of the performance and learnings from the processes are critical for ensuring pandemic recovery and bringing closure towards India's mental health endemic.

Ajay Chandra is a Research Fellow at the Ramaiah Public Policy Centre, Bangalore. His areas of specialisation are mental health, policy analysis, educational psychology, education of the gifted and talented, and higher education. 

Dr Chetan Singai is an Associate Professor at the School of Social Sciences, Ramaiah University of Applied Sciences. He works in higher education, university governance, policy formulation, public health and developmental studies. He has been nominated as Member-Convenor to the Sub-Committee to draft the Implementation Roadmap on Governance and Regulation in Higher Education aligned to the NEP-2020 by the Government of Karnataka.