How To Bridge India’s Mental Health Gap: An Interview With NIMHANS's Director Pratima Murthy

The first National Mental Health Survey 2015-16 carried out by NIMHANS found that one in ten persons had a diagnosable mental disorder. But it must be remembered that there are many more who suffer symptoms of mental distress. Globally, the mental health gap differs for different kinds of mental illnesses, as it does in our country. For severe mental disorders like schizophrenia, it is more than 75 per cent, while for substance use disorders it is upwards of 90 per cent. Again, this differs across different states and regions of the country. The Mental Health Programme was launched in our country in the 1970s. It has now expanded to most districts, but to a different extent on the ground. While the number of people seeking help for mental disorders has certainly increased, it is undoubtedly true that this represents only a small percentage. Mental health service delivery needs adequately trained human resources. While in the last decade, we have been certainly training more psychiatrists, clinical psychologists, psychiatric social workers and psychiatric nurses, for such a large country, the numbers are grossly insufficient. We need to look towards more, better, as well as other solutions.

The number of psychiatrists being trained has increased over time. While about a decade ago, only about 450 psychiatry seats were available per year, presently it is about 1500. Based on that, there are about 0.7-0.9 psychiatrists per 100,000 population. We must acknowledge that a significant number also leave the country for better prospects abroad. Thus, the ratio is way below the recommended median of 3/100,000. We have about 6000 PG seats in general medicine per year. So certainly, there is scope to increase the number of seats in psychiatry to match these numbers. Less than 50 per cent of the medical colleges presently offer post-graduation in psychiatry. Thus, while there is scope to increase post-graduates, it is critical that we maintain the quality of teaching and ensure employability of those who are trained. There are doctors, for example, who are specialised in child psychiatry, geriatric psychiatry and addiction, and it is important to use their skills effectively not just for services, but for training of doctors and other health care providers in these areas as well. This means creating job opportunities in different settings, so that their skills are appropriately utilised.

At NIMHANS, we have demonstrated that a multi-disciplinary approach is particularly important for the treatment of mental disorders, especially for those that tend to be chronic and relapsing and those that require psychosocial support. This means that in addition to psychiatrists, we also need more clinical psychologists, psychiatric social workers and psychiatrically trained nurses. The ratio of such professionals is much lower than even psychiatrists. While we endeavour to increase the specialist mental health providers, we need to focus on integrating training in mental health along with physical health in the undergraduate curriculum, so that all doctors and health care providers can offer basic mental health care, just as they provide physical care. Many task-sharing models have shown promise, but the challenge is in the scaling up, so that care is available to all, and services can be properly networked and tasks truly shared. This would include all credible care resources including government care, private care, and the NGO space. The focus needs to be on providing basic mental health care as well as specialised care.

There are certain universal and scientifically tested approaches for certain mental disorders. Early diagnosis and treatment for example is considered important to prevent negative symptoms and chronicity in schizophrenia. The prompt recognition of bipolar mood disorder and its prophylaxis can prevent dangerous relapses. Identification of obsessive-compulsive disorder and its effective care reduce distress and improves functioning. Effective treatment of substance use disorders is critical for the individual as well as family. Each of these mental disorders have specific symptoms and signs. They are often the result of a combination of biological vulnerability (just as in physical disease) and can be brought on or exacerbated by life events and other kinds of environmental stress. They can be effectively managed by a combination of medications as required, other physical methods of treatment and psychosocial interventions, including psychological therapies. Even for medications, research suggests that the doses and side-effects can differ based on ethnicity, gender, metabolic differences and even climatic conditions. Therefore, it does become important to standardise the same for our population and determine differences across different populations within the country, in order to truly personalise care. However, we are presently more focused on providing care to people that need it the most.

With regard to psychological interventions, most of them are based on Western models, which tend to be more focused on individualism and autonomy and are individual-centred. There are certain universal principles for well-being, self-care and problem-solving/coping, which are applicable across all contexts. In addition, in cultures like ours, which generally focus more on collectivism and interdependence, appropriate modifications are often required. Further, socio-economic determinants, cultural beliefs and family structure are all important considerations. At NIMHANS, we also explore and research psychological interventions based on yoga, meditation and spiritual practices, as well as using Indian epics in psychotherapy. Our psychotherapy training programme tries to integrate different theoretical principles and the individual’s needs into an eclectic approach towards understanding and helping individuals in their contextual backgrounds. Family therapy is also offered to resolve conflicts and help family members support individuals to overcome their problems.

It is important to screen persons coming to primary care centres to identify and manage common mental disorders. Screening tools have been developed for use by community health workers for identifying depression, anxiety and substance use. It’s also important to train the primary care providers to effectively recognise symptoms of psychotic disorders, as well as suicidality, equip service providers to provide ‘psychological first-aid’ and refer to appropriate specialists as required. Such training is being done through the District Mental Health Programme. NIMHANS has also undertaken research projects in states like Karnataka, Odisha, Gujarat, Madhya Pradesh, Uttarakhand and Bihar, to develop local capacity. At the Ayushman Arogya Mandirs, which focus on both physical and mental well-being, elements of mental health and yoga are also included.