FUTURE OF COMMUNITY MENTAL H

1. Community-Based Mental Health Services in India:
Current Status and Roadmap for the Future
• An estimated 197.3 million people have mental disorders in India,
and majority of the population have either no or limited access to
mental health services.
• Thus, the country has a huge burden of mental disorders, and there
is a significant treatment gap.
• Public mental health measures have become a developmental priority so that
sustainable gains may be made in this regard.
• The National Mental Health Program (NMHP) was launched in
1982 as a major step forward for mental health services in India, but
it has only been able to partially achieve the desired mental health
outcomes

2. • Despite efforts to energize and scale up the program from time to time,
progress with development of community-based mental health
services and achievement of the desired outcomes in India has
been slow.
• Public health measures, along with integration of mental health services in
primary healthcare systems, offer the most sustainable and effective model
given the limited mental health resources.

3. MAIN BARRIERS
• The main barriers to this integration include already
overburdened primary health centres (PHCs), which face the
following challenges:
• limited staff; multiple tasks;
• a high patient load;
• multiple, concurrent programs;
• lack of training, supervision, and referral services;
• an non availability of psychotropic medications in the primary
healthcare system.
• Thus, there is an urgent need for a fresh look at implementation of
the NMHP, with a focus on achieving sustainable improvements in a
timely manner

4. WHO ESTIMATES
• Estimates made by the World Health Organization (WHO) suggest
that mental and behavioral disorders account for
around 12% of the global burden of disorders.
• It has been suggested that this may be an
underestimation, considering the interconnectedness
between mental illness and other socioeconomic
conditions, especially in low- and middle-income
countries (LMICs), which account for almost three
quarters of the global burden of mental and behavioral
disorders. An estimated 197.3 million people have
mental disorders in India.

5. SIGNIFICANT TREATMENT GAP.
• Additionally, there is a significant treatment gap present in both
developed and developing countries, with the vast majority of
patients in LMICs(LOW AND MIDDLE INCOME COUNTRIES).
• lacking any access to treatment facilities for mental and behavioral
disorders.
• Thus, public mental health measures have become increasingly
important and should be a development priority, especially in LMICs,
including India.

6. Progress in this regard can be assessed according to the following criteria:
• presence of an official mental health policy;
• programs or plans for mental health;
• budgetary allocations; a dedicated mental health workforce
• reduced suicide rates;
• and protection of the human rights of those who are mentally ill
• availability of essential psychotropic medications in primary care.
• increased treatment coverage;

7. ROADMAP FOR THE FUTURE
(1) BUDGETARY CONSIDERATION
• One of the primary reasons for the initial shortcomings following
launch of the National Mental Health Program in 1982 was the
shortage of allocated funds.
• Lack of a designated budget for mental health within a nation’s health
budget is a major impediment to service development.
• Another major difficulty which has been seen in India
• is underutilization of allocated funds
• because of multiple factors, ranging from difficulty in employing
mental health manpower to an inability to execute infrastructure
projects in a time-limited manner.

8. • ‘Red tapism’(Red tapism can also refer to official rules and processes
that seem unnecessary and delay results) and lack of a coordinating
nodal agency can also be a major hurdle in the timely execution of
projects.
• Funds allocated to the NMHP have decreased significantly in recent
years, and this is a matter of concern.
• The Union Budget of India 2021–22 set a corpus sum of 712.69 billion
Indian Rupees (INR) for the health budget, including 5.97 billion INR
for mental health.

9. • Only 7 percent of the allocated amount for mental health has been
earmarked for the NMHP.
• By way of comparison, the budget allocation for the NMHP in 2010 was
0.44% of the total budget allocated to the Ministry of Health and Family
Welfare, but this was reduced to 0.06% in 2020.
• Moreover, another major cause for concern is that major cuts have been
made in the revised NMHP budget estimates in recent years.
• For example, in 2018–19, the allocated amount of 500 million INR was
slashed to 55 million INR, and in 2019–20, the allocated amount of 400
million INR was slashed to 50 million INR.
• Thus, underfunding continues to be a major barrier, contributing to slow
gains under the NMHP.

10. • For example, in 2018–19, the allocated amount of 500 million INR
was slashed to 55 million INR, and in 2019–20, the allocated amount
of 400 million INR was slashed to 50 million INR.
• Thus, underfunding continues to be a major barrier, contributing to
slow gains under the NMHP.
• Hence, ring-fencing allocated funds to be used exclusively for mental
health services, along with a nodal agency to ensure this, may go a
long way towards ensuring proper utilization of funds allocated for
mental health.

11. 2)MENTAL HEALTH SERVICES DELVERY
• The recommendation to deinstitutionalize mental health
• (Deinstitutionalization refers to the conscious effort to remove patients
from an institutional environment and begin to support them in
community-based scenarios.) and to adopt a primary health model for
service delivery has been longstanding.
• While institutionalization has been seen as a major challenge in the West
since adoption of a rights-based approach to mental health, this has not
been the case in India, along with other LMICs.
• Direct adoption of the same approach in LMICs (including India) may not
necessarily have similar desirable effects on overall service provision in
these countries as they already have a dearth of mental health resources

12. • However, existing mental hospitals and institutions can serve as
referral centres in the management of patients with severe
mental illnesses, especially where there is insufficient social support
and for mediclegal while the transition to predominantly
community-based services is being planned and implemented.
• The current policy of strengthening and upgrading existing
mental hospitals to ‘Centres of Excellence’, along with provisions for
strengthening of the mental health training being incorporated
into the National Mental Health Program, will provide the
essential building blocks for successful community-based
services as envisioned

13. • However, periodic reappraisal of the goals set, achievement
thus far and course corrections is essential, and the
mechanisms ensuring this must be built into the program to
prevent skewed development.
• In recent years, the overall scope of mental health services and a
significant reduction in stigma have been achieved, but this comes
with the caveat that these services are essentially concentrated
around urban and semiurban areas

14. MENTAL HEALTH WORKFORCE
• Factors contributing to the shortage of mental health professionals
in LMICs (including India) are urban concentration, a preference for
private practice and the brain drain.
• There is an acute shortage of mental health professionals in India,
with two mental health workers and 0.3 psychiatrists per 100,000
population, which is a major limiting factor when it comes to planning
mental health services for communities.
• Retaining mental health professionals is an even greater challenge,
along with ensuring their equitable distribution.

15. • Minimizing the brain drain and retaining professionals in the public
sector must be afforded a high priority by means of financial
incentives, favourable working conditions, and provisions for career
advancement.
• At the same time, efforts should be made to ensure that enhanced
training capacities are adequately utilized by ensuring equal
professional opportunities for trained personnel.
• It is envisaged that, in the District Mental Health Program, existing
manpower will be trained in PHCs (like doctors and paramedical staff)
and equipped with the skills and knowledge necessary to provide
mental health services.

16. • Nonspecialist health workers contribute to service delivery and play
an important role in detection, diagnosis, treatment, and prevention
of common and severe mental disorders as part of a complex
steppedcare approach.
• There should be better provision for their in-service training to enable them
to deliver effective services to the general population.
• Another important approach to improving service provision for the
general population is to improve psychiatry education and training at
the level of undergraduate medical courses.
• The ability to independently diagnose and treat mental disorders and
make appropriate referral decisions will improve service provision on
a much wider scale, with visible improvements.

17. MOBILIZATION OF COMMUNITY RESOURCES
• In many LMICs, including India, faith healers, religious leaders
and practitioners of alternative systems of medicine are often the first
point of contact for patients with psychiatric disorders, rather than
mental health services.
• Efforts must be made to educate and sensitize this subgroup of the population
about the importance of seeking a professional diagnosis and
undergoing appropriate treatment (with regular followup),
supported by better delivery of mental health services in the
community.

18. • Some services can be sought as time-limited interventions (like
camp services), which can mobilize large numbers of people in a limited
time, in remote areas.
• Community campaigns to increase awareness about psychiatric
illnesses and decrease the associated stigma should also be prioritized
as stigma and discrimination against people with mental health
problems are important barriers to identification and treatment of mental
disorders.
• Family members are essentially the primary caregivers in most
LMICs, including India, and can contribute to detection,
treatment-seeking, and management of family members with
mental disorders.

19. INTEGRATION WITH PRIMARY CARE
• Currently, integration of community mental health services with primary
healthcare is the most viable method to provide mental health services in
most LMICs, including India, but significant shortcomings still exist in terms of
achieving this goal.
• The main barriers to integration include the following: already
overburdened PHCs with limited staff; multiple tasks; patient load; multiple concurrent
programs; lack of training, supervision and referral services; and non-availability of
psychotropic drugs in the primary healthcare system

20. • In this context, alternative mechanisms for program delivery,
like the National Health Mission (which subsumed the National
Rural Health Mission and National Urban Health Mission in
India), should be considered.
• It has also been suggested that mental healthcare should be
integrated with better performing services for other chronic
conditions or, alternatively, with other systems like social care or
education.

21. MENTAL HEALTH RESEARCH
• The WHO’s Mental Health: Global Action Program envisages multidimensional research
efforts in LMICs to improve the mental health situation.40 There is a wide gap
between research efforts focused on developed countries and those focused on
LMICs (in terms of mental health), and this divide has not decreased over
time.
• Furthermore, research does not seem to have had an impact on the policy
and practice of mental health due to a disconnect between researchers
and communities.42 Attention needs to be focused on a systemic
approach in order to debate the relevance of research questions, with the
involvement of all stakeholders at appropriate levels (including
policymakers, practitioners, advocacy groups and the community at large),
and to generate resources and funds for this.

22. • Although progress has been slow in development of community-
based mental health services and achievement of the desired
outcomes in India, the importance of these cannot be understated a
huge burden of mental disorders and a significant treatment gap.
• Public health measures, along with integration of mental health
services in primary health systems, offer the most sustainable and
effective model for LMICs with few resources, including India.

23. • Despite the National Mental Health Program having been in effect
since 1982, it has only been able to partially achieve the desired
mental health outcomes.
• It is important to continuously assess performance with independent
audits and periodic reviews in order to identify problems at the
earliest and initiate corrective measures.
• Thus, there is an urgent need to take a fresh look at implementation
of the program, with a focus on achieving sustainable improvements
in a timely manner.

24. TIMES OF INDIA
• Addressing healthcare challenges in a country as diverse and vast
as India is a difficult feat as it is, leaving aside the stigma, and social
and structural barriers that prevent people experiencing mental
health problems from seeking care.
• The National Mental Health Survey (2015-16) estimated that close
to 150 million Indians require mental health interventions and
there exists a treatment gap of 70 to 92%.
• Considering that the overall impact is not just on the person, but
also on those around them (hidden burden), the actual affected
population may be much higher. This burden has been aggravated
by the Covid-19 pandemic due to the rise in uncertainty and
anxiety, and is now becoming increasingly critical to address.

25. • India has only 0.75 psychiatrists per lakh population largely concentrated in
urban areas even though nearly 70% of the country’s population resides
in rural areas, against the desirable 3 per lakh population- a deficit that
would take at least 42 years to meet given the current pace of psychiatric
education in the country.
• The government of India is launching a national tele-mental health program.
It provides 24×7 free counselling and care to people.
• India’s current finance minister Nirmala Sitharaman announced it in Budget
2022.

26. • In 2017, the President of India, Ram Nath Kovind asserted that
India was “facing a possible mental health epidemic”.
• A study revealed that in the same year, 14% of India’s
population suffered from mental health ailments, including 45.7
million suffering from depressive disorders and 49 million from
anxiety disorders.
• The Covid-19 pandemic has further accentuated this mental
health crisis, with reports from across the world suggesting that
the Virus and associated lockdowns were having a significant
impact on the population – particularly younger individuals.

27. THE STATE OF MENTAL HEALTH IN INDIA
• A study by the India State-Level Disease Burden Initiative showed
that the disease burden in India due to mental disorders increased
from 2.5% in 1990 to 4.7% in 2017 in terms of DALYs1 (disability-
adjusted life years), and was the leading contributor to YLDs (years
lived with disability) contributing to 14.5% of all YLDs in the country
(India State-Level Disease Burden Initiative, 2017).
• The prevalence of depression and anxiety disorders, as well as eating
disorders, was found to be significantly higher among women.
• The association between depression and death by suicide was also
found to be higher among women.

28. • In India, having a mental health disorder is perceived with a sense of
judgement and there is stigma associated with those having mental health
issues (The Live Love Laugh Foundation, 2018). Mental disorders are also
considered as being a consequence of a lack of self-discipline and
willpower.
• The stigma associated with mental health as well as lack of access,
affordability, and awareness lead to significant gaps in treatment.
• The National Mental Health Survey (NMHS), 2015-16 found that nearly
80% of those suffering from mental disorders did not receive treatment for
over a year.
• This survey also identified large treatment gaps in mental
healthcare, ranging from 28% to 83% across different mental disorders
(National Institute of Mental Health and Neuro-Sciences (NIMHANS),
2016).

29. • Mental disorders place a considerable economic burden on those
suffering from them – the NMHS (2015-16) revealed that the median
out-of-pocket expenditure by families on treatment and travel to
access care was Rs. 1,000-1,500 per month.
• Discussions with respondents also revealed that expenditure incurred
on treatment of mental disorders often drove families to economic
hardship.
• This burden was more pronounced in the case of middle-aged
individuals – who were also most affected by mental disorders – as it
affects their productivity thereby amplifying the burden not just on
the individual, but also the economy.

30. • The World Health Organization (WHO) estimates the economic loss
to India on account of mental health disorders to be US$ 1.03 trillion.
• The NMHS also found that mental health disorders
disproportionately affect households with lower income, less
education, and lower employment.
• These vulnerable groups are faced with financial limitations due to
their socioeconomic conditions, made worse by the limited resources
available for treatment.
• Lack of State services and insurance coverage results in most
expenses on treatment – when sought – being out-of-pocket
expenses, thus worsening the economic strain on the poor and
vulnerable.

31. Legislation and building State capacity
• The Mental Healthcare Act, 2017 makes several provisions to improve
the state of mental health in India. This Act rescinds the Mental
Healthcare Act, 1987 which was criticised for failing to recognise the
rights and agency of those with mental illness (Mishra and Galhotra
2018).
• This includes stating access to mental healthcare as a ‘right’; and
instituting Central and State Mental Health Authorities (SMHA),
which would focus on building robust infrastructure including
registration of mental health practitioners and implementing service-
delivery norms.
• Although the Act required states to set up an SMHA in nine months
of the Act being passed, as of 2019, only 19 out of 28 states had
constituted an SMHA.

32. • The National Mental Health Programme (NMHP)2 was
introduced in 1982, in keeping with the WHO’s
recommendations, to provide mental health services as part of
the general healthcare system.
• Although the programme has been successful in improving
mental healthcare access at the community level, resource
constraints and insufficient infrastructure have limited its impact
(Gupta and Sagar 2018).

33. • As of 2021, only a few states included a separate line item in
their budgets towards mental health infrastructure.
• After the passing of the Act in 2017, budget estimates for the
NMHP increased from Rs. 3.5 million in 2017-18 to Rs. 5 million
in 2018-19.
• However, this figure was reduced to Rs. 4 million in 2019-20 and
has remained at the same level in subsequent years – even
2021-22 where several reports have indicated the worsening of
mental health issues during the Covid-19 pandemic

34. A survey
• A survey by the Indian Psychiatry Society indicated that 20%
more people suffered from poor mental health since the
beginning of the Covid-19 pandemic.
• Emerging evidence indicates that during the Covid-19
pandemic, women exhibit relatively higher levels of
psychological stress among the urban poor (Afridi et al. 2020),
and households with migrant workers in rural areas – who were
acutely affected by the lockdown restrictions – show higher
incidence of mental health issues relative to those without
migrants (Sarin et al. 2021).

35. • Students were also severely affected by the lockdowns as it
required adapting to a new learning medium and environment,
as well as increased concerns about future prospects.
• To provide psychosocial support to students during the
pandemic, the government introduced an online platform,
‘Manodarpan’ – with an interactive online chat option, a
directory of mental health professionals, and a helpline number.

36. • Developed countries allocate 5-18% of their annual healthcare
budget on mental health, while India allocates roughly 0.05%
(Organization for Economic Co-operation and Development,
2014).
• In 2018 and 2019, the annual budget also accounted for
expenditure on the National Institute of Mental Health
Rehabilitation.
• The institute was sanctioned in 2018 with the aim of capacity-
building in terms of human resources and research in the area
of mental health.

37. • Additionally, the government annually allocates funds to the
Lokopriya Gopinath Bordoloi Regional Institute of Mental Health and
NIMHANS – both under the Ministry of Health and Family Welfare.
• Although NIMHANS pledges to provide affordable and accessible
mental healthcare to all those who require it, these efforts are
regionally isolated as NIMHANS operates out of a single city
(Bengaluru).
• Initiatives such as the NIMHANS Centre for Well Being – which
provides affordable counselling sessions from trained professionals –
would be a huge boon if expanded to more regions across the
country but as it stands, its impact is limited to an urban metro.

38. Community outreach services
• Atmiyata is a community volunteer service that identifies and
supports people experiencing distress in rural communities of
Gujarat state in western India.
• The Gujarat branch of Atmiyata was established in 2017 in the
Mehsana district of Gujarat state, home to 1.52 million people
and 645 villages, following a successful pilot project in 41
villages of Maharashtra State in 2013-2015.

39. Volunteers have the following roles
• Volunteers have the following roles:
• to raise awareness in the community about mental health issues;
to identify individuals experiencing distress and provide 4-6
sessions of counselling;
• to refer people who may have a severe mental health condition
to the public mental health service;
• and to support people in need with access to social care
benefits

40. Atmiyata
• Gujarat was evaluated in 2017 over a period of eight months using a
stepped wedge cluster randomized controlled trial.
• Results showed that recovery rates for people experiencing distress were
clinically and statistically higher in people receiving support from the
Atmiyata service compared with the control.
• Improvements in depression, anxiety, and overall symptoms of mental
distress were seen after three and eight months.
• Significant improvements in functioning, social participation and quality of
life were reported at the end of eight months.
• Atmiyata Gujarat was initially funded by Grand Challenges Canada but now
receives support from Mariwala Health Initiative, in partnership with
Altruist, a local non-governmental organization funded by the Government
of Gujarat and TRIMBOS Institute.

42. The District Mental Health Program (DMHP)
• The District Mental Health Program (DMHP) was launched in the year 1996
(in the ninth 5-year plan) in four districts under the NMHP.10 Now, it has
developed to include 123 districts under the 12th 5-year plan.
• DMHP has been highly successful in providing mental health care to the
community at least on the district level.
• However, providing mental health care beyond the district level has been very
difficult.
• In this program, either a trained psychiatrist or a general duty medical officer is
provided training for early identification of mental illness and its management.

43. • The Rural Unit for Health and Social Affairs (RUHSA)–A Rural Community
Health Care Program is run by Christian Medical College, Vellore, India, since
1977 to develop a model rural health care center primarily focused on rural
health (maternal, child health, infectious diseases, and dental problems),
poverty alleviation, and so on. It also covers community-based rehabilitation
program for mentally and physically challenged individual.

44. • While presenting the national Budget in
February 2022, India’s finance minister Nirmala
Sitharaman mentioned that there is increasing
mental distress in the country.
• She said that the pandemic had accentuated the
mental health problems in people of all ages
and announced the plan to set up a National
Tele-Mental Health programme in India to
improve the access to quality mental health
counseling and care services.