Can India walk the talk when it comes to mental health?BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8507 (Published 21 December 2012) Cite this as: BMJ 2012;345:e8507
India’s public health community is cautiously optimistic: mental ill health, a problem desperately in need of attention, now seems to be high on the health establishment’s agenda. Two factors—money and staffing—will decide how far and how soon policy prescriptions are translated into practice.
India has a huge unmet need for mental healthcare (box). Without reliable, up to date, disease specific data, it is hard to say how serious the situation is. But official data on suicides are a telling indicator of the challenge ahead: in the decade 2001-11, the number of recorded suicides in the country increased by around 25%, from 108 506 in 2001 to 135 585 in 2010, according to the latest annual report from the National Crime Records Bureau.1
Burden of mental illness
“One of the problems of getting data on mental illnesses is that it represents a class of disorders and the data you get will depend on what is included in the list and what is left out,” Dr Soumitra Pathare—currently a consultant psychiatrist at Ruby Hall Clinic, Pune, India and co-ordinator, Center for Mental Health Law and Policy at the Indian Law Society, Pune—told the BMJ. Pathare pointed out that in older epidemiological studies the prevalence of mental illness varied widely throughout India, from 10 to 370 per 1000 people. This was because of differences in the settings (urban, rural, tribal) and methods used.
An oft-cited report in 2005 by the Indian government’s National Commission on Macroeconomics and Health estimated that nearly 20.5 million Indians had severe mental health disorders.2
This figure was higher in a later study. “All these studies, synthesised, broadly estimate almost 70 million people suffering from mental illnesses,” says Pathare. Several researchers have suggested a prevalence of around 6%.
The Ministry of Health and Family Welfare is currently working on draft proposals for the national mental health programme and the district mental health programme (DMHP) for India’s 12th “five year plan.” These plans, integral to India’s governance, are developed, executed, and monitored by the Planning Commission. The 12th plan will be submitted for approval to the National Development Council on 29 December 2012.
The DMHP, the mainstay of India’s psychiatric treatment in the public sector, operates in 123 of the 640 districts in the country. It currently requires each district to have a psychiatrist, a clinical psychologist, a psychiatric nurse, and a psychiatric social worker to deliver essentially facility based services. The problem is that India does not have the human resources necessary to carry out the programme.
“We are hoping in the 12th plan to shift emphasis to community and home based services, delivered through governmental and non-governmental agencies. Very few, if any, of the 123 districts where the DMHP is being implemented actually have the full time services of the four professionals required. It would be pointless to think about expanding the DMHP to cover all districts in the country when we know that adequate numbers of trained professionals in the disciplines required do not exist,” Keshav Desiraju, special secretary at the Ministry of Health and Family Welfare, told the BMJ.
The new plans for mental healthcare should have started earlier, but two factors have caused delays. Firstly, only recently has the health ministry had some idea of the budget that is likely to be at its disposal. Secondly, the Planning Commission also has a proposal to set up a national health mission to subsume the existing national rural health mission (NRHM), India’s flagship public health programme.3 If this happens, all other disease control programmes, including the DMHP, would become part of this new health mission, according to a health ministry official; this would require changes to the way the 12th plan is formulated.
India has traditionally focused more on infectious diseases and maternal and child health, but mental health is quickly moving up the list of public health priorities. “There is growing awareness of the epidemiology of mental disorders in India: the high rate of suicides among young people, for example,” Vikram Patel, professor of international mental health and Wellcome Trust senior research fellow in clinical science, told the BMJ.
“Then there have been human rights issues involving quality of care and the fact that there is virtually no community based mental healthcare system in the country,” he added. “Meanwhile, India is witnessing a transition from [a burden of] infectious diseases and maternal and child health issues to non-communicable diseases. Mental illnesses have to be seen in this context.” Patel is director of the newly established Centre for Mental Health in the Public Health Foundation of India, an Indian non-governmental organisation, and is part of the 12 member group set up by the health ministry to rewrite mental health policy in India.
Disability activists have also drawn attention to mental ill health in India. The ministry began to amend the Mental Health Act 1987 in January 2010 because of ratification of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). A series of regional and national consultations brought attention to mental health policy.
“While the mental health lobby has been generally neglected, the disabilities lobby has always been very strong,” said Desiraju. “The ministry began the process of amendment to legislation (the Mental Health Act, 1987) in January, 2010, as a response to the commitments we have undertaken as a country following the ratification of the UN Convention on the Rights of Persons with Disabilities (UNCRPD). Discussions on legislation were held in series of regional and national consultations and this may have led to policy visibility. It is also true that while the mental health lobby has been generally neglected, the disabilities lobby has always been very strong. Since UNCRPD led also to a process of amendments to the Persons with Disabilities Act, 1992, and since mental illness in India is regarded as a disability under the Persons with Disabilities Act, the disability activists have been very active. While addressing the new legislative changes it also become clear to the government that both mental health policy and mental health programming needed attention,” Desiraju added.
The challenges in implementation will be to ensure that adequate technical skills and leadership exist at district and state levels; to ensure accountability; to enable community based mental health teams; and to tackle the current fragmentation of mental healthcare among various ministries and departments, said Patel. “The abysmal shortage of mental health professionals is clearly a constraint,” admitted Desiraju. According to the health ministry, the public sector has only 358 clinical psychiatrist and 129 clinical psychologists.
One way to tackle limited human resources is to have a team of community workers in rural areas, said Dr Rangaswamy Thara, head of the Schizophrenia Research Foundation (SCARF), a Chennai based non-governmental organisation that works for people with chronic mental illnesses. The organisation has used lay volunteers in the community, selected with the help of village leaders. “SCARF’s response to poor human resources is partly training of community workers and the use of telepsychiatry, including mobile tele-psychiatry,” Thara told the BMJ. Volunteers should be trained as part of the DMHP, so that they are permanent features of the programme, she added.
Although such community workers would help, India must substantially increase its fully qualified mental health workforce. “We are hoping that the six new AIIMS [All India Institute of Medical Science] institutions [expected to open next year] will each develop a strong [psychiatry] department,” said Desiraju. “Another constraint is the general indifference in the health system to matters relating to mental illness.
“Nothing is going to be easy, and not much may be possible in the short run. But in the medium term it should be possible to reform the MBBS [bachelor of medicine and surgery] curriculum, with the participation of the MCI [Medical Council of India], in such a way that even a medical officer in charge of a primary health centre is sufficiently well trained to act as the first point of contact for a person with [mental] illness,” said Desiraju.
“This may also be possible in the MBBS curriculum in the new AIIMS institutions, which are outside the jurisdiction of the MCI. Similar reform will be needed in nursing education and in the training of caregivers. In the long term, there are plans to strengthen medical colleges to train the various categories of professionals needed for the implementation of the DMHP. This is expected to continue in the 12th plan.”
Cite this as: BMJ 2012;345:e8507
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.
Commissioned; not externally peer reviewed.