India grappling with an acute mental health crisis

Suicides by Anitha and victims of the Blue Whale Challenge were avoidable and not due to NEET and unrestricted access to the internet, but the absence of counselling services for troubled children in health facilities and school systems. While societal expectations put pressure on Anitha, the curator of the Blue Whale game carefully chose youngsters who were depressed, lonely and desperate for help.

As per the 2016 survey in 12 states of India, it is estimated that the prevalence of morbidity due to mental illness is about 10.6 per cent or about 150 million people, though lifetime prevalence is 13.6 per cent. 10 per cent of them are prone to depression and 1.6 per cent commit suicide. By any standard, such morbidity levels are high.

Mental disorders cover a wide spectrum ranging from mild anxiety to severe forms of behaviour and thought abnormalities. Causes are complex varying from genetic, emotional, immunological to indirect triggers like disruptions and the weakening of family bonds, disasters, migrations, acute poverty, uncertainty and an intense sense of failure, helplessness or loneliness.

Since the mentally ill tend to have deviant behaviour, often outside the boundaries of social norms, the tendency is to stigmatise them. Social stigma is why demand for mental health services is low. Only an average of 30 per cent adhered to treatment as families and individuals tend to deny, suppress and hide their ailment. Treatment gap itself in India is estimated to be a whopping 80 per cent due, in addition to stigma, to weak implementation fraught with technical, administrative and resource constraints. The shortfall of professionals is a major barrier. As per a conservative estimate, India needs 8,500 psychiatrists, 6,750 psychologists, and about 25,000 social workers and nurses.

In the above context then, the Mental Healthcare Act of 2017 notified on April 7, 2017 is a landmark of sorts. Humane, rights-based and community-anchored, the Act makes a progressive shift in three ways: Right to access mental health services; mandated patient consent for the proposed treatment; and decriminalised suicide on the logic that suicide is but the manifestation of acute mental stress and the perception of an inability to cope with it. The Act provides for establishing an autonomous authority at the central and state levels to formulate policy, guidelines, register establishments providing mental health services, review, and supervise compliance. At the district level, a Medical Board under a district judge for grievance redressal has been provided. The Act comes into effect within nine months of the notification of the Act. Recently, the rules have been invited for public comment.

Implementation of the Act is going to be challenging for five reasons: First, the muted demand for mental health services due to lack of awareness and social stigma, necessitating intensive campaigns; second, the acute shortage of professionals making it implausible to achieve international standards within the next ten years, requiring multipronged strategies; third, the lack of adequate number of NGO’s with capacity to handle mental health problems; fourth, non-availability of technical capacity at district levels and below for effectively guiding and implementing a coordinated and responsible response at the community level; and finally, acute underfunding. What is needed is massive sensitisation and training at all levels — within communities in schools, at workplaces and among media, judiciary, and medical professionals. All this requires substantial budgets, sustained political leadership, and imagination. Currently, funds allocated for mental health are less than Rs 800 crore or 1 per cent of the health budget. But there is hope.

The situation is similar to 1991 when HIV/AIDS emerged as a global emergency. There was fear, stigma, no money, no civil society response and a society in denial. Two decades of sustained work in an environment where political support for HIV/AIDS was at its height globally and nationally, liberal funding available and policy space for governments to work with criminalised and stigmatised population groups, resulted in a drop in incidence by 60 per cent. The bedrock of the programme was the 6,000 counsellors contributing to reducing both stigma and suicides. Because of this, a $30 million grant was secured to strengthen schools of social work to generate non-medical professionals. Such concerted attention, building on existing experience and leadership would be required for mental health. Most critical is the need to invest in building the epidemiological database, delineating the aetiology and management of the disease, a surveillance system, and operational studies. Without evidence, the best strategies flounder.

Parliament has spoken about providing the mentally ill the right to live in safety, dignity, and security from abuse. It’s up to the Ministry of Health now to design appropriate strategies, forge coalitions of civil society, community professionals, the mentally ill, and increase the budget fivefold. The Act is undoubtedly ambitious, but one worth striving for.

The author is former Union Secretary, MOHFW, GOI. Views expressed are personal.