COVID-19 offers an opportunity to reform mental health in India
Authors: Rakhi Dandona, Rajesh Sagar
Journal: The Lancet Psychiatry (2020)

The pre-COVID-19 scenario for mental health in India was grim. One in seven Indians had mental disorders of varying severity in 2017,1India 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. 2020; 7: 148-161Summary Full Text Full Text PDF PubMed Scopus (332) Google Scholar and Indians accounted for 26·6% of the global suicide deaths in 2016.2India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; 3: e478-e489Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar The proportional contribution of mental disorders to the total disease burden in India is estimated to have almost doubled between 1990 and 2017,1India 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. 2020; 7: 148-161Summary Full Text Full Text PDF PubMed Scopus (332) Google Scholar and 5·1% of the adult population is estimated to have some level of suicidality.3Amudhan S Gururaj G Varghese M et al.A population-based analysis of suicidality and its correlates: findings from the National Mental Health Survey of India, 2015–16.Lancet Psychiatry. 2020; 7: 41-51Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar Like elsewhere, the variety and extent of the implications of the COVID-19 pandemic for mental health are yet to be fully understood in India.4Moreno C Wykes T Galderisi S et al.How mental health care should change as a consequence of the COVID-19 pandemic.Lancet Psychiatry. 2020; 7: 813-824Summary Full Text Full Text PDF PubMed Scopus (1003) Google Scholar Since its launch in 1982, the National Mental Health Programme in India has undergone many strategic revisions, with the national mental health policy guiding its most recent revision. Most literature since then has detailed the issues and gaps in the diagnosis and treatment of mental disorders under the National Mental Health Programme. The programme has also long been criticised for being treatment-centric and ignoring preventive and promotive aspects.5Gupta S Sagar R National mental health programme—optimism and caution: a narrative review.Indian J Psychol Med. 2018; 40: 509-516Crossref PubMed Scopus (46) Google Scholar However, because of the spotlight on mental health issues arising amid COVID-19, some noteworthy guidelines for prevention activities have been released by the Ministry of Health and Family Welfare during the past few months to address mental health in India, under the guidance of the National Taskforce for the finalisation, implementation, and monitoring of the psychosocial action plan for COVID-19 response (appendix). A national psychosocial behavioural helpline was established, which is seated within the Ministry of Social Justice and Empowerment rather than the Ministry of Health and Family Welfare.6Agrawal S Govt launches KIRAN, a 24 × 7 helpline for people to seek mental health counselling.https://theprint.in/health/govt-launches-kiran-a-24x7-helpline-for-people-to-seek-mental-health-counselling/497542/Date: Sept 7, 2020Date accessed: November 11, 2020Google Scholar This initiative sets a good example for intersectoral collaboration for improving mental health. Written and audio-visual guidelines were released targeting the general population, people living with mental disorders, and health-care providers to facilitate management of mental health issues during the pandemic (appendix). Importantly, these guidelines focus on different age groups, including older people and children, and cover a variety of issues ranging from managing mental health to addressing stigma and discrimination, managing alcohol-related and tobacco-related issues during lockdown, and providing clinical guidelines for managing patients with mental illness. Although it will take time to assess the effects of these guidelines on mental health in India, these steps taken by the government and other stakeholders to reduce the risk of adverse mental health outcomes caused by the COVID-19 pandemic are certainly in the right direction for mental health in India. An important consideration for the Ministry of Health and Family Welfare should now be to build on the momentum and scope of these mental health-related activities to address the mental health of Indians more effectively. The COVID-19 pandemic has provided a unique opportunity for the National Mental Health Programme to broaden the national mental health agenda from a focus on reducing the treatment gap for people affected by mental disorders, to the improvement of mental health for the whole population, including suicide prevention. An immediate requirement for the National Mental Health Programme is to understand the extent of the additional burden of mental health disorders in the population owing to the COVID-19 pandemic, to plan appropriate mitigation strategies. The pandemic is likely to have resulted in mental health problems varying from mild, time-limited distress to chronic, progressive, and severely disabling conditions. Therefore, diagnosis will be important to ensure that the diversity and complexity of the mental health needs of individuals or populations is captured appropriately.7Patel V Saxena S Lund C et al.The Lancet Commission on global mental health and sustainable development.Lancet. 2018; 392: 1553-1598Summary Full Text Full Text PDF PubMed Scopus (1351) Google Scholar, 8Sagar R Chawla N Sen MS Is it correct to estimate mental disorder through online surveys during COVID-19 pandemic?.Psychiatry Res. 2020; 291113251Crossref PubMed Scopus (11) Google Scholar This concern is of particular importance given that many surveys now rely on online data collection rather than face-to-face interviews, which is known to result in misclassification or overestimation of mental health problems.8Sagar R Chawla N Sen MS Is it correct to estimate mental disorder through online surveys during COVID-19 pandemic?.Psychiatry Res. 2020; 291113251Crossref PubMed Scopus (11) Google Scholar A significant increase was reported in online searches for suicide-seeking and help-seeking following a recent celebrity suicide in India.9Ganesh R Singh S Mishra R Sagar R The quality of online media reporting of celebrity suicide in India and its association with subsequent online suicide-related search behaviour among general population: an infodemiology study.Asian J Psychiatr. 2020; 53102380Crossref PubMed Scopus (20) Google Scholar Suicide prevention thus far has not received the attention it deserves in the National Mental Health Programme,1India 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. 2020; 7: 148-161Summary Full Text Full Text PDF PubMed Scopus (332) Google Scholar, 2India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; 3: e478-e489Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar which cannot afford to ignore suicide prevention during these unprecedented times, which are causing distress and leaving many people vulnerable to mental health problems and suicidal behaviour.2India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; 3: e478-e489Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 3Amudhan S Gururaj G Varghese M et al.A population-based analysis of suicidality and its correlates: findings from the National Mental Health Survey of India, 2015–16.Lancet Psychiatry. 2020; 7: 41-51Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar The COVID-19 pandemic also offers the opportunity to broaden the reach and scope of National Mental Health Programme activities through engagement with a wide range of stakeholders within and beyond health care, including sectors in education, workplaces, social welfare, gender empowerment, child and youth services, criminal justice and development, and humanitarian assistance.1India 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. 2020; 7: 148-161Summary Full Text Full Text PDF PubMed Scopus (332) Google Scholar, 2India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; 3: e478-e489Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 7Patel V Saxena S Lund C et al.The Lancet Commission on global mental health and sustainable development.Lancet. 2018; 392: 1553-1598Summary Full Text Full Text PDF PubMed Scopus (1351) Google Scholar The National Mental Health Programme needs to consider how emerging digital technologies, which have shown promise in countries that have a low investment in mental health services and low capacity therein, might support the scale-up of mental health treatment and prevention efforts to manage the gap between supply and demand for treatment.4Moreno C Wykes T Galderisi S et al.How mental health care should change as a consequence of the COVID-19 pandemic.Lancet Psychiatry. 2020; 7: 813-824Summary Full Text Full Text PDF PubMed Scopus (1003) Google Scholar, 10Naslund JA Aschbrenner KA Araya R et al.Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature.Lancet Psychiatry. 2017; 4: 486-500Summary Full Text Full Text PDF PubMed Scopus (296) Google Scholar Lastly, because the mental health consequences are expected to be present for longer than the COVID-19 pandemic itself, now is also the time for mental health care delivery to transform towards an ethic of "nothing about us without us", with meaningful participation by service users in strengthening the mental health system. RS is a member of the National Taskforce for finalisation, implementation, and monitoring of the psychosocial action plan for COVID-19 response in India. RD declares no competing interests. Download .pdf (.16 MB) Help with pdf files Supplementary appendix Frontline 2020: the new age for telemental healthTelemental health care has been widely available for several decades and encompasses the remote delivery of psychiatric and psychological services.1 Telemental health care has been found to be effective in assessing and diagnosing mental health conditions across the lifespan and ethnic groups.2 Benefits of telemental health include the engagement of friends or family and the wider professional network in consultations; savings in the time required to deliver health care;3 and the reach to populations that might not be able to access mental health services owing to lack of, or insufficient service provision or high care costs. Full-Text PDF What has happened to children's wellbeing in the UK?"Modern life has been chipping away at children's happiness over time"; this statement was the pessimistic conclusion of The Good Childhood Report 2020,1 which focused on wellbeing in children between the ages of 10 and 15 years across the UK. The report emphasised that children in the UK, especially girls, are among the most unhappy and least satisfied in Europe. The UK ranked lowest of 24 European countries in its proportion of children aged 15 years with high life satisfaction, lowest in its proportion with a positive sense of purpose in life, and second highest in its proportion with high sadness levels. Full-Text PDF Perspectives of lived experience across continents: our reality and call for universal health coverageThe Global Action Plan,1 signed by major global health agencies, provides a framework that guides collective action towards universal health coverage (UHC) and accelerates progress on the health-related Sustainable Development Goals.2 However, according to WHO, the world remains a long way from meeting its 2030 targets. Additionally, the COVID-19 pandemic has highlighted how fragile our health systems are in the provision of quality and holistic care. The Global Mental Health Peer Network (GMHPN) aims to highlight the lived experiences of people in various world regions, showcasing that if true recovery is to be achieved, UHC must include the most vulnerable individuals among us and the uniqueness of diverse lived experiences. Full-Text PDF Decriminalising being Black with mental illnessMental illness should not be a death sentence. Being Black should not be a death sentence. Yet, in 2020 alone we have witnessed how these intersecting identities—Blackness and having a mental illness—have disproportionately led to the murder of Black people by police officers in the USA.1 The deaths of George Floyd, Ahmaud Arbery, Rayshard Brooks, and Breonna Taylor focused international attention on excessive force used by police. These deaths sparked global protests, centring the Black Lives Matter movement and drawing attention to the grim reality that in the USA Black people are at an increased risk of death at the hands of the police. Full-Text PDF