|Year : 2019 | Volume
| Issue : 1 | Page : 4-12
Analyzing Indian mental health systems: Reflecting, learning, and working towards a better future
Preetam B Mahajan, Prahan Kumar Rajendran, Bhuvaneswary Sunderamurthy, Sumedha Keshavan, Joy Bazroy
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||18-May-2019|
|Date of Acceptance||20-May-2019|
|Date of Web Publication||19-Jun-2019|
Preetam B Mahajan
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry
Source of Support: None, Conflict of Interest: None
Mental health has been long neglected. Even though it causes substantial loss of disability-adjusted life years, it does not receive proportionate funding. India spends <2% of its annual health budget on mental health. India has been witnessing a great push for mental health. A number of policy-level reforms have been undertaken, and efforts are on to tackle this issue in a better way. In this study, we have reviewed various factors contributing towards policy, implementation, and utilization gaps based on published studies and Mental Health Survey reports and suggested ways to address these. Bottleneck analysis reveals that interventions to improve mental health scenario extend beyond the ambit of the National Mental Health Policy and requires strong policy negotiations and reforms to resuscitate the dying public health-care system of India.
Keywords: Bottleneck analysis, health systems strengthening, mental health, patient care pathway
|How to cite this article:|
Mahajan PB, Rajendran PK, Sunderamurthy B, Keshavan S, Bazroy J. Analyzing Indian mental health systems: Reflecting, learning, and working towards a better future. J Curr Res Sci Med 2019;5:4-12
|How to cite this URL:|
Mahajan PB, Rajendran PK, Sunderamurthy B, Keshavan S, Bazroy J. Analyzing Indian mental health systems: Reflecting, learning, and working towards a better future. J Curr Res Sci Med [serial online] 2019 [cited 2020 Jan 18];5:4-12. Available from: http://www.jcrsmed.org/text.asp?2019/5/1/4/260634
| Introduction|| |
The World Health Organization (WHO) defines mental health as “a state of wellbeing in which every individual realizes his/her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community." Disturbance to this Mental State, compromises individual capacity, and their level of functioning leading to welfare losses to self, their household and society at large.
In 2004, Mental Disorders accounted for 13% of global disease burden. About a third of this disease burden (i.e. overall 4.3%) was due to depression, which alone is expected to be No 1 contributor to disease burden by 2030. If one had to factor only the disability component, mental disorders would account for 25.3% and 33.5% of all years lived with a disability in low- and middle-income countries, respectively. In terms of economic output, mental disorders would result in losses of 16 trillion US$ by 2030. Mental health-related issues have long been neglected. Most nations (low and middle income) spent <2% of health budget to the treatment and prevention of mental disorders. More than 80% of these are spent on mental hospitals.
The WHO for thefirst time adopted a comprehensive mental health action plan (MHAP) 2013–2020 that called for change in attitudes that perpetuated stigma, expansion of services, and efficient use of scarce resources in promoting mental well-being, preventing mental disorders, and protecting rights of people suffering from mental illnesses. It focused on four key objectives: “to strengthen effective leadership and governance for mental health; provide comprehensive, integrated, and responsive mental health and social care services in community-based settings; implement strategies for promotion and prevention in mental health; and strengthen information systems, evidence, and research for mental health.", Amid some progress, many challenges and barriers are yet to be surmounted. There is a renewed agenda for achieving global mental health with considerable global and national responses.
India was one of thefirst countries in developing world to have adopted a Mental Health Program (MHP) in 1982. A series of setbacks and implementation failures collectively led to its underperformance. However, interest of multiple stakeholders got reignited after the WHO called for scaling up action against mental illnesses in 2013. Since then, India has been witnessing a great push for mental health with revamping of its MHP,, framing of itsfirst mental health policy fully in line with human rights covenants, and enactment of mental health legislation. Underlying principles of newly rolled out District MHP (DMHP) was based on six key perspectives, namely life course, recovery, equity, evidence based, health systems, and right based.
It's time we review our current mental health scenario, identify various policy implementation gaps, learn from success stories in other resource-constrained settings, and accordingly, shape mental health-care services, which is the primary focus of this review article.
| Mental Health-Care Scenario in India|| |
Baxter et al. modeled prevalence estimates of mental, neurological, and substance use (MNS) disorders in India but cautioned about generalizability citing inadequate underlying population-based data. Depression and anxiety were the most common. They predicted a 23% rise in burden between 2013 and 2025. There was a strong recommendation for developing effective surveillance programs to capture trends; understanding of local context; to inform local area needs assessment and workforce requirements; urgent prioritization of interventions focused on targeted prevention, early identification, and effective treatment; and monitoring and evaluation of mental health services.
In 2016, India carried out the National Mental Health Survey (NMHS-2016) in 12 states (first phase). Lifetime prevalence and current prevalence for number of MNS disorders were provided for individuals >18 years of age (57%–68% of total population) and a subsample of 13–17 years in four states. In addition, treatment gaps, health-care utilization patterns, disability status of mentally affected individuals, and impact on individual and their family in the surveyed population were systematically assessed. They also assessed the mental health systems, services, and resources in different states. This could guide context-specific planning of health-care services at state level and strengthen mental health systems in the country.
It appeared that nearly 150 million Indians (urban > rural) were in need of active interventions posing a formidable challenge to our insufficient, inequitably distributed, and inefficient mental health system. The overall weighted lifetime prevalence and current prevalence for any mental morbidity were 13.7% and 10.6%, respectively. People from 40 to 49 years were predominantly affected (psychotic disorders, bipolar affective disorders (BPADs), depressive disorders, and neurotic and stress-related disorders). The prevalence of substance use disorders was highest among 50–59 years (29.4%).
Treatment gap for mental disorders ranged between 70% and 92% for different disorders: common mental disorder – 85.0%, severe mental disorder – 73.6%, psychosis – 75.5%, BPAD – 70.4%, alcohol use disorder – 86.3%, and tobacco use – 91.8%. The median treatment delay varied from 2.5 months for depressive disorder to 12 months for epilepsy. Government facility was the most common source of care. The median monthly amount spent for care and treatment varied between disorders: alcohol use disorder – ₹2250, schizophrenia and other psychotic disorders – ₹1000, depressive disorder – ₹1500, neurosis – ₹1500, and epilepsy – ₹1500. This was sufficient enough to plunge many families into poverty spirals.
A detailed report about health system assessment is available. A systems approach is crucial to identify various bottlenecks within health systems and facilitate effective implementation of simple as well as complex mental health interventions in real-world settings. Before this attempt, a number of other evaluations,,,,,,, were carried out uncovering various implementation issues and possible solutions, but none of these had a systems approach.
DMHP gradually increased its coverage over three decades after its launch, but its implementation and community integration always remained a weak link. Toward beginning of the 12th 5-year plan in 2012, a policy group was constituted to review the existing situation and then play a crucial role in revamping the DMHP and lay foundation toward the development of Mental Health Policy. At present, the availability of health system assessment (NMHS-2016) report could prove crucial to further strengthen implementation steps. It would also serve as an interim assessment of the progress made since major mental health reforms in India after 2012 and allows midcourse correction or at best serve as a benchmark for future comparisons.
From [Figure 1], it becomes evident that states with a higher prevalence of mental morbidities suffer from poor coverage by DMHP. It was found that Tamil Nadu (TN) and Kerala (KL) had the highest number of mobile mental health units (432 and 22, respectively); day-care centers (137 and 43, respectively); and de-addiction centers (120 and 66, respectively). While TN had 43 residential halfway homes, KL had 146 long-stay homes. An adequate number of these facilities were lacking in other states which are prerequisites for successful implementation of community-based mental health-care services. For every one lakh population, KL and Manipur had the highest density of psychiatrist (1.2 and 0.56, respectively); nonspecialist medical doctors trained in mental health (2.75 and 9.73, respectively); clinical psychologists (0.63 and 0.49, respectively); rehabilitation workers; and special education teachers (10.26 and 5.99, respectively); and psychosocial counselors (2.79 and 61.42 respectively). It appears that there is gross inadequacy and inequity in terms of availability of mental health resource personnel and health facilities that could provide appropriate care at different levels and need urgent attention in coming years.
|Figure 1: Comparison of population covered by the District Mental Health Program and prevalence of mental morbidity in surveyed states of India (National Mental Health Survey-2016)|
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Except Gujarat (GJ) and KL, no other surveyed state has a stand-alone state mental health policy, and this could be a hindrance in developing context- and culture-specific MHAPs. It was also observed that state mental health coordination for implementation of DMHP was weak and needed reforms.
At present, India spends 1.3% of its total health budget on mental health. This is grossly less as compared to other nations and a proxy indicator of low priority on health agenda. This could probably be due to the absence of groundswell of public opinion on mental health-related issues that would compel higher fund allocations. Further, this meager amount is not fully utilized due to issues related to untimely distribution, lack of clarity on utilization mechanisms, etc. Most of what is available is spent toward upgrading hospitals, salaries of staff, or procuring medicines. In 2015, 16% of total inpatients were being institutionalized for >5 years, an indicator of poor availability of community-based rehabilitative and homestay services. The quantum of expenditure needs to tilt toward community-based services but is perhaps possible with an increase in budgetary allocation. Funds allocated specifically to mental health has been ringed-fenced (i.e. cannot be utilised elsewhere). Additionally Mental health has also been included under Non-communicable disease (NCD) flexipool budget. These are welcome initiatives.
Health-care utilization depends on robust information, education, and communication (IEC) efforts. However, IEC activities were merely restricted to preparing posters and distributing pamphlets at most places, rather than being population centric, targeted toward local situation, uniform in coverage, highly visible, and continuous over time. Thus, stigma prevailed resulting in poor utilization of whatever services available and perpetuating problems. This has to change followed by more effective engagement of community in health seeking and utilization of services. This is where civil society could play a major role. At present, 69 such organizations are prominently functioning in mental health, and there is a need for more that could contribute in mental health advocacy, service delivery, and research.
With regard to availability of drugs, most primary health centers across country had poor state of affairs narrowing down to availability of benzodiazepines alone, while private pharmacy had adequate stock of most essential drugs. This could trigger an increase in out-of-pocket expenditure, leading to either poverty or discontinuation of care and defeating the very purpose of making services accessible at community level. This happens due to delay in receipt of funds, tendering issues, inventory control, etc., This is mainly a health management-related issue that needs separate attention.
With regard to the Health Management Information System (HMIS), only 33% of surveyed states had mental health included in their HMIS. This means that one could anticipate a delay in monitoring and evaluation activities in most places. Without robust HMIS, it would be difficult to plan and provide services.
[Box 1] summarizes the implications of health system evaluation and in next section leads us toward discussion of why some of these gaps exist and what could possibly be adopted from lessons learned elsewhere and work toward more effective implementation of MHAP in future.
| Recognizing Policy Planning, Implementation, and Utilization Gaps and Planning Future Course|| |
The gaps appear to be operational at policy, implementation, and utilization level. To better conceptualize the implications of these gaps, we have shown disease progression and patient care pathways in [Figure 2] and [Figure 3], respectively. We have also demonstrated an interplay of various risk factors and intermediary outcomes along this pathway. Delay in diagnosis and treatment often results in poor mental health outcomes.
|Figure 2: Disease progression pathway in a patient with mental illness and possible modes of intervention|
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Most of these gaps have been operational even at the time of revamping of DMHP in 2012 as pointed out by the mental health policy group, and some continue to exist even today [Box 1]. Since the underlying strategy of DMHP was to integrate mental health with general/primary health-care services, it invariably inherited various barriers/gaps of the existing primary health-care system besides having its own., With lack of supervision, lack of follow-up to check the effectiveness of training of primary care workers in mental health, and frequent drug shortages, integration of mental health services with primary health care is bound to pose unsurmountable challenge. Similar situations exist in other low-income countries as well. Cross-cultural learning and sharing of solutions could be a worthwhile exercise.
At present, riding on the highest possible political commitment, India seems to be at the crossroads of witnessing a major transformation in health-care delivery (Ayushman Bharat [AB]) through Health and Wellness Centers (HWCs) that are being hoped to address all the bottlenecks discussed earlier. Mental health care is being projected as one of the key components of comprehensive care strategy of HWCs. However, careful scrutiny of operational guidelines of AB suggests that mental health care has been identified under additional skills offirst-line workers (FLWs), which could be read as desired skills, and so could variably get compromised at different centers. There is a need for shifting these to core skill sets to acquire prompt attention. Second, there is no plan to immediately adopt mental health-related indicators in HMIS, which can only delay progress in this important area. These things require urgent policy negotiations for effective integration. Situation analysis should be followed by policy reforms to strengthen this weak link.
In [Figure 4], we have shown primary mechanisms leading to unfavorable outcomes using red arrows and other secondary mechanisms using black arrows. The picture is an inverted bottle with health system factors at its neck. Some of these are nonmodifiable, especially under the mental health policy framework, thus perpetuating unfavorable outcomes. The existing primary health-care systems are plagued with issues such as inadequate workforce, substandard quality of care, inequitable distribution of health facility, inaccessibility, and ineffective private sector engagement through safety nets of health insurance. These serve as bottleneck [Figure 4] in effective implementation of MHAP at district levels. Mental health advocates have an additional responsibility of holding policy cross talks at various levels to circumvent these issues. MHAP will have to be more articulate to push for reforms such as increased allocation of funds, leverage to improve quality of care, and effective engagement of civil society.
|Figure 4: Bottleneck analysis of factors hampering effective implementation and integration of the District Mental Health Program with primary health-care services|
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The major drawback of DMHP is diagnostic and treatment delay besides delay in seeking care. The reasons are manifold [Figure 3] and [Figure 4]. Caregivers of people suffering from psychotic illness are more likely to face stigma. These can delay treatment and further worsen the situation both for patients and caregivers., Sometimes, simple messages can be very powerful in gathering empathy of community members, as shown by Koschorke et al.,, and hence, stigma reduction measures should be culture and context specific. Faith healing is a very common cause of treatment delay. Very interesting models have risen from GJ and TN, where health systems collaborated with faith healers to tap patients with mental illnesses early and provide evidence-based treatments with successful outcomes. This is worth a try in other states as well.
Patients reporting to health facilities may not get quality care. The WHO has done a pioneering job in preparing various guidelines and testing cost-effective interventions that can be used in resource-poor settings to improve the quality of services. Training health workforce in mental health continues to be Achilles heel. Institutes such as National Institute of Mental Health and NeuroSciences in India along with Central Institute of Psychiatry, Ranchi, have started training members of health team in community mental health in bid to exponentially increase the capacity to provide quality care in mental health and substance use disorders. Efforts are on to provide standard simple diagnostic and therapeutic algorithms that can be used in primary health centers.[49.50] E-videos are also available that can support on-site learning. Posttraining on-site support by a specialist is essential to optimize case detection and management. NIMHANS has been attempting this, and its impact will be clear in due course of time. Trainings can be made more effective using Kirkpatrick models.
Some models have demonstrated the success of engaging grassroots workers/FLWs to screen individuals with mental disorders and decrease treatment delays. There are challenges involved as India is a multicultural society, and screening tools need to be cross-culturally adapted for this purpose. They are also expected to participate in IEC activities to improve care-seeking practices. More studies are needed to demonstrate successful ways of engaging FLWs in real-life settings as very often there are competing priorities to fulfill requirements of other national programs leading to opportunity costs. In fact, India needs to seriously consider increasing the number of FLWs at village levels and the economics of doing so needs to be worked out keeping in mind overall gain in health achieved by doing so.
There is a need to engage both service users and caregivers in planning and utilization of services. However, there is a lack of high-quality research about successful ways of engaging these community resources. Community volunteers (nonhealth sector) can also be potential partners in delivering mental health care, as shown in Maharashtra and Goa. Another review explores different ways of addressing barriers to treatment access.
The management of mental illness includes drug management and psychosocial interventions (PSIs). There are some models of successful applications of these PSI and community-based models of rehabilitation that can with little application scaled up at district levels. PSI includes psychoeducation of patients and their caregivers, muscle relaxation techniques, counseling support, and mind relaxation techniques, and their administration requires certain special skills. The workforce available for these is already scarce and often used for other administrative works in overburdened PHCs again leading to opportunity costs. One of the PSIs is meditation, that has no religious connotations but often underutilized due to unawareness and unavailability of trainers. Many organizations are active in promoting meditation practice in India.
Patients with a severe illness often need referral and inpatient support, but patients are unwilling to stay longer due to poor finances. Newer models are emerging that holds promise (more studies needed) in integrating ideas of day-care hospitals as part of holistic mix of services for unwilling patients to reduce utilization gaps.
DMHP is the primary fulcrum for planning and delivering services at primary level of care. Integration of mental health service with general health is easier said than done given various bottlenecks and limiting factors. However, there are some interesting steps outlined by Hanlon et al. for integrating mental health care in general health services. Very often, we fail to follow the implementation process of public health interventions that have shown a demonstrable success. We know what works, but we should also know how it worked? A very interesting article highlights the processes in one such model in Sehore, Madhya Pradesh. Here, theory of change workshops and mixed methods were used for developing a Mental Healt Care Policy/Program that comprised three enabling packages (program management, capacity building, and community mobilization) and four service delivery packages (awareness for mental disorders, identification, treatment, and recovery). There were some interesting lessons learned, and it pointed toward the need for developing capacity of dedicated district-level mental health coordinator in public health skills for successful implementation of MHCP using a standard approach. It would be prudent to follow similar steps in every district of India to contextualize culture-specific interventions. The Indian Association of Preventive and Social Medicine and the Indian Psychiatric Society state that chapters could gainfully contribute in this endeavor and join hands with other stakeholders in devising ways to continuously support activities of DMHP.
It is well accepted that designing effective community-based mental health services has culture- and context-specific challenges. There is no one-size-fits-all formula. However, there are some basic steps that need to be followed which have also been explained by Ng et al. Few reports/reviews,,, are available that provide deeper insights into basic models that have been tested and could possibly be adapted to one's local settings. Of course, policy reforms should also happen simultaneously.
In this review, we looked at care pathways, factors resulting in gaps in health care. We also looked at the availability of evidence-based interventions/health-care delivery models that could possibly be adopted while designing and scaling up culture- and context-specific MHAPs across different states of India. A few research gaps do exist posing grand challenges to global mental health. This has been highlighted elsewhere, and more research in this direction is needed. Answers to these could possibly provide the final push to achieve mental well-being in years to come. Scaling up community-based mental health services require a systems approach.,, Most importantly, reflecting on the mistakes of the past,, learning from the present, and striving for a better future are what will help us achieve desired outcomes. Now, only time and untiring efforts of all concerned will hold the key.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]