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| PLENARY SYMPOSIUM |
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| Year : 2021 | Volume
: 3
| Issue : 3 | Page : 160-164 |
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Innovations in Social Psychiatry across the World – India
Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| Date of Submission | 14-Nov-2021 |
| Date of Decision | 20-Nov-2021 |
| Date of Acceptance | 06-Dec-2021 |
| Date of Web Publication | 23-Dec-2021 |
Correspondence Address:
Dr. Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_58_21
India is a large country with a huge population, high mental illness burden, and a substantive treatment gap, with inadequate infrastructure, human resources, and funding related to mental health care. Given this challenging scenario, innovations utilizing social psychiatric principles have come from the government sector, nongovernmental organizations, and like-minded professional associations. The focus has been on integrating mental health care with primary health care, reducing stigma, early detection, enhancing access to affordable care, continuity of care, and promoting recovery and social integration. Digital technology is being increasingly explored to partly further these goals. Although there have been appreciable improvements, there is a long way to go!
Keywords: Challenges, India, innovations, mental health care, social psychiatry
How to cite this article:
Basu D. Innovations in Social Psychiatry across the World – India. World Soc Psychiatry 2021;3:160-4 |
| Introduction | |  |
With 3,287,263 sq.km area (world's seventh largest) and nearly 1.4 billion population (world's second largest after China), India is a vast and hugely populous country. The magnitude of mental health problem is large. The National Mental Health Survey 2015–2016 estimated that excluding tobacco use disorders, mental morbidity of individuals above the age of 18 years currently was 10.6% and the lifetime prevalence was 13.6%. Translated to weighted real numbers, nearly 150 million Indians are in need of active interventions.[1] Another landmark study estimated an even larger number of people with mental disorders and, most importantly, found that the burden of mental disorders, expressed as disability-adjusted life years, had increased from 2.5% of the burden due to all health problems in 1990 to 4.7% in 2017, thus nearly doubling over less than three decades. It also estimated that this burden was the leading contributor to years lived with disability (YLDs), contributing to 14.5% of all YLDs in the country.[2]
Unfortunately, the country has not allocated budgetary funding for mental health proportionate to this rising burden. Only 0.83% of the total health budget announced for 2021–2022 (itself a paltry proportion of the gross domestic product of the country) was allocated for mental health, grossly disproportionate to the nearly 5% of the health-related burden attributable to mental disorders. Of this amount, the flagship National Mental Health Programme (NMHP) was allocated an even meager sum of INR 0.4 billion, or just 6.7% of the already negligible mental health budget. Further, this amount remained the same as the previous year's budget.
The mental health-care infrastructure and, importantly, the mental health-care-related human resources, have remained grossly inadequate. India, surprisingly, does not feature in the latest Mental Health Atlas 2020 published by the World Health Organization on October 8, 2021 (probably because no data were received from India), but the country profile for India in the Mental Health Atlas 2017 shows a grim picture.[3] These data are from 2016, but there is no good reason to believe that the situation has improved substantively (Indeed, given the COVID-19 pandemic situation, it may well have worsened further).
India's total expenditure on mental health per person per year is just about 4 Indian National Rupees (0.05 USD). The payment for mental health care is largely out-of-pocket personal expenditure. Only 1.3% of total government expenses for health care is allocated for mental health care (the budget data cited above shows it is actually <1%).
Mental health workforce per 100,000 population is 0.29 psychiatrists, 0.80 mental health nurses, 0.07 clinical psychologists, and 0.06 social workers. These are telling figures!
Regarding service provision and service utilization, the figures from the Mental Health Atlas 2017 for India are no less telling. In the domain of outpatient care per 100,000 population, while the number of visits made by service users in the last year in mental health outpatient facilities attached to a hospital is 369, the corresponding figures for “community-based/nonhospital” mental health outpatient facility and for other outpatient facility (e.g., mental health day care or treatment facility) are 11.1 and 1.8, respectively. Thus, the outpatient service utilization pattern remains largely hospital based, with a negligible representation at the community level. The inpatient bed capacity is grossly inadequate too, as reflected by 1.43 mental hospital beds and 0.56 general hospital psychiatric unit beds per 100,000 population, respectively.
Given this scenario, not surprisingly, the mental health-care needs are largely unmet. The treatment gap (difference in the proportion of people who need mental health care and those who actually receive it) for various mental disorders is huge, ranging from 70% to 90% depending upon the disorders.[1]
The challenges are many:
- Lack of facilities
- Lack of trained personnel
- Lack of instrumental resources
- Lack of support services
- Lack of awareness
- Lack of access/affordability
- Stigma!
Given these formidable challenges, what can be done?
- Take the mental health-care system to the community!
- Build up awareness and education
- Continuity of care:
- Promotion of mental health
- Prevention of mental illness
- Early detection of mental health issues
- Facilitate affordable access to mental health care
- Path to recovery.
All these, it is to be noted, belong to the broad domain of social psychiatry, even if the specific phrase is not mentioned.
Against this backdrop, the national-level innovations in social psychiatry may be considered at three sectors:
- Initiatives by the government sector
- Initiatives by the nongovernmental organization (NGO) sector
- Initiatives by the professional associations or organizations.
A disclaimer is necessary at this juncture. These are not exhaustive or specific; indeed, there are cross-cutting initiatives and innovations at multiple levels. Furthermore, there may be other activities relevant to social psychiatry at each of these levels.
| Innovations by the Government Sector | | |
These are shown in [Table 1].
The first important initiative was the launch of the NMHP in 1982, keeping in view the heavy burden of mental illness in the community, and the absolute inadequacy of mental health-care infrastructure in the country to deal with it. The District Mental Health Programme (DMHP) was added to the program in 1996. The program was re-strategized in 2003 to include two schemes, namely Modernization of State Mental Hospitals and Upgradation of Psychiatric Wings of Medical Colleges/General Hospitals. The manpower development scheme (Scheme-A and B) became part of the program in 2009.[4]
| Three Main Components of National Mental Health Programme | | |
- Treatment of mentally ill
- Rehabilitation
- Prevention and promotion of positive mental health.
Objectives
- To ensure the availability and accessibility of minimum mental health care for all in the foreseeable future
- To encourage the application of mental health knowledge in general health care and in social development
- To promote community participation in the mental health service development, and
- To enhance human resource in mental health subspecialties.
Strategies
- Integration of mental health with primary health care through the NMHP
- Provision of tertiary care institutions for treatment of mental disorders
- Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions such as the Central Mental Health Authority and State Mental Health Authority.
| District Mental Health Programme | | |
DMHP envisages provision of basic mental health-care services at the community level, potentially to cover every district in all states.
Objective
- To provide sustainable basic mental health services to the community and to integrate these services with other health services
- Early detection and treatment of patients within the community itself
- To reduce the stigma of mental illness through public awareness
- To treat and rehabilitate mental patients within the community.
Although a lot has been achieved over the nearly 4 decades since NMHP and 25 years since DMHP was launched, the progress has been rather slow, erratic, and nonuniform. More detailed critique is beyond the scope of this article but available elsewhere.[5] To be fair, NMHP was ahead of its time when launched, and the intent was clearly aligned to social psychiatric principles.
Another milestone in this path was the publication of the National Mental Health Policy of India (NMHPI) in October 2014.[6] It is aptly titled “New Pathways, New Hope.” More than any other document, the NMHPI clearly and strongly endorses and encourages application of social psychiatric principles and their application for mental health care in India. A bare reading of the contents of the NMHPI buttresses this point, starting from the Vision, Values and Principles, Goals, Objectives, Cross-Cutting Issues, and Strategic directions and recommendations of action. For example, the chapter on “cross-cutting issues” includes the following headings:
- Stigma
- Rights-based approach
- Vulnerable populations
- Adequate funding
- Support for families
- Promotion of mental health.
The NMHPI is a lofty document with a highly ambitious vision and formulation of overarching strategies for comprehensive mental health care at the national level. However, it is a policy document that is designed to lay out the directions but is not legally mandated.
For the legal teeth, we now have the third and very important Mental Healthcare Act 2017,[7] which replaced the earlier Mental Health Act 1987. This Act was promulgated to “align and harmonize” with the United Nations Convention on the Rights of Persons with Disabilities, to which India is a signatory, and hence has a strong and explicit human rights-based orientation. Again, social psychiatric principles are ensued in this legal instrument, though its implementation on ground are fraught with several challenges, including lack of funding, infrastructure, human resources, legal and administrative issues, among others.[8]
| Initiatives by the Nongovernmental Organization Sector | | |
Many innovations in social psychiatry have been brought in the NGO sector, a number of which operate in the country or regions with varying objectives and spheres of activities. These include, among others:
- Task-sharing: training of nonspecialist human resources at various levels
- Reduction of stigma
- Practical help
- Counseling
- Facilitating access to the government sector
- Helping in recovery or rehabilitation.
Many NGOs have been working tirelessly and innovatively in these areas. An incomplete but indicative list is mentioned in [Table 2]. An excellent article by Thara and Patel provides a broad overview of the history, objectives, scopes, activities, strengths, and challenges faced by the NGOs in India.[9] | Table 2: An incomplete but indicative list of nongovernmental organizations working in the area of mental health in India
Click here to view |
| Initiatives by Professional Associations | | |
Professional associations bring together like-minded people to promote the cause of social psychiatry and allied disciplines in their application and advocacy for mental health care. A number of such associations have been in existence in India, some of the prominent and relevant ones being:
- Indian Association for Social Psychiatry (IASP - affiliated with the World Association of Social Psychiatry and the World Psychiatric Association)
- World Association for Psychosocial Rehabilitation India Chapter
- Indian Psychiatric Society (affiliated with the World Psychiatric Association)
- Indian Association for Child and Adolescent Mental Health.
Of these, IASP deserves a special mention, because, by definition, it is devoted to the cause of social psychiatry. Founded in 1984, it is the culmination of the collective effort of mental health professionals across the country to create a platform for exploration, discussion, research, and action on the social determinants of mental health and ways and means to improve mental health utilizing social psychiatric principles. The Indian Journal of Social Psychiatry, which is the official journal of IASP, is being published since 1986. The Journal focuses on issues related to health, ethical, and social factors in field of social and community psychiatry and is highly acclaimed by the mental health academia.
| Digital Technology and Social Psychiatric Innovations | | |
A last but by no means the least innovation in social psychiatry is the growing use of digital technology. While growing at a slow rate since the last two decades or so, a tremendous spurt has been provided – almost forced upon us – by the COVD-19 pandemic. The scope of digital technology in providing mental health care and enhancing reach to the unreached populations in low- and middle-income countries is found to be promising.[10] Smartphone technology can be tapped to enhance mental health-care coverage and to reduce stigma and exclusion among people.[11] The NMHP and DMHP need to be “digitalized” to an extent. As Prof. Sudhir Khandelwal, a past President of IASP, wrote in his musings on the Silver Jubilee Conference of IASP, “It (DMHP) is an offshoot of the NMHP, a revolutionary idea in the 1980s. However, since then, the health systems have undergone tremendous changes. We are stuck with the old delivery methods. It is time the mental health too adopts new digital technologies to reach its unreached population. IASP can and must take lead in making collaborations with all the stakeholders and partners and use modern health systems to achieve its aims and objectives. After all, the nation's prosperity depends on mental well-being of its citizens.”[12]
Various models, modules, and modalities of application of digital technology in mental health care have been extensively discussed and are beyond the scope of this paper. However, a broad range includes models such as:
- E-health model
- M-health model
- Synchronous versus asynchronous model
- Direct care model
- Hub-and-spoke model
- Self-help model.
| A Long Walk, Still Miles to Go… | | |
Given the huge multidimensional and multilevel challenges and barriers in scaling up mental health care at the primary health-care level, a recent publication reviewed various innovative efforts in India.[13] Based on the review of 22 studies from 9 states, most innovations are broadly summarized into 5 categories: (1) quality improvement mental health programs, (2) community-based mental health programs, (3) nonspecialist mental health programs, (4) mobile technology-based mental health programs, and (5) telemental health programs. The findings were encouraging in all these categories. A similar study reviewed 72 case studies of mental health-care integration into primary and community care in India by 34 government and NGO initiatives. It found that India needs to evolve its own model based on what works best.[14]
The focus, as always, has to remain on (a) early detection of mental illnesses in the community, (b) enhancing access to mental health care, (c) reducing stigma, (d) facilitating treatment and follow-up, again preferably at the community level, (e) integrating primary health care with specialized mental health care, and (f) integrating mental health care with social services sector.
Not surprisingly, all these innovative approaches and ideas belong to the broad domain of social psychiatry.
In conclusion, we have come a long way since independence of India in 1947. In particular, there has been a slowly growing awareness of the need for, and success to a varying extent regarding:
- Community-based efforts
- Tele-based efforts
- Collaboration between government and NGO sectors
- Reduction of stigma and facilitating affordable access to mental health-care facilities.
There have also been successes on other fronts, utilizing principles of social psychiatry, such as:
- Partial integration of mental health care with primary health care
- Partial recognition of social factors relevant to all aspects of mental illness
- Official recognition of person-centric and rights-based approach to persons with mental illness.
However, there are still miles to go! We still are struggling with:
- Very limited resources
- Very low spend on mental health care
- Imperfect translation of policies, programs, and legislations to ground-level action
- Less-than-ideal coordination between health and social care sectors
- Need for more advocacy, more action, and more persistence….
This is a long-standing, ongoing, persistent uphill struggle, almost of a Sisyphean nature! However, we should not give up!
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health Survey of India, 2015-16: Summary. Bengaluru: National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 128; 2016.  |
| 2. | India State-Level Disease Burden Initiative Mental Disorders Collaborators. The burden of mental disorders across the states of India: The global burden of disease study 1990-2017. Lancet Psychiatry 2020;7:148-61. |
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| 5. | Gupta S, Sagar R. National mental health programme-optimism and caution: A narrative review. Indian J Psychol Med 2018;40:509-16. [ PUBMED] [Full text] |
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| 8. | Math SB, Basavaraju V, Harihara SN, Gowda GS, Manjunatha N, Kumar CN, et al. Mental healthcare act 2017 – Aspiration to action. Indian J Psychiatry 2019;61:S660-6. |
| 9. | Thara R, Patel V. Role of non-governmental organizations in mental health in India. Indian J Psychiatry 2010;52 Suppl 1:S389-95. |
| 10. | Naslund JA, Aschbrenner KA, Araya R, Marsch LA, Unützer J, Patel V, 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;4:486-500. |
| 11. | Rozatkar AR, Gupta N. Smartphone technology for mental health services. Indian J Soc Psychiatry 2019;35:221-3. [Full text] |
| 12. | Khandelwal SK. From the immediate past president: Musings on Indian social psychiatry on the occasion of silver jubilee conference of Indian Association for Social Psychiatry. Indian J Soc Psychiatry 2018;34:268-72. [Full text] |
| 13. | Pandya A, Shah K, Chauhan A, Saha S. Innovative mental health initiatives in India: A scope for strengthening primary healthcare services. J Family Med Prim Care 2020;9:502-7. [Full text] |
| 14. | van Ginneken N, Maheedhariah MS, Ghani S, Ramakrishna J, Raja A, Patel V. Human resources and models of mental healthcare integration into primary and community care in India: Case studies of 72 programmes. PLoS One 2017;12:e0178954. |
[Table 1], [Table 2]
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