India is ramping up its response to the nation’s high burden of mental health problems with a new policy to scale up care but questions remain over implementation. Dinesh C Sharma reports.
A September, 2014, report by WHO found that India had the most deaths by suidice worldwide—258 000 of 804 000 deaths reported in 2012. The country’s suicide rate—21 suicide deaths per 100 000 people—is almost twice the world average. The high number of suicides is just one indicator of India’s mental health burden and poor state of mental health care (India has just 3500 psychiatrists, most of whom are working in urban areas).
Newspapers often report cases of people with mental health disorders being chained and detained in custody homes or being treated by quacks in places of worship. Reports of human rights violations and sexual abuse of people with mentall illnesses are common too. A new document—National Mental Health Policy of India (NMHPI)—seeks to remedy the situation by emphasising universal access to mental health care and protection of all rights of people who are mentally ill.
The policy seeks to “promote mental health, prevent mental illness, promote destigmatisation and desegregation, ensure socioeconomic inclusion of persons with mental illness by providing accessible, affordable and quality health and social care to all persons through their lifespan, within a rights-based framework”.
It calls for enhanced understanding of mental health and strengthening of leadership in the mental health sector at all levels to achieve universal access to mental health care. “Roles to be played by the central government, state governments, local bodies, and civil society organisations have been clearly spelt out in the policy”, Health Minister Harsh Vardhan pointed out during the launch of the document.
Acknowledging that some populations are more susceptible to mental illness than others, the policy identifies groups who might need special attention, including people living in extreme poverty, those who are homeless or in custodial institutions, orphaned people with mental illness, children of people with mental illness, internally displaced groups, and people affected by disasters and emergencies.
Experts have welcomed the policy for two of its key features—a rights-based approach to mental health and recognition of the close inter-relationship between social disadvantage and mental health.
“It is a sign of public articulation of political commitment to a highly neglected area within the health sector”, said Thelma Narayan, secretary of the Society for Community Health Awareness Research and Action in Bangalore.
The policy’s greatest strength, according to Vikram Patel, professor of international mental health at London School of Hygiene & Tropical Medicine, UK, is its “unflagging commitment to an inclusive approach to mental health, acknowledging a wide range of mental health goals from promotion of mental health to long-term needs of persons with enduring mental health problems”.
In response to shortages of mental health experts in smaller towns and villages, India rolled out a District Mental Health Programme (DMHP) in 1996 to increase access to mental health care by training general physicians and health-care workers at the district level to provide this care.
As a first step to implement the new policy, DMHP will have to be expanded to all 648 districts from the present 182. This plan, however, will need additional funding. Simultaneously, teaching programmes for mental health professionals such as psychiatric nurses will have to be scaled up. “Implementation of DMHP in its entirety is the single most important obligation of central and state governments, practitioners, as well as civil society”, added Patel.
Expansion of DMHP is necessary to ensure delivery of low-cost psychosocial interventions by appropriately trained and supervised community-based workers, availability of acute inpatient beds at district hospitals, and to reach out to the most vulnerable. Parliamentary approval for the Mental Health Bill is also necessary to ensure the rights of people with mental illness and to decriminalise suicide.
Experts noted that although community-based care is viable, it needs to be part of a coordinated system of care with access to specialised services for those who need it. P Satish Chandra, director of National Institute of Mental Health and Neurosciences, Bangalore, added: “Higher investment in mental health care is justifiable because the economic benefits of effective, equitable, and accessible care far outweigh cost of disability and loss of livelihood due to mental illness.”