Mental Health

Introduction

• Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.

• It incorporates a wide range of issues, from clinically diagnosed mental disorders to substance abuse and addiction. Similarly, symptoms and manifestation of mental health issues vary between individuals depending on life experiences, family history, genetic factors, nature of immediate surroundings, gender etc.

• Mental health issues – as a sub-set of non-communicable diseases – add to the Double Burden of Diseases of most developing countries including India. The Double burden refers to the added burden of non-communicable diseases (NCDs), to the traditional menace of communicable diseases and their impact on human population. In India, the burden of NCDs is higher than that of CDs.

• While its impact remains immense, mental health is typically underreported, and under-diagnosed.

Mental Health: A Global Concern

• Mental Health finds explicit mention in Goal 3 of Sustainable Development Goals. It highlights the need to reduce mortality through NCDs and promote mental health and well-being. Suicide rates are an indicator of measuring progress.

• About 14% of the global burden of disease is attributed to neuropsychiatric disorders, which is a conservative estimate since this is only a small portion of what counts as a mental health issue.

• Around 800 000 persons approximately die from suicide globally each year (1 death every 40 seconds).

• It is estimated that 970 million people worldwide had a mental or substance use disorder in 2017. The largest number of people had an anxiety disorder, estimated at around 4 percent of the population.

• Over 264 million people of all ages suffer from depression across the globe.

Mental Health in India: Some Statistics

Important Mental Health Challenges in India

• Top three disorders in respect of percentage share of total disease burden for the country are related to substance abuse: tobacco (13.1), psychoactive substance (5.0), and alcohol (4.6).

• Neurotic and stress-related disorders account for 3.5 percent, mood affective disorders are at 2.8 percent, closely followed by depression (2.7). According to the World Health Organization (WHO), at least 57 million people in India are affected by depression – the highest in the world.

• More issues include phobic and other anxiety disorder, schizophrenia, bipolar affective disorder, and obsessive compulsive disorder (OCD) among others.

• Common Mental Disorders – depression, anxiety disorders and substance use disorders affect nearly 10.0 percent of the population, and are often related to causes and consequences of several NCDs.

• Translated to real numbers (based on weightage for different levels), nearly 150 million Indians are in need of active interventions. This includes nearly 9.8 million of young Indians aged between 13-17 years.

• The age-adjusted suicide rate per 100,000 population is 21.1; the world average in 10.5.

Distribution: Across Regions and Amongst Gender

• Mental health issues are more prevalent in urban areas, as opposed to rural. This value is even higher for metro cities. Specific disorders like schizophrenia and other psychoses, mood disorders and neurotic or stress related disorders are nearly 2-3 times more prevalent in urban metros.

• The overall prevalence of mental morbidity was higher among males (13.9%) than among females (7.5%). However, some disorders like mood disorders (depression, neurotic disorders, phobic anxiety disorders, agarophobia, generalised anxiety disorders and obsessive compulsive disorders were higher in females.

• Women are at greater risk for neurosis stress related disorders, especially in primary care settings where they are usually missed or misdiagnosed. Tobacco, alcohol and substance abuse were higher in men than women.

• The above trends are also observed for mental health issues at the global level.

Affordability: Financial Burden on People

• Affordability varies between urban and rural areas – lower in rural areas.

• It costs approximately Rs. 1000 – 1500 on average for a family per month to treat a mental illness.

• Lack of government assistance in the same leads to the burden falling on the patient’s family in most cases.

Gaps in Preventive and Curative Care

• Mental health workforce in India (per 100,000 population) include psychiatrists (0.3), nurses (0.12), psychologists (0.07) and social workers (0.07).

• This amounts to less than 4000 psychiatrists in the country.

• Additionally, not enough attention is given to training. Becoming a psychiatrist involves only 1.4 percent of total lecture hours and a two-week internship in a medical school.

• In India, healthcare providers involved in mental healthcare are not well informed of the objectives of various state programmes and believe that these programmes serve only to spread awareness.

• Three is a huge treatment gap still for all types of mental health problems: ranging from 28 to 83 percent for mental disorders and 86 percent for alcohol use disorders.

• The number of beds for mental health issues is only 2.15 beds per 100,00 which is well below the global average of 6.5.

Lack of Funds: Government Expenditure

• In the financial year 2019, the budget allocated to the National Mental Health Programme (NMHP) was brought down to Rs 40 crore from Rs 50 crore in FY18. And the funds actually spent were only about Rs 5 crore each during the years.

• While the total healthcare budget increased by 7 percent in 2020, there was no corresponding increase in the budget for NMHP. The allocated amount is only 0.05 percent of the total healthcare budget.

• The actual current spending to implement provisions of the Mental Healthcare Act, 2017 is a very small fraction of the conservative estimate of Rs 94,073 crore.

Social Perceptions and Lack of Awareness

• The Live Love Laugh Foundation (TLLLF) conducted a study on Indian perception of mental illness. Around 71 percent respondents used language and terms associated with stigma to describe mental illness.

• Stigma and discrimination are negative consequences of ignorance and misinformation. Mental health literacy among adolescents in 2016 was very low: depression was identified by 29.04 percent and schizophrenia/psychosis was recognized only by 1.31 percent.

• Lack of knowledge about the mental illnesses poses a challenge to the mental health care delivery system.

Implications of Mental Disorders

Three out of four persons with a severe mental disorder experience significant disability in work, social and family life.

Disability Adjusted Life Years

• The disability-adjusted life year is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death.

• Nearly 50 percent of persons with major depressive disorders reported difficulties in carrying out their daily activities.

• The proportion of disability proportion was relatively higher among individuals with bipolar affective disorders (63 – 59 percent), major depressive disorder (67-70 percent) and psychotic disorders (53-59 percent).

Social and Emotional Cost

• Families of patients incur social costs, such as the emotional burden of looking after disabled family members, diminished quality of life for caregivers, social exclusion, stigmatization and loss of future opportunities for self-improvement.

Economic Cost

• Males in the age group of 30 – 49 years – usually identified as the productive population – are the most affected by all mental health issues, which peak during this time.

• The indirect costs attributable to mental disorders outweigh the direct treatment costs by two to six times in developed market economies, and are likely to account for an even larger proportion of the total treatment costs in developing countries, where the direct treatment costs tend to be low.

• By 2030, The Mental Health Crisis is going to cost India a trillion dollars in lost productivity.

Combating Health Issues – the Government’s Approach to Mental Health

Timeline of Developments

• The Lunatic Removal Act, 1851, the Lunacy (Supreme Courts) Act, the Lunacy (District Courts) Act and the Indian Lunatic Asylum Act – all three in 1858, and the Military Lunatic Act, 1877 were consolidated in 1912 under the Indian Lunacy Act, which drew heavily on the English Lunatics Act, 1845.

• Shortly after independence, a modern mental health act was drafted, but it was finally adopted after 35 years as the Mental Health Act, 1987.

• In 2007, India ratified the United Nations’ Convention on the Rights of Persons with Disabilities (CRPD) and this provided further impetus for updating the legislation.

• In 2014, the government came out with India’s first ever Mental Health Care Policy.

• The Mental Healthcare Act, which replaced the Mental Health Act, 1987 was passed in 2017, and enforced the following year.

Mental Healthcare Act, 2017

• Addressing issues of access and equality, the legislation ensures healthcare, treatment and rehabilitation of persons with mental illness from mental health services run or funded by the appropriate government in a manner that does not intrude on their rights and dignity.

• It decriminalizes suicide; it also disallows sterilization and solitary confinement of mentally unwell patients. Electroconvulsive treatment will not be given to minors, and for adults it will not be administered without muscle relaxants and anesthesia.

• Advance Directives are introduced which give people suffering from a mental illness the right to choose their mode of treatment, and by nominating representatives who will ensure that their choices are carried out.

• It provides for the setting up of Central Mental Health Authority at the national-level and State Mental Health Authority in every State for registration and training of medical professionals. It will also have an advisory role regarding mental healthcare and services.

• It also mandates insurance companies to provide mental health insurance on similar lines with physical health insurance.

Other Related Legislations and Policies

• The passage of the Rights of Persons with Disabilities Act, 2016 also had significant implications for people with psychosocial disabilities as it included mental illness in the definition of disability in the CRPD.

• Ayushman Bharat or the National Health Protection Mission – initiated in 2018 – is a medical insurance scheme for the poor and economically deprived people. It includes detection and treatment of mental health issues, as well as mental health-related services, through Wellness Centres across the country.

• Models to ensure deeper penetration of services and staff now include ASHA workers. These community health workers not only educate and sensitize women and children about mental diseases but also guide them to reach the right expert in their locality.

Recommendations

• There is an urgent need to sensitize and educate individuals about the signs and symptoms of mental illness while normalizing the idea of seeking support for themselves and their loved ones.

• Efforts to increase awareness and mental health literacy should take actively involve the conventional media, the internet and social media, government programs, and the educational system. These are essential to narrow the gap between access to physical and mental health.

• Steps to connect the patients with each other by forming a peer network, so that they could listen and support each other.

• A National Commission on Mental Health, and a National Plan for Mental Health Literacy should be envisaged.

• Mental Health should be integrated with National Urban Health Mission to deal with high prevalence of mental health issues in urban areas.

• Mental health should also be integrated with programmes of NCD prevention and control, child health, adolescent health, elderly health and other national disease control programmes.

• Mental healthcare should be integrated with community healthcare in order to make it more accessible and affordable.

• The role of ASHA workers needs to be scaled up to ensure deeper penetration of health care access at the community level.

• Prioritized mental health questions should be included in ongoing future national surveys like NCD risk factor survey, National Family and Health Survey, NSSO and others.

• Overall allocation and expenditure in mental health must be augmented.

• Improvement in the quality and duration of learning modules for psychiatry is imperative.

• An incentive based approach should be utilized to encourage interest in the field of psychiatry and psychology and to solve the shortage of medical professionals in the field.

• Research and development in the field of mental health should be encouraged, and funded by the government.

• While Ayushman Bharat allows for insurance for medical treatment of the mentally unwell, financial protection in form of allowances should be initiated. Those with minor issues should be assisted through participation in skill development programmes.

• Corporate Social Responsibility (CSR) should be in encouraged in the field of mental health.