Mental Health: Current Issues and Challenges in India

The World Health Organisation defined “Health as a state of complete physical, mental and social being and not merely absence of the disease or infirmity”. It is very vital for the growth, development and productivity of a society. There is no health without mental health as it is the integral and essential component of health. Mental disorders are known to be caused by a complex interaction of biological, social, environmental, cultural and economic factors. A close association between mental disorders and several other morbid conditions or diseases was shown by different studies. For example, depression and cancer are known to coexist, while anxiety disorders are linked to the occurrence of cardiovascular disorders. Non-recognition of associated mental health problems often leads to delayed recognition and recovery. Mental disorders are gradually on increase in recent times. This is probably due to industrialisation, rapid urbanization, globalization, changing lifestyles, acculturation, improved recognition, and biological vulnerabilities. Consequently, depression, anxiety, alcohol use, suicidal behaviours, drug use, sleep disorders and several others are on the increase.

It is estimated that 6-7% of population suffers from Mental and behavioural disorder. Together these disorders account for 12% of the global burden of disease and an analysis trends indicates this will increase by 15% by 2020. As per Global Burden of Disease report, mental disorders accounts for 13% of total DALYs lost for Years Lived with Disability (YLD) with depression being the leading cause. Depression, alcohol use disorders, schizophrenia and bipolar disorders constitute the top 10 conditions contributing to the global burden of disease among the age group of 15-44 years. Mental and behavioral disorders are present, in about 10% of the adult population, at any given point of time. Mental health is now recognised as a critical requirement and is engaging the attention of policy-makers, professionals and communities in India and across the globe. Recognizing the importance, severity and consequences World Health Organization (WHO) observed this year on the most important mental health disorder-“Depression which affects people of all ages, from all walks of life, in all countries. The risk of becoming depressed is increased by poverty, unemployment, life events such as the death of a loved one or a relationship break-up, physical illness and problems caused by alcohol and drug use. Untreated depression can prevent people from working and participating in family and community life.

Mental Health: Current Issues in India

India has given importance to the health of neople and has highlighted the need for a hysically and mentally healthy society. With hanging health patterns among Indians, ental, behavioural and substance use isorders are coming to the fore in health care ielivery systems. These disorders contribute or significant morbidity, disability and even ortality amongst those affected. Due to the revailing stigma, these disorders often are idden to the society and consequently persons with mental disorders lead a poor quality of life. revalence rates of mental disorders are also ritically influenced by a wide variety of actors, ranging from socio-economic and other nvironmental determinants, variations in erceived threshold of stress differences in nssessment tools, choice of symptom thresholds in disease definition and interpretations of results.

It is evident from different studies, reviews, eta analysis and independent reports that nearly 100 million persons in India are in need nf systematic care. Health and family welfare minister JP Nadda informed the Lok Sabha in Vlay 2016, Nearly 10-20 million (1-2% of the opulation) Indians suffered from severe ental disorders such as schizophrenia and nipolar disorder, and nearly 50 million (5% of opulation) suffered from common mental isorders like depression and anxiety at the end nf2005. Even though several studies point to the rowing burden, the extent, pattern and utcome of these mental, behavioural and substance use disorders are not clearly known.

To ensure availability of mental health care ervices for all, especially the community at risk and underprovided section of the population, to encourage application of mental health knowledge in general health care and social development, Government of India has launched the National Mental health Programme during 1982. With a vision to promote mental health, prevent mental illness, treatment of mental illness, promote destimatization and socioeconomic inclusion of the mentally ill person by providing accessible, affordable and quality health and social care, Govt. of India has launched National Menial Health Policy on the occasion of the World Mental Health day(10^th October 2014.). In addition, recommendations from National Human Rights Commission and directives from the Supreme Court of India have accelerated the pace of implementation of mental health services. Several advocacy groups, including media, have highlighted need for scaling up services and providing comprehensive mental health care.

Though unmeasured, the social and economic impact of these conditions is huge. To develop data driven programmes, the Ministry of Health and Family Welfare, Government of India commissioned NIMHANS to plan and undertake a national survey to develop data on prevalence, pattern and outcomes for mental disorders in the country and also systematic assessment of resources and services that are available to meet the current demands was a felt need. Thus, the National Mental Health Survey was undertaken by NIMHANS to fulfil these objectives across 12 selected states of India during 2015 - 16.

Current Challenges in India

It was observed from the National Mental Health Survey 2016 that mental morbidity excluding tobacco use disorders currently is 10.6% and life time prevalence was 13.7%. Mental Morbidities include a range of mental disorders F10 - F49 categories within the International Classification of Diseases (ICD - 10). It was estimated that nearly 150 million Indians are in need of active interventions (National Mental health Survey.2016). Substance use disorders (SUDs), including alcohol use disorder, moderate to severe use of tobacco and use of other drugs (illicit and prescription drugs) was prevalent in 22.4 % of the population above 18 years in all the 12 surveyed states. Nearly 1% of the population reported high suicidal risk. Nearly 1.9% of the population were affected with severe mental disorders in their lifetime and 0.8% was identified to be currently affected with a severe mental disorder. The most common prevalent problems were Depression (2.7%), Agoraphobia (2.3%), Intellectual Disability (1.7%), Autism Spectrum disorder (1.6%), Phobic anxiety disorder (1.3%) and Psychotic disorder (1.3%). The prevalence of depression for both current and life time was 2.7% and 5.2%, respectively, indicating that nearly 1 in 40 and 1 in 20 suffer from past and current depression, respectively. Age wise prevalence of all disorders showed peak in the age group of 30-49 years and thus affecting work productivity and earning potential, and quality of life. Among the adolescents, prevalence was 7.3% and nearly equal in both genders. Prevalence of mental disorders was nearly twice (13.5%) as much in urban metros as compared to rural (6.9%) areas. The prevalence in urban metros is higher than in rural and urban non-metro areas (with less than 10 million populations). The prevalence of schizophrenia and other psychoses (0.64%), mood disorders (5.6%) and neurotic or stress related disorders (6.93%) was nearly 2-3 times more in urban metros. Despite prior and current efforts in enhancing mental health care delivery across the country, the study revealed that a huge treatment gap still exists for all types of mental health problems: ranging from 28% to 83% for mental disorders and 86% for alcohol use disorders .

Stigma contributes to the huge burden of mental morbidity, being a road-block to treatment seeking. Nearly 80% of persons suffering from mental disorders had not received any treatment despite the presence of illness for more than 12 months. Stigma associated with mental disorders affects access to work, education and marriage of those with a disorder and it also affects family members of those affected.

The key components of mental health system includes policy and legislative framework, community mental health services, mental health in primary health care, human resources, Intersectoral co-ordination, monitoring and research. The Mental Health Programmes in India have a low priority on the public health agenda-mental health programmes and activities were fragmented and had a low priority during implementation. It is important for all states to have a policy as seen in other health and non-health programmes as it sets a vision, mission and direction for future activities. In all the surveyed states, health management information systems were in different stages of integration and implementation. With the predominant focus being on maternal and child health and a few other national programmes, a fully integrated system was absent. The current mental health programmes in India are hampered by the lack of valid, reliable, timely, sensitive and specific outcome indicators for mental health developed on routine data gathering methods.

According to WHO report, budgetary allocation on mental health is only 0.06% of health budget in India whereas most developed country spends about 4%. There is a paucity of mental health professionals (psychiatrists, psychologists and psychiatric social workers) in India. This necessitates the engagement of non specialist professionals for mental healthcare. The health workforce density (per lakh population) across states ranged from 146 in Uttar Pradesh to 995 in Kerala. In five states (Kerala, Manipur, Punjab, Rajasthan and Tamil Nadu), the density of the health workforce was relatively higher. The doctor (MBBS) density (per lakh population) varied widely across states from 64.4 in West Bengal to 5 in Chhattisgarh. With grass root level health functionaries like ASHA / USHA, ANM and health workers contributing significantly to the workforce density, there is a need to involve them in mental health programmes through the development of skill enhancing programmes. Past experiences and reviews have shown the feasibility of involving primary care doctors, health workers, general practitioners, and others and such practices need to be made the norm.

This huge burden of mental, behavioural and substance use disorders, in India, calls for immediate attention of political leaders, policy makers, health professionals, opinion-makers and society at large. Most significantly, mental health should be given higher priority in the developmental agenda of India. All policies and programmes in health and all related sectors of welfare, education, employment and other programmes should include and integrate mental health agenda in their policies, plans and programmes. Mental health care should be included as one of the elements of Primary Health Care and integrated with programmes of NCD prevention and control. The primary health works should be properly trained for screening of the common mental disorder during their day to day activities and should involve in continuity of care and referral.

A National Commission on Mental Health comprising of professionals from mental health, public health, social sciences, the judiciary and related backgrounds should be constituted to oversee, support, facilitate, monitor and review mental health policies - plans - programmes in a continuous manner. Such a task force that works closely with the Ministries of Health at the national and state levels can provide strategic directions for mental health care programming to ensure speedy implementation of programmes.

The development of the National Mental Health Policy (2014), a new Mental Health Bill (2016), recent judicial directives, initiatives by the National Human Rights Commission18 (2016) increase in resource allocation, expansion of the District Mental Health Programme to 241 districts, establishment of new Centre of Excellence, improvement of care in mental hospitals are few examples of new hopes in this direction.