NITI AAYOG

Office of Member (Health, WCD & Education)

….
Examination of the subject “Mental Health Care and its Management in Contemporary
Times” by the Department-related Parliamentary Standing Committee on Health & Family
Welfare

1. Present Status of mental health issues, major causatives, challenges faced and
awareness in India

• Present Status of Mental Health in India- India has approximately 17% of the world
population (World Population Review) and witnesses a significant burden from non-
communicable diseases including mental morbidities which has doubled in the last
30 year (GBD, 2019). The National Mental Health Survey (NMHS), which was the last
comprehensive survey of mental health conditions and systems in 2015-16, found
that the lifetime prevalence of mental disorders in the surveyed population was 13.7%
(150 million, according to Census 2011). However, according to the Lancet Study on
State-wise Disease Burden of Mental Disorders (2019), as many as 197.3 million
Indians were living with mental disorders in 2017.

• Prevalence of Mental Disorders- Common Mental Disorder (CMDs) including

Depressive disorders which were the third leading cause of Years Lived with
Disability (YLDs) and affected over 45 million people living in India in 2017 (GBD,
2019) and anxiety and substance use disorders affect 10 % of the population.
Millions of young Indians are affected by CMDs, thereby hindering familial, social and
economic progress of the country. Additionally, more than 40 million Indians are
affected by Severe Mental Disorders (SMDs).

• Prevalence of suicides in India- With a suicide rate of 12% (NCRB, 2021), India also
accounts for over 36.6% in females and 24% percent of all deaths by suicides globally
(GBD, 2018).

• Major Causative/ Risk Factors- the NMHS highlights that the prevalence rates of
mental disorders are also critically influenced by diverse factors apart from genetic
predisposition and history that range from socio-economic and other environmental
determinants, variations in perceived threshold of distress, differences in
assessment tools, choice of symptom thresholds in disease definition and
interpretations of results.

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• Risk factors may include social and occupational factors like gender based violence
including intimate partner violence, childhood abuse, bullying and discrimination,
academic and professional stress.

• Further, prevalence of depressive disorders is significantly higher in females than in

males, starting at 45 years. The NMHS reported that the weighted prevalence across
diagnostic categories in urban metros was higher than in rural and urban non-metro
areas. The contribution of several factors (fast paced lifestyle, stress, complexities of
living, breakdown of support systems, challenges of economic instability)
experienced by the urban population could impact higher prevalence in urban
metros and further investigations are needed to understand the relationship
between urbanisation and mental illness in India.

• Challenges in Mental Health- Despite consistent efforts to provide mental health

support at population level, both supply and demand side challenges prevail. The
NMHS reports that nearly 80% of those suffering from mental disorders did not
receive treatment for over a year. This survey also identified large treatment gaps in
mental healthcare, ranging from 28% to 83% across different mental disorders and
86% for alcohol use disorders.
o Availability of drugs at HWCs (Health and Wellness Centres)- Since mental
health is one of the services provided under the extended package at HWC
level, availability of drugs at HWC level is yet to be prioritised.
o Human Resources for Mental Health- There is attrition and overall lack of
mental health professionals (including nurses and psychologists) amongst all
domains ranging from public to private sector. Specifically, there is an urgent
need to understand these gaps at the level of district hospitals under the
rubric of IPHS, 2021 norms. There is a need to augment the psychiatry
postgraduate seats by analysing its potential under the ambit of NMC and
NBEMS systems, in a systematic manner.
o Metrics of coverage of the DMHP- There is a gap in developing metrics to
measure the coverage of the District Mental Health programme in
quantifiable terms. Currently, due to the gaps that exist between DMHP and
tertiary care, compromises the continuum of care. There is need to cull out
the critical coverage, delivery and outcome indicators for mental health and
systematically collect them.
o HMIS for Mental Health Programme- Presently there is no HMIS (Health
Management Information System) for the National Mental Health
programme.
o Ensuring insurance coverage for mental illness- the progress on insurance
coverage for treatment of mental illness as mandated by the MHCA, 2017 has
not been adequately prioritised. Despite IRDAI’s circulars most private

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 insurance providers continue to preclude mental illnesses from their
packages. The OOPE for treatment acts as a huge deterrent for health-
seeking in mental health.

• Awareness- Mental health literacy is a concept which is increasingly seen as an

important measure of the awareness and knowledge of mental health disorders. The
NMHS has attributed low uptake of existing resources that widen the treatment gap
to poor awareness among the Indian population. Present mental health education
activities are isolated, sporadic in nature.
• There is a need for extensive IEC activities in all states, the NMHS found that even
states with otherwise robust health systems like Kerala and Gujarat carried out
mental health IEC activities in less than 50% of the districts. Limited IEC activities
were reported from Madhya Pradesh, Jharkhand and Uttar Pradesh in the NMHS.
• Another study found mental health literacy among adolescents to be very low, i.e.
depression was identified by 29.04% and schizophrenia/psychosis was recognized
only by 1.31%. Stigma was noted to be present in help-seeking as well. (Ogorchukwu
et al., 2016). However, with mental health services now been included in the
Comprehensive Primary Care Package of the AB-HWCs, IEC on mental health has
received renewed impetus.

2. Availability, Affordability and accessibility of mental healthcare services

Mental health although traditionally has been area of low priority within the public
health field, has received a lot of attention in the past decade. India has
institutionalised several progressive measure in the field of mental health since 2014,
namely, the National Mental Health Policy, 2014, the Mental Healthcare Act, 2017
and the most recent National tele-mental health programmes

While the causes, risk factors and protective factors vary in urban and rural
populations, availability, accessibility and affordability of mental health services as
well as awareness are major drivers of service utilisation. Thus, the need for
coverage of mental health services across India on an equitable basis merits
importance.

Efforts to make mental health more available, accessible, and affordable in India-

• National Mental Health Programme-

• India was one of the first countries to have a National Mental Health
Programme in 1982 to address the heavy burden of mental health conditions.
While it includes components of awareness, manpower development,

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 upgradation of mental health institutions, its main focus is on providing services
through the District Mental Health programme (DMHP).

• As of 2022, the Government is supporting implementation of the District Mental

Health Programme (DMHP) under NMHP in 704 districts of the country, under
which, enhanced financial assistance is provided for detection, management and
treatment of mental disorders/ illness and additional components like suicide
prevention services, work place stress management, life skills training and
counselling in schools and colleges, etc.

• Under the Tertiary care component of National Mental Health Programme, 25

Centres of Excellence have been sanctioned to increase the intake of students in
PG departments in mental health specialities as well as to provide tertiary level
treatment facilities. In addition, the Government has also supported 19
Government medical colleges/institutions to strengthen 47 PG Departments in
mental health specialities.

• National Mental Health Policy- The National Mental Health Policy, 2014 informs
mental health services and rights in India. It propounds a rights focussed, community
based, and participatory approach to mental health services. It has been discussed in
detail in the following section.

• Mental Health Care Act, 2017 (MHCA, 2017)- is a landmark development in the field
of mental health in India. It establishes access to quality, affordable government (or
government funded) mental health services as a right for Indians while
decriminalising suicides in India. It further espouses the right to non-discriminatory,
collaborative, community based recovery for Persons with Mental Illness (PWMI).
Finally, through the MHCA, 2017, India is now one of the few countries globally to
have progressive measures like the Advanced Directives and Nominated
Representative. It further mandates insurance cover for treatment of mental
illnesses.

• Ayushman Bharat – This is a national initiative was launched as recommended by

the National Health Policy 2017, to achieve the vision of Universal Health Coverage
(UHC). The 1,50,000 Health and Wellness Centres deliver Comprehensive Primary
Health Care (CPHC) bringing healthcare closer to people covering both maternal and
child health services and non-communicable diseases, including mental health.
Operational guidelines on Mental, Neurological, and Substance Use Disorders (MNS)
at Health and Wellness Centers (HWC) have been released under the ambit of
Ayushman Bharat. Through these guidelines, mental health services are being
provided to all sections of the society, at primary level. The provision of mental

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 healthcare at primary level is an important step in increasing access and awareness
on mental illness.

• National Tele- mental Health programme- The National Tele- mental Health
programme which has been launched on October 10th, 2022 provides tele-services
for mental health all around the country. The programme that was conceptualised at
the NITI Aayog in collaboration with the National Institute of Mental Health And
Neurosciences (NIMHANS) has developed a nationwide hub and spoke service
involving 32 state cells, 23 mentoring institutions and with NIMHANS anchoring the
programme.

3. Flaws/Problems in the National Mental Health Policy and the proposed changes

• The National Mental Health policy of India, 2014 (NMHP) aims to “promote mental
health, prevent mental illness, promote destigmatisation and desegregation, ensure
socioeconomic inclusion of persons with mental illness by providing accessible,
affordable and quality health and social care to all persons through their lifespan,
within a rights-based framework”

• Acknowledging that some populations are more susceptible to mental illness than
others, the policy identifies groups who might need special attention, including
people living in extreme poverty, those who are homeless or in custodial institutions,
orphaned people with mental illness, children of people with mental illness,
internally displaced groups, and people affected by disasters and emergencies

• Although the NMHP has been a well-conceptualized and planned policy, its
objectives can only be achieved through increased synergy among the parallel health
and social welfare policies and strategies.

• Due to the difficulty in the implementation of an encompassing policy like the NMHP,
it warrants that the policy is periodically evaluated and revised, on a five-yearly or
decade basis; this would ensure that ever-evolving MH issues get incorporated in to
the policy and effectively get addressed, thereby making the policy relevant across
times.

• The following changes may be considered for stakeholder discussion for possible
inclusion in the NMHP-

o Acknowledgement of mental health ramifications of digital platforms

including social media

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 o Conversely, mainstreaming accessible and affordable technology driven
solutions to diverse mental health conditions
o Close convergence with the allied laws including Juvenile Justice Act, POCSO,
RPWD Act, etc. that impact mental health of the population
o Adding focus on post-partum and geriatric mental health along with the
already mentioned vulnerable groups
o Promoting hypothecated State and Central funds to mental health services
for effective implementation of the the DMHP, MHCA, and the National tele-
mental programme
o Ensuring norms for mental health institutions are followed for registration
under the MHCA, 2017.

4. Measures required at the policy and personal level to mitigate challenges posed by
mental health disorders

• Augmenting the Mental health Professional Workforce- Despite an increment of

M.D. Psychiatry postgraduate seats from 250 seats to above 1000 seats over the last
decade; the ratio of psychiatrists required per population is still alarmingly low, with
further geographic and rural/ urban discrepancies. Further, under the NBEMS system,
there are 67 seats for Psychiatry (38 seats as DNB and 29 seats as post-diploma).

Additionally, there is a greater deficit of other human resources such as

psychologists, social workers, psychiatric nurses etc. According to the National
Mental Health Survey, considerable state level variations exists in the number of
Clinical Psychologists from 211 (Kerala) to 9 (Rajasthan) in the country. Globally,
the suggested number of Clinical Psychologists range from 1.5 to 4 for Middle
income countries. However, currently per lakh only .07 Clinical Psychologists are
practicing in India (NMHS).

Further, the recently introduced National Education Policy, 2020 has decided to
discontinue all M Phil courses. In this light, the current M. Phil. Clinical Psychology
course which is mandated by the MHCA, 2017 is also under consideration for
discontinuation. However, since this course is the major pipeline contributing to the
Clinical Psychology workforce for the Nation, its alternatives need to be urgently
addressed.

• Notification of State rules of the MHCA, 2017- Despite it being 5 years since the
MHCA, the constitution of the State Mental Health Authority and subsequent
notification of rules and formation of the Mental Health Review Boards continue to
be slow. To implement the NMHP and the MHCA in providing holistic mental

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 healthcare in the aftermath of the pandemic, the states must prioritise the
notification of the MHCA rules.

• Development of state level suicide prevention programme- Recently the MoHFW

launched a comprehensive National Suicide Prevention Strategy to combat the rising
rate of death by suicides in India. It aims to reduce mortality due to suicide by 10%
between 2020 to 2030. To achieve this target, States must prioritise developing
inter-departmental programmes for suicide prevention.

• Expedited training of CHOs under Health and Wellness Centre- Through the AB-
HWC platform, services for Mental, Neurological and Substance Use Disorders (MNS)
are available at primary care level. Community Health Officers (CHOs) are tasked
with basic screening, tele-consultations, referral and follow-up, as per the guidelines.
However, the training process is still underway and will require to be expedited for
efficient delivery of services at primary level.

• Recording of routine administrative data on mental health- Administrative data

recording mechanisms through the HMIS system and the AB-HWC or NCD portal
need to be institutionalised for routine data collection and evidence generation in
mental health.

• Norms for mental health institutions in alignment with the MHCA and the NMHP-
Currently 47 government mental health institutions are operational around the
country. Despite the National Human Rights Commission (NHRC) being involved in
quality of services available in these, there still remain large gaps in services and
rights of persons with mental illness in institutional care. The NHRC has recently
observed that PWMI are still kept in mental hospitals against their own volition and
that the conditions in the hospitals are deplorable. To truly implement the tenets of
the MHCA, 2017 and in line with the Central Mental Health Authority guidelines on
Mental Health Establishments, norms in accordance with the IPHS need to be
developed for both government run and private mental hospitals, fulfillment of
which would ensure registration as a Mental Health Establishment as mandated by
the MHCA, 2017.

5. Steps to address mental issues in employees in private, public and unorganised sector,
students and other affected sections of the society-

• Mental health care should be delivered in diverse settings; most care would be
expected to occur outside traditional specialist delivery avenues — for instance, in
schools, primary health care facilities, the workplace, and patients' homes.

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 o Workplace Mental Health policy for India- As the younger population of
India start seeking employment and joining the workforce, it is important to
have in place a policy to ensure the wellbeing of the employed population.
The said policy should be binding for the private, public and unorganised
sector to prevent rapid increase in distress and disorders in the working
population, thereby limiting their overall health, social and economic
consequences.
o Focus on suicide prevention in students- Since the pandemic there has been
a reported increase in death by suicides in the student population across all
ages. There needs to be concerted effort including training in mental health
first aid, peer support and available information of low cost/no cost
resources along with an inclusive environment for students from all
backgrounds to address this issue. There are available resources (including
manual on peer support, mental health first aid etc.) that are required to be
adapted to our culture and mandatorily adopted by academic institutions at
secondary and above levels.
o Strengthening the non-specialist workforce for mental health- Although
steps towards empowering the CHOs to effectively provide the first level of
screening and support for mental health conditions has been institutionalised
already, additional steps to involve Panchayati Raj Institutions, Self-help
groups and religious institutions in early detection and referral linkages to the
health system may be put in place to reduce the treatment gap.
o Development of a national mental health awareness campaign- Large scale
awareness and sensitisation campaigns have historically made an indelible
impact on several social and health issues including sex-selective elimination
(Beti Bachao Beti Padhao) and Polio Eradication campaign. Similar nationwide
campaign on mental health awareness, acceptance and promotion of
wellbeing should be undertaken.

6. Impact of COVID-19 on mental health

• An online survey of the psychological impact of COVID-19 lockdown conducted

under the aegis of the Indian Psychiatric Association on 1900 respondents reported
that that more than two-fifths of the people surveyed experienced common mental
disorders, due to lockdown and the prevailing COVID-19 pandemic. Moderate level
of stress was reported by about three-fourth (74.1%) of the participants and 71.7%
reported poor well-being. (Grover et al., 2020)

• Another review of available evidence suggests that the major mental health issues
reported during COVID were stress, anxiety, depression, insomnia, denial, anger and
fear. Children and older people, frontline workers, people with existing mental

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 health illnesses were among the vulnerable in this context. COVID-19 related
suicides have also been increasingly common. (Roy et al., 2021).

• A preliminary analysis of the National Crime Records Bureau, shows an increase of

7.2% in the number of cases of deaths by suicide in comparison to 2020 and an
increase in the rate of suicides by 6.2% during 2021 over 2020. The suicide rate in
cities (16.1) was higher as compared to All-India suicide rate (12.0). It has also has
increased by 8.5% between 2020-2021.

• Globally, lockdowns and COVID restrictions have led to an increase in gender based
violence which has a severe impact on mental health and wellbeing of both women
and children. NCRB data report that the crime rate registered per lakh women is 64.5
in 2021 in comparison with 56.5 in 2020 showing an increase of 15.3% over 2020.

7. Need for a framework to gauge people’s qualitative assessment of their lives,

mental wellbeing and overall happiness through quantitative indicators

• Measuring wellbeing happiness, should not only consider observable objective well-
being measures (e.g., health and socioeconomic status), but also subjective well-
being measures, such as domain satisfaction and quality of life, inter-alia.
• Happiness Index- India could develop a Happiness Index for subjective reporting of
wellbeing and overall happiness of its population. The Happiness Index is a tool for
the use of researchers, community organizers and policy makers seeking to
understand and enhance individual happiness, community well-being, social justice,
economic equality, and environmental sustainability. Other countries including
Bhutan and Finland already have an existing framework in place which could be
contextually adapted to the Indian setting.
The concept of gross national happiness (GNH) was developed of by the Kingdom of
Bhutan. The Happiness Index developed by Bhutan with the Happiness Alliance
includes the following domains : (a) Satisfaction With Life; (b) Positive and Negative
Experiences; (c) Domain Satisfaction; (d) Psychological Well-Being; (e) Health; (f)
Time Balance; (g) Community Vitality; (h) Social Support; (i) Access to Education, Arts,
and Culture; (j) Your Neighborhood; (k) Environmental Quality; (l) Governance; (m)
Material Well-Being; and (n) Work (Musikanski et al., 2017). Further details of the
framework can be found on this comprehensive document-
https://www.oecd.org/site/progresskorea/44120751.pdf

• Measurement of Wellbeing- The qualities to be measured in these domains akin to

the GNH in Bhutan are-
• Psychological Well-Being: optimism, senses of purpose and of accomplishment;
• Health: energy level and ability to perform everyday activities;

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 • Time Balance: enjoyment, feeling rushed, and sense of leisure;
• Community: sense of belonging, volunteerism, and sense of safety;
• Social Support: satisfaction with friends and family, feeling loved, and feeling
lonely;
• Education, Arts, and Culture: access to cultural and educational events and
• diversity;
• Environment: access to nature, pollution, and conservation;
• Governance: trust in government, sense of corruption, and competency;
• Material Well-Being: financial security and meeting basic needs;
• Work: compensation, autonomy, and productivity.

• Development of Self- reporting questionnaire- Finally contextually adapted and

validated self-reporting questionnaires (in line with the WHO guide on self-
reporting) assessing wellbeing and impact of services that contribute to it
including Yoga, tele-mental health programmes and access to public spaces for
exercise need to be developed and made available in health facilities, schools,
and offices to assess overall wellbeing of the population.

8. Blueprint for any future strategies in mental health care and its management

• Integrating AYUSH systems into mental health services- Due to the paucity of
specialists and doctors in the field of mental health, a paradigm shift in enabling the
non-specialist taskforce to provide care is being rolled out in India. However, efforts
to include pluralistic medicine in providing mental health support to the population
still remains to be explored. This is also likely to impact stigma and discrimination in
society and increase health seeking behaviour for mental health conditions.
Ayush systems can contribute to mental health-related issues significantly both in
terms of prevention and therapeutic interventions. The 12th five-year plan on health
recommended that the State would be encouraged to integrate Ayush facilities and
provide Ayush services in all facilities offering treatment in modern medicine. It
further talks about mainstreaming of Ayush using their areas of strengths like
preventive and promotive healthcare, diseases and health conditions relating to
women and children, the elderly, NCDs, mental diseases, palliative care,
rehabilitation and so on.
The National Health Policy 2017 recognizes the need to halt and reverse the growing
incidence of chronic diseases. For Ayush, it emphasizes developing protocol for
mainstreaming AYUSH as an integrated medical care. This has a huge potential for
effective prevention and therapy that is safe and cost-effective.
Further, initiatives like Centre of Excellence project in the Department of Integrative
Medicine, NIMHANS, Bengaluru as part of “AYURSWASTHYA YOJANA”, a flagship
programme under Ministry of Ayush started recently can strengthen the efforts in

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 this direction, and more such initiatives need to be taken. The main objective of this
CoE project is to conduct clinical trials in four neuro-psychiatric disorders to establish
efficacy, safety and proposed mechanism of Integrated Yoga and Ayurveda
treatment approaches.

• Home based care for mental health- Another vulnerable section that is in need of
intensive mental health support is the senior population. With almost 9 percent of
the population being aged above 60 currently and the numbers rising to almost 20%
by 2050, there will be an increasing need for mental health and psychosocial support
for the senior population. The LASI reports that over 100 million seniors report
diagnosed depressive symptoms and other problems. Therefore added attention
needs to be provided to the psychosocial needs of the seniors. One important step
towards making care more accessible to the senior and other high needs population
is developing a home-based care model for mental health through adequate training
and empowerment of the care workforce.

• School Mental Health (as a part of the School Health and Wellness Programme)-
Another important population group that are in need of focused attention
particularly in the wake of the COVID pandemic are children of school going age. The
National Suicide prevention strategy and literature suggest the health promotive and
preventive impacts of mental health programmes in school. It is important that both
school going and out-of-school children be screened routinely and provided
information and services on managing their wellbeing and addressing mental health
issues. The LOOK-LISTEN-LINK model (WHO) on psychological first aid needs to be
included compulsorily in the curriculum to build peer support and early detection in
the formative years.

• Digital/technological clinical decision making support tools- A final area if mental

health services identified that could make services more efficient and accessible are
developing tools for clinical decision making support for the non-specialist medical
professionals at primary health care level and upwards. The reliance on specialist
interventions and increased need for institutional care particularly for CMDs can be
greatly limited if such tools were introduced in the screening and diagnosis process.

**********

N.B- This paper has been prepared by the health team at NITI Aayog for further discussion
with the Hon’ble Standing Committee. This is work in progress, several action pathways
require more insightful synthesis. In its present form, it does not represent the official
position of the NITI Aayog.

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 References-

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Adolescents in South India: What They Know and What Attitudes Drive Them. Indian
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• Grover, Sandeep; Sahoo, Swapnajeet; Mehra, Aseem; Avasthi, Ajit1; Tripathi,

Adarsh2; Subramanyan, Alka3; Pattojoshi, Amrit4; Rao, G. Prasad5; Saha, Gautam6;
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• Musikanski, L., & Polley, C. (2016). Life, liberty and pursuit of happiness: Measuring
what matters. Journal of Social Change, 7, 48–72. doi:10.5590/JOSC.2016.08.1.05

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