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Boosting India’s mental health care apparatus – analysis

Mental health has had its Cinderella moment this year. From being the neglected and stigmatised domain of health care, it has become, in the wake of the socio-economic upheaval caused by Covid-19, the newest woke slogan. Public health experts, media, policymakers, self-styled gurus and social media influencers, among others, have expressed their views on this in the past six months. Everyone has a story and a solution; but little has changed on the ground.

Many myths about mental health remain in our collective thinking — those who face mental health problems are weak; seeking help makes one dependent; psychiatric medicines are addictive; and psychotherapy and counselling can alter people’s thinking instantly.

In a recent study in Lancet on the Burden of Mental Health in India, it was reported that, in 2017, there were 197.3 million people with mental disorders, comprising 14·3% of the total population. Mental disorders contributed 4·7% to the total Disability Adjusted Life Years (DALY) in India in 2017 as compared to approximately 2·5% in 1990 (one DALY essentially being one lost year of “healthy” life). Various studies have reported that the treatment gap is as high as 95%. Treatment, even when available, is largely focussed on medicines. Access to psychological and social interventions for mental health problems is not available to most people. The more vulnerable — children in institutions and in need of care and protection, the homeless, women who face violence, people living in conflict areas and those facing discrimination due to identity and disability — are the least likely to have access to mental health services.

One of the key barriers to access is the lack of mental health human resources. The World Health Organization’s Mental Health Atlas in 2017 documents that India has around a total of 25,000 mental health workers. India spends 1.3% of its health budget on mental health. The current strategies for developing human resource are focussed on training more psychiatrists, clinical psychologists, psychiatric nurses and psychiatric social workers, whose numbers are woefully inadequate.

But if all commissions for women, child care and protection organisations, schools, universities, employee-assistance schemes, neighbourhood clinics and wellness centres were to integrate mental health in the services they provide (as required by the law), the need for mental health human resources would be a few hundred thousand skilled professionals.

If access to mental health services for all has to become a reality, we have to rethink the current traditional definition of mental health human resources and revamp the methodology for developing these.

In an article to be published in Indian Journal of Social Psychiatry, a case has been made to synchronise the mental health human resource strategy with the development of community mental health services. India needs to work towards a three-tiered mental health workforce comprising associates, practitioners and specialists.

The associates would be the primary level workers for mental health interventions at the village or urban cluster-level. They would make up a new cadre of frontline community mental health workers which can be set up by repurposing the present Accredited Social Health Activist (Asha) cadre, first-response community development workers or members of women’s self-help groups. More importantly, employment guarantee schemes in both rural and urban areas could include community mental first aid as one of the activities which qualify as work provided by them.

The mental health associates would be the first point of contact, and would be able to form empathetic relationships, support people in decision-making and work with an individual or a group of individuals under supervision. They would also work towards increasing awareness and linking people to crisis intervention and secondary and tertiary mental health services.

The next level, practitioners, would form the spine of mental health service delivery and would be graduates with specific training in community mental health. Their competencies would include supporting adaptive coping programmes; providing online behavioural and cognitive interventions; supporting care and protection processes in residential and community settings; facilitating informed choices, independence, safety, dignity, privacy and participation in everyday life for those living with mental health problems. These practitioners would also start conversations and galvanise communities around initiatives to challenge stigma and facilitate inclusion.

The specialists would include the current mental health professionals, but would also strategically allow post-graduates in psychology and social work to upgrade their skills through an advanced diploma in community mental health. They will provide leadership, training, tertiary services and supervision.

We have lived with the legacy of institutional care mechanisms and related limitations of human resource planning for too long. The current pandemic should precipitate a disruptive change. It must be used to not only mitigate the present psycho-social impact, but lay the foundations for a more comprehensive network of mental health services in India.

Dr. Achal Bhagat is senior consultant psychiatrist and psychotherapist, Apollo Hospitals, Delhi, chairperson, Saarthak and chairperson, AADIThe views expressed are personal

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