What we need from India’s mental healthcare infrastructure in 2021
As 2020 comes to a close, many of us are heaving a sigh of relief. The year has been a testing one, thanks to the pandemic throwing our lives out of order. It has also brought focus on health and healthcare infrastructure overall, including on mental health. In fact, experts have warned that even as we grow nearer to getting vaccines for COVID-19, the mental health fallout will persist in the time to come.
Several studies have documented increases in mental health issues. According to a publication in the Indian Journal of Psychiatry, psychological distress (34%), stress (34%), and poor sleep quality (40%) are commonly reported issues faced by the general population, health workers and COVID-19 patients across studies. An online survey of 1,871 respondents showed that 40.5% of them said they experienced anxiety or depressive symptoms. Suicide rates may also increase as a result of the pandemic, and a survey by the International Labour Organisation found that 50% of the 12,000 respondents were prone to anxiety and depression. There is plenty of anecdotal evidence from mental health practitioners (MHP) that shows increase and/or exacerbation in mental illness symptoms too.
It is not as though India’s mental healthcare system was adequate prior to the pandemic – however, this fraught time has made painfully clear the gaps that exist and must be plugged. So, as we look at 2021, here is what mental health practitioners are suggesting India needs to do to ensure that its people’s mental healthcare needs are met better.
Not enough MHPs
MHPs that TNM spoke to all agreed on one thing – that there just aren’t enough of them in the country. According to the National Mental Health Survey (NMHS) 2016, which was conducted on a representative population from 12 states, 10.6% of the population had a mental disorder. Translated into real numbers, nearly 150 million Indians are in need of active interventions, the survey said. And, nearly 80% of the people who have mental health disorders had not received treatment for over 12 months. Meanwhile, all states have less than one psychiatrist per one lakh population, except Kerala.
“Except a few premier institutions like National Institute of Mental Health and Sciences (NIMHANS), Bengaluru, there aren’t enough institutes that train and churn out MHPs,” says Dr Manika Ghosh, professor of psychology and director of Bengaluru-based Eudaimonic Centre for Positive Change and Wellbeing. “Few institutes look at health psychology as a discipline too.”
Health psychology studies the intersection of biology, psychology, behaviour and social factors that affect health and illness. “Unlike clinical psychology that focuses on clinical diagnosis and treatment, health psychology also looks at prevention, developing mental health and hygiene. This is important because the time has come to look at mental health as a whole not just mental illness. This is in line with the World Health Organisation’s (WHO) definition of health as not just the absence of disease, but a state of wellbeing,” Dr Manika says.
Experts also point out that because there are so few MHPs, people do not know whom to consult, and there are a number of quacks who may claim to be counsellors. Rashi, director of Communications and Strategy and co-founder of The Alternative Story, an organisation that offers counselling and other mental health services, points out there is also a gap in terms of licensing MHPs in India. The Rehabilitation Council of India, a statutory body, only recognises and licenses clinical psychologists and rehabilitation psychologists.
“We are swimming in the dark because neither do we have enough MHPs, nor do we have standardised licensing for them. So, people don’t know where they can go – they will either go to institutes like NIMHANS or worse, end up going to quacks. We urgently need more courses that train MHPs per current needs with rigour. We could also perhaps set up protocols for a robust referral system where MHPs can refer patients to specialists if needed,” Dr Manika says.
A more systematic commitment to mental health
Tanvi Mallya, founder of Tanvi Mallya's ElderCare Services in Mumbai, says that apart from the scarcity of MHPs reducing accessibility to mental healthcare, affordability also becomes an issue. “This is not to say that a lot of them overprice sessions, many, in fact, under-price too. But it remains unaffordable. This gap can be plugged if we get aid and funding.”
According to the Organisation for Economic Co-operation and Development (OECD), of which India is a part, the country’s total expenditure on healthcare (out of pocket and public) is 3.6% of the GDP, which is much lower than 8.8% of the other OECD countries. In 2017-18, India’s public expenditure on health was even lower, at 1.28% of its GDP. And though the Narendra Modi-led government had said that it aims to increase the public expenditure on health to 2.5% of the GDP by 2025, it is still quite low.
The government has acknowledged the mental health impact of the pandemic. Last month, the Union government had issued guidelines saying that COVID-19 facilities in the country should provide for psychiatric consultation as well. However, Tanvi anticipates that getting the government to adequately aid mental healthcare may take years. “In the meantime, perhaps corporations can step in and set up funds, thus making mental healthcare affordable without the MHPs having to be underpaid. We need long term investment from the government, from academicians, from panels looking at education and training.”
“The state’s responsibility in people’s mental health is a huge gap,” Rashi adds. “All the government is doing is reacting. We saw this time how unprepared we were – initially, as soon as the OPDs and physical centres shut, mental healthcare became inaccessible for so many. Psychiatric medication was scarce or unavailable. What we need in response in the form of a much heavier investment, so that five years from now we see a change.”
Further, when we go beyond cities and metros, to smaller cities, towns and villages, the accessibility and awareness is lower. Experts say that telemedicine, and tele counselling could help address this to an extent.
More advocacy around telemedicine
Telemedicine and tele counselling being allowed in the country – including giving prescriptions which were not allowed earlier – are a result of the pandemic, which also moved much else online. Rashi questions why COVID-19 was required to give this push in a country where internet penetration is good. “We need more guidelines for telemedicine to take leaps and bounds to make mental healthcare more accessible,” she says.
Tanvi points out that telemedicine and tele therapy also need more advocacy work, because people seem to have a mental block that without being face-to-face, it won’t work. “I work with the elderly for instance, and with this group, this is particularly an issue as they are uncomfortable with technology as well. Like them, several other groups like those with disabilities, those in rural areas, and women are also the ones who could perhaps benefit more from telemedicine as it improves access.”
Gautam Saha, the president elect of the Indian Psychiatry Society, says that doctors at the Public Health Centres (PHC) need to be trained to contact MHPs when they think a patient requires it, and enable access through tele therapy or medicine. “There needs to be a pyramid structure wherein even if there are lesser MHPs than needed, till the time this is remedied, their services should be made accessible sustainably to people who may not be in proximity using digital connectivity,” he says.
Building culture, openness and community
Apart from all of the above, one of the biggest hurdles to accessing mental healthcare — even when it’s available — remains stigma. “This, along with the fact that we haven’t still understood the entire [mental health] impact of the pandemic yet, and perhaps we won’t till the physical health impact of it settles down. We are still in crisis mode, where the gaps are visible, people are talking about it more. What we need is to understand mental health at a community level, and to emphasise the role of community in managing mental health,” Rashi says.
She adds that even if the government mandates counsellors and psychiatrists at the district or PHC level, there just aren’t enough of them. “What we need are people who are trained to provide emotional support. Many people may not even need counsellors, they need emotional first aid. So, decentralising by training some people in basic empathy and listening skills – people who are aware of the local context and ways and are able to talk to affected persons. We also need to start building these qualities and skills in students in schools and colleges.”