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Printed in India India Prepared for the Ministerial Roundtable of the 75th Session of the WHO Regional Committee for South-East Asia 6th September 2022 Addressing mental health in Source: World Bank https://data.worldbank.org/ - accessed on 10th June 2022 Gross National Income per capita, Atlas method (current US$) UHC coverage index As a % of GDP Doctors Community health workers Gross National Income per capita, Atlas method (current US$) Nurses and midwives Hospital beds Govt health expenditure For each 100,000 population 2120 (2019) 67 (2019) 3.01 (2019) 92.8 (2019) 58.1 (2016) 63.75 (2019) 232.9 (2019) 289.4 (2017) 28 States and 8 Union Territories, 750 Districts Population 1.37 billion (2019) Life-expectancy 69.7 (2019) Addressing mental health in India2 The overall weighted prevalence of mental morbidity for those over 18 years of age was 10.6% and 13.7% for lifetime prevalence. Lifetime prevalence (by ICD 10 classification) • Schizophrenia and psychotic disorders (F20–F29) 1.4% • Depressive disorders (F32–F33) 5.1% Current prevalence (by ICD-10 classification) • Epilepsy (Generalized Tonic-Clonic Seizures) 0.3% • Schizophrenia and psychotic disorders (F20–F29) 0.4% • Depressive disorders (F32–F33) 2.7% • Bipolar (affective) disorder (F30–F31) 0.3% • Neurotic and stress-related disorders (F40–F48) 3.5% • Alcohol use disorder (F10) 4.6% • Other substance use disorders (F11–F19 except F17) 0.6% Intellectual Disability (ID) screener positivity rate: 0.6% The National Suicide incidence rate per 100,000 was 10.6 (male 14.3, female 7.2) • The prevalence of mental health conditions was higher among males (13.9%) than females (7.5%). However, mood disorders were higher among women. Males in the age group of 30–49 years were the most affected by mental illnesses. • Residents of urban metros had a greater prevalence of mental disorders and persons from lower income quintiles had a greater prevalence of one or more mental disorders. • Of those over 18 years, 0.9% was at high risk and 0.7% at moderate risk of suicide. The highest-risk groups were females (1.14%) compared males (0.66%), those living in urban metros (1.71%) and those between the ages of 40–49 years. • The prevalence of mental health disorders in the age group of 13–17 years was 7.3% and similar among boys and girls. Depressive disorders were the commonest conditions. Nearly 9.8 million young Indians aged between 13 and 17 years were in need of active interventions. The prevalence was significantly higher (13.5%) in urban metros compared to rural areas (6.9%) in this age group. Source: National Mental Health Survey of India, 2015-16: Prevalence, Pattern and Outcomes. National Institute of Mental Health and Neuro Sciences 2016 Prevalence The burden of mental health problems World Health Organization 3 Mental health policies, programmes and laws • The treatment gap for all types of mental health problems ranged from 28% to 83%. It was 85.2% for common mental disorders, 75.5% for psychoses, 70.4% for bipolar affective disorders and 86.3% for alcohol use disorder. • The median duration for seeking care from the time of onset of symptoms differed from 2.5 months for depressive disorder to 12 months for epilepsy. A government facility was the commonest source of care. Treatment gap • The National Mental Health Policy (NMHP) 2014 calls for universal access to quality services, equitable distribution, community participation, a rights-based approach, intersectoral coordination, use of appropriate technology, and a holistic approach to mental health. It is fully implemented, and its principles have been incorporated in the NMHP/DMHP (National and District Mental Health Programmes), and Mental, Neurological and Substance Use (MNS) package at health and wellness centres (HWCs) operating at the primary care level. • The Mental Healthcare Act 2017, has provisions for mental health care and services for persons with mental illness and for protecting, promoting and fulfilling the rights of such persons during delivery of mental health care and services. The national rules for implementation of the Act have been endorsed. Further, states are in the process of developing their own rules, drawing from the national rules. It safeguards the rights of persons with mental illnesses, decriminalizes suicide and regulates electroconvulsive therapy. Elements of mental health promotion can be included as appropriate. Source: National Mental Health Survey of India, 2015-16: Prevalence, Pattern and Outcomes. National Institute of Mental Health and Neuro Sciences 2016. Addressing mental health in India4 Prevention and promotion: organization and coverage • To generate awareness of mental illnesses, information, education and communication (IEC) activities are already an integral part of the NMHP. Posters and videos to generate awareness of mental health, and advisories for promotion of mental well-being are periodically released on the Ministry of Health and Family Welfare (MoHFW) website and social media handles. • At district level, funds up to INR 400 000 per annum are provided to each district for IEC and awareness generation activities in communities, schools and workplaces, with community involvement. Under the District Mental Health Programme (DMHP), various IEC activities such as messages to generate awareness in local newspapers and the radio, street plays, wall paintings, etc. are undertaken by the states/Union Territories (UTs). Since public health is a state subject, details of specific activities may be requested from the states. • Early childhood and good parenting: the Rashtriya Bal Swasthya Karyakram (RBSK), under the National Health Mission, screens children from birth to 18 years of age for 4 D’s – Defects at birth, Diseases, Deficiencies and Development delays, spanning 32 common health conditions for early detection and free treatment and management. These include surgeries at the tertiary level. Mental health and neurological conditions are identified (1). Children diagnosed with identified selected health conditions are provided early intervention services and follow-up care at the district level. • Preventing bullying: the School Health Programme under Ayushman Bharat – a joint initiative of the MoHFW and Ministry of Human Resource and Development – takes care of this aspect. Prevention of bullying is included under school health promotion activities (2). • The Ministry of Human Resource, in collaboration with Ministry of Health, is implementing the School Health Programme under Ayushman Bharat. • The Ministry of Social Justice and Empowerment has schemes to address alcohol and other psychotropic substance addiction. 1. Rashtriya Bal Swasthya Karyakram (RBSK). In: Ministry of Health and Family Welfare, Government of India [website] (https://rbsk. gov.in/RBSKLive/, accessed 20 August 2022). 2. Operational guidelines on school health programme under Ayushman Bharat. New Delhi: MoHFW and Ministry of Human Resource and Development; 2018 (https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/AH/guidelines/Operational_guidelines_ on_School_Health_Programme_under_Ayushman_Bharat.pdf, accessed 20 August 2022). World Health Organization 5 Mental health services: organization and coverage • The Mental Health Division, Ministry of Health and Family Welfare (MoHFW) at the national level, Mental Health Division of the MoHFWs of state governments at the state level and the District Mental Health Programme (DMHP) govern mental health services. However, on occasion, the responsible officers are entrusted with responsibilities to run multiple programmes, thus they are not able to give focused attention to mental health. • The DMHP component of the NMHP has been sanctioned for implementation in 704 out of 750 districts for which support is provided to all states/UTs through the National Health Mission. • Facilities made available under the DMHP include outpatient services, assessment, counselling/psychosocial interventions, awareness generation, continuing care and support to persons with severe mental disorders, drugs, outreach services at the community health centre (CHC) and primary Addressing mental health in India6 health centre (PHC) levels, ambulance services, etc. In addition to the above services ,there is provision for a 10-bedded inpatient mental health treatment facility at the district level. • To increase the availability adequately trained mental health workforce at all healthcare levels, tailor made courses have been initiated through a digital academy. • The government is also taking steps to strengthen mental health and neurological care services at the primary level. Mental health services are provided to the primary level through the DMHP through outreach services at the community health centre and primary care level. Operational guidelines on mental, neurological and substance use disorders (MNS) at HWCs have been released under Ayushman Bharat, which define the roles of multiple cadres of primary health workers, including accredited social health activists (ASHAs). Primary health-care workers are being trained in line with these guidelines to provide mental health services to all sections of the society at the primary level. • DMHP guidelines makes provisions for medications to be made available at the CHC level, where they are dispensed by the Medical Officer. • Half-way homes and community rehabilitation centres have been established by certain states in collaboration with nongovernmental organizations (NGOs). • The Drug De-Addiction Programme under the MoHFW provides treatment facilities in selected Central Government hospitals/ institutions. • To provide psychosocial support and mental health services during emergencies, a 24 x 7 toll free helpline (toll-free number: 080–4611 0007) has been established to provide psychosocial support and mental health services during emergencies. People from any part of the country can call up at this number and avail psychosocial support and mental health services from mental health professionals. • Human resources is a major challenge, although the government provides grants to education and training institutions to produce qualified mental health professionals. The District Mental Health Programme (DMHP) component of the NMHP has been sanctioned for implementation in 704 out of 750 districts for which support is provided to all states / UTs through the National Health Mission. World Health Organization 7 • The National Trust, a statutory body of the Ministry of Social Justice and Empowerment, was set up under the “National Trust for the Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities” Act (Act 44 of 1999), based on the principles of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). It works to provide opportunities for capacity development of persons with disability and their families. Under the Disha scheme (early intervention and school readiness scheme), early interventions, including therapies to affected persons, and training and support to family members are carried out (3). • The Ministry of Social Justice and Empowerment has schemes to address alcohol and other psychotropic substance addiction. • The Ministry of Education is implementing the Ayushman Bharat School Health and Wellness Programme in collaboration with the MoHFW. Services through different sectors 3 https://www.thenationaltrust.gov.in/content/innerpage/introduction.php Addressing mental health in India8 • The country has a high capacity for interventional research, with centres of excellence situated in different parts of the country. • To strengthen mental health programmes and develop data- driven programmes, the MoHFW, Government of India commissioned the National Institute of Mental Health and Neuro Sciences (NIMHANS) to conduct the National Mental Health Survey, which was completed in 2015–2016. Planning for the second version of the survey is now under way at the national level. • Components of alcohol and tobacco use are covered in the National Family Health Survey. Mental health information system and research World Health Organization 9 (approximately 7.2 million individuals) need help for their cannabis use problems • 2.1% of the country’s population (22.6 million) uses opioids which include opium, heroin and different pharmaceutical opioids. About 0.55% of Indians are estimated to need help for their opioid use problems. At the national level, the most common opioid used is heroin, (current use 1.14%) followed by pharmaceutical opioids (current use 0.96%) and opium (current use 0.52%). The overall prevalence of current use of opioids is 2.06% . Issues requiring urgent attention Analysis • Due the large population of the country, the numbers affected by mental health conditions are significant. The National Mental Health Survey 2015–2016 (4) showed that 150 million people in India needed intervention for mental disorders. However, less than 30 million are seeking care at present. • Except for epilepsy, all the other mental disorders had a treatment gap of more than 60% with the highest treatment gap being for alcohol use disorders (86%). • One in 20 persons in the country suffers from depression, out of which 39% suffer from severe depression. Three out of four persons with severe mental disorders have disabilities affecting their work, family, education and other aspects of life. • Of the population over 18 years, 0.9 % is at high risk of suicide. • According to the Magnitude of Substance Use in India (2019) (5): • 14.6% of people about (160 million) were current alcohol users between 10 and 75 year of age. About 5.2% of Indians are estimated to be affected by harmful or dependent alcohol use. • About 2.8% of Indians (31 million) reported using cannabis products within the previous year and about 0.66% What needs to be sustained and supported • The NMHP is being implemented in all states and UTs in India, with the objective of ensuring the availability and accessibility of minimum mental health care for all, with a special focus on the most vulnerable and underprivileged sections of the population. • The DMHP is currently being implemented in 704 of the 750 districts in the country to facilitate early detection and treatment and to generate public awareness. • To ensure the availability of health-care services at the community level, the Government of India, under its Ayushman Bharat initiative, included the “Mental 4. National Mental health Survey of India, 2015–16. Bengaluru: NIMHANS; 2016 (http://www.indianmhs.nimhans.ac.in/Docs/Summary. pdf, accessed 20 August 2022). 5. Magnitude of substance use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India, NDDTC, AIIMS; 2019 (https://www.aiims.edu/images/pdf/Departments_Centers/NDDTC/Magnitude_Substance_Use_India_ REPORT.pdf, accessed 20 August 2022). Addressing mental health in India10 Areas needing further investment health, Neurological and Substance use disorders” (MNS) package at HWCs. The government has a target of operationalizing 150 000 HWCs by the end of 2022. • These initiatives are ensuring the availability of trained human resources by building the capacities of non-specialist cadres with a capsule of in-service training, which is in line with the WHO mental health Global Action Programme (mhGAP). Priority is also given to ensure the availability of medicines and other essential equipment for diagnosis and treatment of mental health conditions. • Recently, the government has announced the launch of telemedicine services to be implemented through NIMHANS as the nodal centre. Preparations are ongoing. • Strengthening the capacities of community mental health workforce to address issues related mental health. • Availability of medicines, addressing disabilities and other essentials for treatment of mental health and substance use disorders. • Effective implementation of the Mental Healthcare Act 2017, which ensures the rights of the people with mental health conditions Challenges and possible solutions • There is a lack of awareness among people that mental health, neurological and substance use disorders are conditions that require interventions. This is a major challenge at the community level. Such conditions are usually considered as punishment for sinful actions or curses by evil spirits. The stigma associated with mental health and substance use disorders further dissuades people from accessing services. The NMHP/DMHP and services at HWCs have a major component of community awareness, generating demand for the available mental health services. • Although a comprehensive mental health law and policy and treatment guidelines are available, their implementation needs strengthening to ensure the effectiveness of these policies, laws and guidelines at the ground level. World Health Organization 11 SWOT Strengths Opportunities Strong central- and district-level organization is available for mental health preventive and curative services. A comprehensive mental health policy and law and guidelines are in place. Prevalence data are available at the state level. An established community and primary care system is in place. There is a plan to implement the Mental health, Neurological and Substance use disorders (MNS) package at 150 000 HWCs by the end of 2022. Mental health has been given high importance during the pandemic. High-quality technical expertise is available within the country. Addressing mental health in India12 Administrators are entrusted with other programmes in addition to mental health. Human resource constraints related to clinical, primary care and field staff need to be addressed. Weaknesses Threats Stigma and lack of mental health literacy are widespread. Conditions for mental health professionals in the government sector are not attractive. The current high treatment gap could escalate. There is a large number of substance users who may develop mental disorders. World Health Organization 13 Notes Addressing mental health in India14 World Health Organization 15 Notes Addressing mental health in India16
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