New Delhi: Mental health is a hot topic across the world now because of growing awareness about its impact on people. Despite noise, however, not much has been done to actually address the pressing issues on mental health with the approach being more curative than preventive. This approach contradicts what was envisaged in the first mental health policy of India in 2014.
During the discussion organized by Ashoka University – 'India's Way Through the Second Wave' on Tuesday – Dr Soumitra Pathare, Director, Centre for Mental Health Law & Policy said with disappointment, "Everyone is talking about how India's health system has collapsed, there has been no collapse of the mental health system…it never existed in the first place. So there is nothing to collapse," he said.
Dr Pathare was joined by Dr Gagandeep Kang, Dr Shahid Jameel, Dr Gautam Menon, Dr Ramanan Laxminarayan, Professor Priscilla Rupali who had gathered to discuss issues in mental health.
How did we get here? What could we have done better? And, looking forward, what might unfold in the coming weeks?
These were some of the questions asked by the experts who also discussed the need for large-scale changes the Indian health care system to prevent crises like the one the country is facing at present.
Pre pandemic data – a warning
The National Mental Health Survey (NMHS) of India was implemented by National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore in 2016 by way of recognizing the need for good quality, scientific and reliable information for strengthening mental health policies and programs
The findings of the survey – The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity – revealed that the “treatment gap for overall mental morbidity was 84.5 percent."
NMHS concluded in its largest reported survey of mental morbidity in India, "Survey estimated that nearly 150 million individuals suffer from one or the other mental morbidity in India. This information is to be used for planning, delivery and evaluating mental health programming in the country."
Citing the data that as the best academic study to come out in India on mental health, Dr Pathare said, “Way before the pandemic, NIMHANS implemented a national mental health survey and what they found was 150 million Indians had diagnosable mental health illness… and roughly 85 percent of them did not receive any treatment."
This is the reality of mental health care in India way back in 2016, "This survey results have nothing to do with pandemic. If the treatment gap was 85 percent then it must have gone to 95 percent by now. So there is likely an increase in 10 percent. The reason it becomes such a big noise now is because of the 10 percent of people who are now getting affected – people like you and me."
"Earlier, there were 85% who did not have a voice, and we did not bother," he added.
In an EPW article (2017) titled "Treatment Gap in Mental Healthcare Reflections from Policy and Research", authors Reetinder Kaur and RK Pathak wrote about the “wide treatment gap in Indian mental healthcare."
The prevalence of serious mental illnesses estimated at around 6.5% according to the 'Institute of Health Metrics and Evaluation 2013', quotes the paper. The authors said, "One major problem that exists in Indian mental healthcare is the treatment gap," which is the number of individuals (expressed as a percentage) with an illness who need treatment but do not receive it.
There are ways to deal with the challenges on mental health, and one of the challenges is an unnecessary fixation on the strength of psychiatrists. Every time experts talk about solutions, they are met with responses like ‘What can we do…we are a poor country, we do not have enough psychiatrists, we do not have enough psychologists’. That is the answer we usually get," he said.
In his opinion, this approach of pinning hopes on psychiatrists won't help much. "India reduced its maternal mortality by more than 50 or 60 percent in a few decades, not because we suddenly produced lots of obstetrician and gynecologists. India reduced its infant mortality rate because of pediatricians. The fact of the matter is if we are to reduce our mental health treatment gap it is not going to come with psychiatrists alone, it is going to come if we have a proper community based care, which can be provided at various levels," he said.
Giving example of the United States of America he said, "The US has more psychiatrists than the rest of the world put together. The USA has 50 percent of the world's psychiatrists. The USA has the treatment gap of 30 percent. So clearly having all the psychiatrists in the world is not the way to solve the problem."
He emphasized on the need to have preventive approach towards mental health because as a poor country we cannot afford to fall ill, mentally as well.
The National Mental Health Policy of India 2014 stressed on 'expanding availability of adequately trained mental health human resources to address mental health needs of the community'.
The policy has acknowledged reduction of the gap between requirements and availability of trained mental health professionals. Called for integration of mental health in training programs of other allied fields, a seamless transition from a general practitioner/ service to specialized care, providing opportunities to auxiliary nursing midwives for skill upgradation in mental health.
"Mental health should be recognized as everybody's business", policy said.
It further pointed out that “Training programs must acknowledge that while biomedical approach to understanding mental health problems is undoubtedly important there are equally important psycho-social interventions which need to be incorporated into programs across all disciplines that would help alleviate distress in small ways.”
This was to broaden the scope and reach of mental health interventions, and help decrease stigma and position mental health more positively.
The policy under the section 'Community participation for mental health and development' highlights an increase in the space for "voice of persons with mental illness and caregivers in planning and feedback of mental health services."
In the policy, mental health is defined as "not just the absence of mental disorder. It is defined as the state of well being in which the individuals realize their own abilities can cope with normal stresses in life, can work productively and fruitfully, and are able to make a positive contribution to their community…"
No progress since 2014
In India the Government came up with the policy – 'New Pathway, New Hope', National Mental Health Policy of India. Experts like him spent four years in formulating the idea and implementation path of the national mental health policy in 2014 "But nothing after that. No policy was implemented. There was no funding. People believe we have a wonderful mental health policy, hence must be doing great but the second part is not true," he said.
The first wave had already introduced big challenges ahead with regards to mental health. "How much resources or funding has been allocated to mental health this year? Nothing, in fact, the budget has reduced and the mental health budget was raided on the pretext that people are dying," Dr Pathare said. He also stressed that during the first wave of the pandemic, the only wards to have shut down were of mental health and were turned into covid wards. This was not followed for other streams like cardio. He also pointed out that the personnel on mental health were put on Covid-related duties.
Worried about the "demographic dividend killing itself," (suicides) Pathare said, "We do not have a national suicide prevention strategy," and once again rooted for "Preventative rather than curative approach in mental health."