The ticking clock of mental health crisis in India: An analysis of the treatment gap for mental health care services in the country
Mental Health Care is a worldwide public health concern. Addressing inequalities in the system and setting priorities based on the burden of the disease remain issues to be addressed. The delivery of mental health care services has mostly been slow-paced in low and middle-income countries, including India.
The lack of attention given to psychology as a course in colleges and universities-
Colleges and universities that offer psychiatry and psychology as disciplines of study play a paramount role in helping students graduate by equipping them with quality knowledge through their rigorous courses and clinical experiences. Psychiatry and clinical psychology offered at the postgraduate and MPhil levels are not considered lucrative by most state governments. There is a dire need for all the states to increase the seats. Even in undergraduate medical courses, India hardly gives attention to psychology. In addition, around 25% of clinical psychology professionals often leave the country due to better service conditions, pay and job prospects abroad which results in a brain drain for the country and puts more pressure on the already scarcely available mental health professionals.
The treatment gap
“Treatment Gap (TG)” signifies a huge difference in terms of numbers between those who need mental health care and those who actually receive it. According to the 2015-16 National Mental Health Survey in India, the treatment gap for any kind of mental disorder was estimated to be around 83%. Every sixth person in India needs mental health help. Given that the treatment gap and the demand for mental health are undeniably huge, the supply catering to this demand is still abysmally low. In India, there are 0.20 psychiatrists per 10,000 people, 0.03 clinical psychologists per 10,000 people, 0.03 social workers per 10,000 people, and 0.25 psychiatrists per 10,000 beds. There is only 1 psychiatrist for over 2 lakh people in India.
Bitter Pills to Swallow
Many patients in India often visit psychiatrists when the nature of their problems is better suited to be solved by a clinical or counselling psychologist. Moreover, many clinicians are engaged in malpractice and additionally they don't see their patients sufficiently enough to effectively solve their problems due to a strain in the mental health system. Because of the overstretched mental health care system, psychiatrists often prescribe excessive medications after seeing patients for only 10 minutes instead of 45 minutes to an hour and prescriptions keep changing as soon as one set of drugs stops working.
The National Mental Health Survey report shows that nearly 80% of Indians have not received treatment, despite the illness being present for 12 months or more due to the stigma associated with mental illness which becomes a roadblock to seeking treatment. In the year 2013, nearly 31 million disability-adjusted years (DALY) (i.e years lived with a disability, in this case mental illness) were due to mental, neurological and substance abuse disorders (Shankardass, 2017). This incurs enormous costs to the organisations in terms of absenteeism, employee turnover and low rates of productivity etc.
Lack of proper mental health facilities in India and overcrowding
A survey conducted by the National Human Rights Commission, reviewed the conditions of mental health hospitals between 1998 and 2008 it was noted that the conditions of the hospitals were unsatisfactory and nearly 38% of the hospitals retained prison-like structures. Most of the large hospitals were overcrowded and the ratio of beds to patients was 1:1.4, which indicates that many patients slept on floor beds.
The internal report of the NHRC was even more alarming as it was found that patients weren’t treated well - they were made to openly defecate and urinate in an open drain. Many hospitals also faced a shortage of running water. 70% of the hospitals had poor storage facilities, 38% of the hospitals had inadequate lighting, 89% of them had closed wards and 43% had cells for patients who were supposed to be isolated from the rest. Broken windows, doors, leak in the roofs, overflowing toilets, and eroded floors were observed in most of the hospitals. Even archaic practices like wearing a uniform and shaving the heads of the patients were still prevalent.
Most of the hospital staff in India is poorly equipped when it comes to handling patients for mental health care. Case-file recordings are insufficient, clinical psychologists and psychiatric social workers are short in supply in less than half of the hospitals, less than 25% of hospitals had trained nurses present and 81% of the hospital's staff reported a shortage of staff members.
In addition, a survey of 43 hospitals across India found that 36.25% of mental health patients stay in hospitals and residential homes over a period of one year which is above the world average (18%) and is over the six-week minimal requirement, leading to overcrowding in these places and 93.5 % of the patients never step out and over 86.5% of them never have any visitors. Patients refuse to leave because they get no stable source of income once they leave, have no one to rely on, face homelessness, stigma and gender disadvantages - with women more disproportionately affected (54.3%).
Urban vs. Rural mental health scenario -
Urban areas and metropolitan cities certainly don’t fare better in terms of mental health because at least 150 million Indians are in dire need of mental health interventions. Reportedly, almost 1 in 20 suffers from depression in these parts (National Institute of Mental Health and Neurosciences, 2016). On the other end of the spectrum, mental health resources in rural areas are also severely lacking in addition to the population being more vulnerable, with 72.2% of the people in India living rurally but only receiving 25% of the medical manpower.
Burnout of clinicians
The Covid 19 pandemic has created a mental health crisis in India wherein mental health cases increased by 20% following the nationwide lockdown and nearly one in five Indians currently have mental health struggles. One of the consequences of the short supply of mental health professionals can be clearly seen here, as during the last year of the Covid-19 attack, mental health providers ended up facing burnout and becoming overwhelmed due to the excessive workload and their lack of strength to cater to the huge demand.
Meeting the needs of special populations
We have to take the extra effort to ensure that the needs of all types of diverse populations are being met, otherwise, the gap is not bridged at all if some people are left behind. Almost 9.8 million young Indians are in desperate need of active intervention related to mental healthcare , while estimates say that LGBTQIA+ individuals are likely to form 3.8% of the population, i.e., 45.4 million in 2011, but most are unable to access mental health for the serious problems they face due to extreme stigma, fear of ostracization etc.
The affordability to mental health care
Education and awareness are only half the battle because the mental health cause is still incomplete if it doesn’t address the financial unaffordability of mental health services across and the resulting problem of inaccessibility to treatment it creates. Sadly, the population most disadvantaged by unaffordability are also the most vulnerable to mental health issues and bear the brunt of the suffering.
The root cause can be identified as the shortage of funds allocated to mental health in India. Out of the gross domestic product, the annual health expenditure of India is only 1.15%, out of which the mental health budget, in particular, is below 1%.
(NHMS) of India, pointed out that in addition to the cost of treatment, there is the additional higher economic burden that is involved in caring for a person with mental illness and this leads to hefty out-of-pocket expenditures. The NHMS survey noted that families have to spend nearly Rs. 1,000 to 1,500 a month (i.e., paid as out-of-pocket expenses) for access to treatment in addition to travel expenditures and this drives many low-income families into an economic crisis. Poverty and disability add to this, and when they are coupled with lack of access to care and treatment it negatively impacts the quality of life of mental health patients and their families. Lastly, Section 18 of the MHCA 2017 talks about the right to access mental health care and treatment from mental health services run or funded by the appropriate Government. This makes the State responsible to provide adequate mental healthcare to its citizens.
With all said and done, we, as a nation, still have a long way to go when it comes to mental health care services and their accessibility, and bridging the treatment gap must be given the utmost priority.