Are We Ready to Deal With the Mental Health Crisis?

Covid-19 public health crisis has turned into a mental health crisis and the alarming situation demands innovative approaches and concerted efforts.
Narender Yadav
Narender Yadav

A recent visit to the Institute of Human Behaviour & Allied Sciences (IHBAS), the erstwhile infamous Shahdara mental hospital, also referred to as the Shahdara pagalkhana, for a scheduled meeting, proved to be an exercise in melancholy. Perhaps, it was partly due to the gory past of this campus, when patients with mental illness were shackled and locked up here till a few decades back, and partly also due to the eerie hustle-bustle at the OPD of the institute, even during the pandemic or may be due to the pandemic.

COVID-19 has substantially altered our lives. Socio-economic vulnerabilities, and psychological trauma resulting from isolation and loneliness, particularly among COVID positive patients and effected families, is manifesting itself in serious psychological and socially disruptive ways. But what has been a ‘positive’ development is that the pandemic has brought the issue of mental health in the forefront.

Much before the pandemic, it was in 2015, we last saw mental health issues making headlines and briefly dominating the prime time. This was when Deepika Padukone shared her story of battling depression. Sadly, it was treated more as a ‘celebrity’ related issue than a serious health concern that has been impacting millions of lives in India. While Padukone continues to help people struggling with their mental health, through her Live Love Laugh Foundation, but the larger issue of mental illness has largely disappeared from the public domain, after this transient tryst with limelight. The deadly pandemic has once again brought it out in the open as the prevalence of mental health challenges is now being acknowledged more and more.

Even in the pre-pandemic days, the pervasiveness of mental health issues was quite widespread. A few large-scale studies were also conducted, which gives us some perspective about the gravity of the situation now. According to “The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017”, published in Lancet, 197·3 million people had mental disorders in India in 2017, including 45·7 million with depressive disorders and 44·9 million with anxiety disorders. In fact, one in seven Indians were affected by mental disorders of varying severity in 2017. The study also showed that the proportional contribution of mental disorders to the total disease burden in India almost doubled since 1990. The trend seems to be similar across several countries and the burden of mental disorders on individuals and society in low-income settings remains substantial. The mental health treatment gap has always remained quite large and has now reached to unsustainable proportions.

Sadly, mental health care has been given minimal policy attention and the human and organisational resources available are starkly inadequate and inefficiently utilized. India launched the National Mental Health Programme (NMHP) in 1982, and relaunched it in 1996 as the District Mental Health Programme (DMHP). Eighteen years later, a National Mental Health Policy was introduced, followed by a Mental Healthcare Act in 2017, replacing the Mental Healthcare Act of 1987. Next year, Ayushman Bharat (Healthy India) initiative was launched to provide comprehensive primary health care and health insurance coverage for non-communicable diseases including mental disorders, which could contribute to reducing the adverse effect of mental disorders at the population level. Though policy response has been slow and sluggish, but the biggest worry and challenge remains its implementation. With a high treatment gap for mental disorders, shoddy evidence-based treatment, acute shortage of mental health personnel –  availability of two mental health workers and 0·3 psychiatrists per 100 000 population in India, and discriminatory attitude of health workers towards people with mental illness has made it an extremely complex area of intervention. Health is a state issue in India and the socio-cultural and demographic diversity across the states requires that the policies and interventions to contain the burden of mental disorders be integrated in local contexts. However, given the current scenario, state governments are financially and technically ill-prepared to address these issues in a significant way. As a consequence, despite the urgent need for improving MH services, numerous barriers to service provisions remain unaddressed. In addition to accessibility and treatment gaps, what has also been really worrisome, is the demand-side barriers such as low perceived need for care, lack of knowledge of mental disorders, and strong stigma attached to it. These are the challenges that need to be addressed on priority and in a concerted manner.

Globally, from 1970s onwards, advocating the integration of mental health care into primary care has been the standard approach to narrow the treatment gap in low-income countries. To assist this integration, WHO had also provided a Mental Health Gap Action Programme (mhGAP) intervention guide. However, these evidence-based templates of intervention had their own challenges for adaptation and integration into primary care in low-resource settings. Subsequently, a cross-country mental health services research initiative, called the PRogramme for Improving Mental health carE (PRIME) was also launched, with support from UK Aid. The consortium was led by the Alan J Flisher Centre for Public Mental Health at the University of Cape Town (South Africa), and included institutions from Ethiopia, India, Nepal, South Africa and Uganda as research partners. The primary aim of the project was to provide a robust evidence base on how mental health care can be integrated into primary care in low resource settings. Findings from the study showed that though it is feasible to integrate mental health into primary care in low resource settings, but demands substantial investment in training, supervision, and health system strengthening – something which could take decades in several countries.

In India, an integrated approach to diagnose, treat, and manage patients related to mental health is urgently needed. Task-sharing with non-specialists and appropriate training of community health workers can improve mental health service provisions. Furthermore, telemedicine to provide mental health services in remote and inaccessible areas, as well as to underserved communities, internet-based and telephone-based helplines, and mental health mobile apps can reduce the burden on existing mental health services. After the Pandemic, several helplines have been launched by Central as well as State Governments, and NGOs, though their utility and efficacy varies. Communities and families also have an important role in addressing mental health by reducing stigma and discrimination, raising awareness, and promoting inclusion. Community-based programmes also have the potential to reduce the treatment gap for mental disorders in India.

Taking a more holistic view of the problem, World Health Partners (WHP), a not-for-profit organisation, has recently launched a large scale intervention in 17 districts spread over three states, with support from USAID. An year-long intervention – “Comprehensively Address Mental Health Issues related to COVID-19 Pandemic” – involves undertaking early screening, diagnosis and management of mental health issues through an integrated support mechanism of field coordinators and online counsellors, utilizing the potential of tele-counselling and tele-medicine services in imparting care and treatment, addressing stigma, and bringing about a change in the health seeking behavior of people on mental health. It also strives to integrate mental health services into public health system and scaling up of mental healthcare through consolidation into primary care by various cadres of providers and organizations to make the intervention sustainable and accessible. 

The infamous Shahdara mental hospital, built by the British, as part of a chain of lunatic asylums, is now history and has been replaced by IHBAS – a new-age center for treatment, training, and research. However, as mental health disorders continue to intensify, substantial work needs to be done within the government and in the community to fulfil the objectives of providing equitable, affordable, and universal access to mental health care.

(Writer is a senior journalist and Public Health Communication practitioner. Views are personal)

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