Unburden mental health in India: it's time to act now
Authors: Rahul Shidhaye
Journal: The Lancet Psychiatry (2019)

The National Mental Health Survey (NMHS)1Pradeep BS Gururaj G Varghese M et al.National Mental Health Survey of India, 2016—rationale, design and methods.PLoS One. 2018; 13e0205096Crossref PubMed Scopus (32) Google Scholar and studies based on the Global Burden of Disease 2013 data, published as part of the China-India Lancet series,2Charlson FJ Baxter AJ Cheng HG Shidhaye R Whiteford HA The burden of mental, neurological, and substance use disorders in China and India: a systematic analysis of community representative epidemiological studies.Lancet. 2016; 388: 376-389Summary Full Text Full Text PDF PubMed Scopus (183) Google Scholar had earlier estimated the burden of mental, neurological, and substance use disorders in India. Commissioned by the Government of India in 2014–15, the NMHS covered a representative population of 39 532 individuals from 12 states across six regions of India and estimated the prevalence of mental, neurological, and substance use disorders, identifying treatment gaps and existing patterns of health-care seeking and service use.1Pradeep BS Gururaj G Varghese M et al.National Mental Health Survey of India, 2016—rationale, design and methods.PLoS One. 2018; 13e0205096Crossref PubMed Scopus (32) Google Scholar Moving a step forward, in The Lancet Psychiatry, the study by the India State-Level Disease Burden Initiative Mental Disorders Collaborators3India State-Level Disease Burden Initiative Mental Disorders CollaboratorsThe burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017.Lancet Psychiatry. 2019; (published online Dec 23)https://doi.org/10.1016/S2215-0366(19)30475-4Google Scholar provides comprehensive estimates of the prevalence and disease burden due to mental disorders for every state of India from 1990 to 2017, on the basis of all accessible data sources and using the standard Global Burden of Disease Study methodology. According to this study, one in every seven Indians was affected by mental disorders (197·3 million people, 95% uncertainty interval [UI] 178·4–216·4), the proportional contribution of mental disorders to the total disease burden in India almost doubled from 1990 to 2017 (increasing from 2·5%, 95% UI 2·0–3·1, in 1990 to 4·7%, 3·7–5·6, in 2017), and marked regional variations in the prevalence of disorders were observed. However, this study excluded neurological disorders, such as dementia and epilepsy, and substance use disorders, which have substantial behavioural manifestations, and did not include burden associated with suicide in the overall estimates. Therefore, the burden of mental disorders described in this study is very likely to be an underestimate of the total burden due to mental, neurological, and substance use disorders in the Indian population. The study3India State-Level Disease Burden Initiative Mental Disorders CollaboratorsThe burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017.Lancet Psychiatry. 2019; (published online Dec 23)https://doi.org/10.1016/S2215-0366(19)30475-4Google Scholar has found sex-specific differences in the distribution of mental disorders and association of older age with increased prevalence of depression, which is not only a unique finding compared with previous literature from high-income countries, but is also worrying because the population of India is ageing rapidly. This study is unable to explain the higher prevalence of depressive and anxiety disorders in southern India states than in northern states, which also had higher suicide rates compared with those of northern Indian states. A previous review reported the scarcity of representative community-based studies and high-quality and up-to-date evidence on the socio-economic correlates of mental disorders in India.4Cheng HG Shidhaye R Charlson F et al.Social correlates of mental, neurological, and substance use disorders in China and India: a review.Lancet Psychiatry. 2016; 3: 882-899Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar This highlights the importance of addressing the crucial research gap in the area of social determinants of mental disorders. In addition to demographic and economic factors (which are most commonly studied), the association of neighbourhood, environmental, and social and cultural factors with the burden of mental disorders needs to be assessed.5Lund C Brooke-Sumner C Baingana F et al.Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews.Lancet Psychiatry. 2018; 5: 357-369Summary Full Text Full Text PDF PubMed Scopus (305) Google Scholar Differential exposure to these social determinants leads to different vulnerabilities, leading to different mental health outcomes that, in turn, lead to health inequity in the population. Ongoing, prospective research that tracks the epidemiology of mental, neurological, and substance use disorders during the present social transition is essential for identifying both risk factors and protective factors for these disorders. Improving access to evidence-based mental health services is the only way forward to address this huge burden of mental disorders in India. While good evidence exists for pharmacological interventions, several randomised controlled trials in India have shown that psychosocial interventions developed in high-income countries can be contextually adapted and effectively delivered by non-physician health workers for various disorders.6Patel V Weobong B Weiss HA et al.The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial.Lancet. 2017; 389: 176-185Summary Full Text Full Text PDF PubMed Scopus (207) Google Scholar, 7Chatterjee S Naik S John S et al.Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.Lancet. 2014; 383: 1385-1394Summary Full Text Full Text PDF PubMed Scopus (143) Google Scholar The major challenge is to translate this knowledge into action. The findings of some implementation research projects in India are particularly encouraging, because they show that mental health services can be integrated and scaled up within a public health system context in a very low-resource setting8Shidhaye R Murhar V Muke S et al.Delivering a complex mental health intervention in low-resource settings: lessons from the implementation of the PRIME mental healthcare plan in primary care in Sehore district, Madhya Pradesh, India.BJPsych Open. 2019; 5: e63Crossref PubMed Scopus (5) Google Scholar and that the demand and access to mental health services can be increased at the community level if the work is led by grass-roots community health workers.9Shidhaye R Murhar V Gangale S et al.The effect of VISHRAM, a grass-roots community-based mental health programme, on the treatment gap for depression in rural communities in India: a population-based study.Lancet Psychiatry. 2017; 4: 128-135Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar Along with providing treatment to individuals with mental disorders, improving mental health and the overall wellbeing of the entire population is equally important. India has a rich tradition of yoga, and other culturally rooted interventions that have been shown to be effective in mental health promotion.10Ross A Michalsen A Yoga for prevention and wellness.in: Khalsa SBS Cohen L McCall T Telles S The principles and practice of yoga in health care. SAGE India Publications, New Delhi2017: 471-481Google Scholar Although their therapeutic effectiveness still needs to be firmly established, they can certainly be considered to improve the emotional and psychological resilience of communities, which can be helpful in mitigating distress before it deteriorates into a mental disorder. Several policy reforms have been made in the past decade that make the environment extremely conductive for transforming mental health care in India. The right to mental health care in the new Mental Healthcare Act, the vision in the National Mental Health Policy, and the inclusion of mental health services in the guidelines of the Health and Wellness Centers (part of the Ayushman Bharat Yojana or the National Health Protection Scheme) provide legal and operational foundations for the scaling-up of evidence-based services for mental disorders to improve the health of people living with these conditions. The state-level estimates of the mental disorder burden by the India State-Level Disease Burden Initiative Mental Disorders Collaborators provide a strong impetus for each of the states to increase budgetary allocations for mental health programmes, build the necessary human resource capacity, strengthen information systems, and streamline supply of essential psychotropics to integrate mental health services in their respective public health systems. The time is now ripe in India to translate vision into practice and transform mental health-care services. I declare no competing interests. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017One in seven Indians were affected by mental disorders of varying severity in 2017. The proportional contribution of mental disorders to the total disease burden in India has almost doubled since 1990. Substantial variations exist between states in the burden from different mental disorders and in their trends over time. These state-specific trends of each mental disorder reported here could guide appropriate policies and health system response to more effectively address the burden of mental disorders in India. Full-Text PDF Open Access