Excerpts from the report “National Health Survey of India-2016”, prepared by the Ministry of Health and Family Welfare Government of India:
The National Mental Health Survey of India-2016 was conducted on a nationally representative sample of 34,802 individuals, sampled from 12 states of India. The response rate at households was 91.9%, while individuals interviewed were 88%, with some variations across the surveyed population. One out of every three respondents in the survey was a young adult (aged 18-29 years). One-third of households reported having a BPL (Below Poverty Line) card, with variations as low as 5% in Tamil Nadu to as high as 75.6% of households in Chhattisgarh.
The weighted prevalence across diagnostic categories in urban metros was higher than in rural and urban non-metro areas (with less than 10 million population). However, differences exist across diagnostic categories. The prevalence of schizophrenia and other psychoses (0.64%), mood disorders (5.6%) and neurotic or stress related disorders (6.93%) was nearly 2-3 times more in urban metros. One can speculate and consider the contribution of several factors (fast paced lifestyle, stress, complexities of living, breakdown of support systems, challenges of economic instability) for this higher prevalence and further investigations are needed to understand the relationship between urbanisation and mental illness.
Common mental disorders (CMDs), including depression, anxiety disorders and substance use disorders are a huge burden affecting nearly 10.0% of the population. This group of disorders are also closely linked to both causation and consequences of several non- communicable disorders (NCD), thereby contributing to a significantly increased health burden. These disorders have previously been unaddressed in the planning and delivery of health care programmes. Individuals and families also ignore and neglect these disorders till they become severe.
The weighted prevalence of depression for both current and life time was 2.7% and 5.2%, respectively, indicating that nearly 1 in 40 and 1 in 20 suffer from past and current depression, respectively. Depression was reported to be higher in females, in the age-group of 40-49 years and among those residing in urban metros. Equally high rates were reported among the elderly (3.5%).
Substance use disorders (SUDs), including alcohol use disorder, moderate to severe use of tobacco and use of other drugs (illicit and prescription drugs) was prevalent in 22.4% of the population above 18 years in all the 12 surveyed states. The MINI diagnostic instrument identified those with alcohol use disorder (abuse and dependence) to the extent of 4.6% and the number of users may be much higher. The prevalence of tobacco use disorder (moderate and high dependence) and alcohol use disorder (dependence and harmful use / alcohol abuse) was 20.9% and 4.6%, respectively. The prevalence of alcohol use disorders in males was 9% as against 0.5% in females. The numbers could be much higher as the study instrument captured only the more severe end of the spectrum of alcohol use. Further, the use and the rates of alcohol abuse / harmful use are likely to be underreported in general household studies.
The survey also revealed that 0.6% of the 18+ population were recognised with illicit substance use disorders (dependence + abuse) which included cannabis products, opioid drugs, stimulant drugs, inhalant substances and prescription drugs. Among adult males this was 1.1%. There was a wide variation across different states, and similar high rates of consumption of illicit drugs were reported by participants in many states during our focused group discussions.
The burden of SUDs, contributed mainly by alcohol and tobacco, was more in middle aged (40-59) individuals (29%), among males (35.67%) and in rural areas (24.12%). However, other SUDs (illicit drugs) were more prevalent in urban metro areas. In the context of the bidirectional relationship between mental health and SUDs and their demonstrated role as causative factors for non-communicable disorders, the high prevalence of SUDs in India is of serious concern.
Nearly 1% of the population reported high suicidal risk. The prevalence of high suicidal risk was more in the 40-49 age group (1.19%), among females (1.14%) and in those residing in urban metros (1.71%). While half of this group reporting suicidal risk had co-occurring mental illness, the other half did not report any co-morbid mental disorder.
Nearly 1.9% of the population were affected with severe mental disorders in their lifetime and 0.8% were identified to be currently affected with a severe mental disorder. Severe mental disorders like schizophrenia, other non-affective psychoses and bipolar affective disorder were detected more among males and in those residing in urban metro areas. The current prevalence of severe mental disorders in most states was less than 1%, excepting in Manipur and West Bengal. Even though prevalence is low in comparison to common mental disorders, severe mental disorders are equally important as their manifestation, outcome and impact are overtly different from CMDs. Furthermore, there is significant stigma associated with these disorders as they affect all domains of life and require long term rehabilitation services.
Significant gender differentials exist with regard to different mental disorders. The overall prevalence of mental morbidity was higher among males (13.9%) than among females (7.5%). However, specific mental disorders like mood disorders (depression, neurotic disorders, phobic anxiety disorders, agarophobia, generalised anxiety disorders and obsessive compulsive disorders were higher in females. Small number of female alcohol users identified in the present survey were reported to be dependent users. These gender differences have been reported in earlier studies as well.
Prevalence of mental disorders in age group 13-17 years was 7.3% and nearly equal in both genders. Nearly 9.8 million of young Indians aged between 13-17 years are in need of active interventions. Prevalence of mental disorders was nearly twice (13.5%) as much in urban metros as compared to rural (6.9%) areas. The most common prevalent problems were Depressive Episode & Recurrent Depressive Disorder (2.6%), Agoraphobia (2.3%), Intellectual Disability (1.7%), Autism Spectrum Disorder (1.6%), Phobic anxiety disorder (1.3%) and Psychotic disorder (1.3%).
Mental Health Systems, Resources and Facilities
The delivery of mental health care to Indian citizens is the joint responsibility of the central and state governments. Mental health services should be comprehensive (promotion, care, management and rehabilitation), integrated (within and between different sectors) and delivered to the entire population (public health approach). To deliver good quality mental health care, several activities and programme components should work effectively and efficiently together, and this is referred to as the systems approach.
Though initiated nearly 3 decades back, the programme implementation under the National Mental Health Programme has been slow. Only lately, changes have been noticed in coverage, resource allocation, and other areas. The development of the National Mental Health Policy (2014), a new Mental Health Bill (2016), recent judicial directives, initiatives by the National Human Rights Commission (2016), increase in resource allocation, expansion of the District Mental Health Programme to nearly 200 districts, establishment of new Centers of Excellence, improvement of care in mental hospitals are a few examples in this direction.
However, the implementation of programmes are expected to happen at the state level in terms of access to care, availability of services, utilisation by communities and awareness about mental health issues. In this context, the State Mental Health Systems Assessment (SMHSA) was conducted alongside estimating prevalence of mental disorders under the National Mental Health Survey. This approach is unique as it provides a dual assessment of the prevalence of mental disorders and systems available to address the same at the state level, in the same time period. The 12 states chosen for the SMHSA were diverse with regard to their administrative and economic characteristics like the number of districts, talukas and villages, per capita income and mental health issues.
Except the states of Gujarat and Kerala, no other state had a stand-alone state mental health policy with defined or specified goals, objectives and mechanisms. The state of West Bengal has a policy focusing on the rehabilitation of those with mental illness. All the other states informed that they were following the national policy and had not made any adaptations. d states, health management information systems were in different stages of integration and implementation.
With the predominant focus being on maternal and child health and a few other national programmes, a fully integrated system was absent. In the area of mental health, HMIS was primarily disease focused, limited in scope and coverage, and was not integrated into routine health HMIS. HMIS for monitoring at the state level was limited to providing information on the number of cases registered for treatment (mainly psychosis, neurosis, mental retardation and epilepsy) to the programme managers. Mental health was included in the existing routine HMIS only in Chhattisgarh, Gujarat, Madhya Pradesh and Punjab.
While the information available at the state level was grossly inadequate, even the available data was of limited help; decisions taken were rarely based on information. The current mental health programmes in India are hampered by the lack of valid, reliable, timely, sensitive and specific outcome indicators for mental health developed on routine data gathering methods. An inquiry into the availability of any official reports that are stand alone or include mental health elicited minimal details.
Among the states, Gujarat reported publishing periodical reports specifically covering mental health activities from both the private and government sectors during the last two years. Eight of the 12 surveyed states reported to have compiled mental health data for inclusion in the general health statistics during the last two years; however, no specific reports were available.
Mental health programmes at the state level are still stand alone programmes; however, an assessment of facilities available, indicates the presence of a wide variety of institutions ranging from specialty hospitals to primary health centres, that can be engaged in the delivery of mental health care, both in the public and private sectors. Across the states, the presence of health care facilities varied from 14.8 facilities per lakh population in Uttar Pradesh to 31.2 per lakh population in Rajasthan. A large number of private health care institutions and professionals were available in general and specialised care; however, their numbers, quality and activities are unclear and the role they could play is yet to be delineated.
The availability of psychiatrists (per lakh population) in the NMHS states varied from 0.05 in Madhya Pradesh to 1.2 in Kerala. Except for Kerala, all other states fell short of the requirement of at least 1 psychiatrist per lakh population. Kerala also had the highest number of clinical psychologists (0.6 per lakh population). The availability of psychiatric social workers was relatively low across all the NMHS states. The limited availability of specialist mental health human resources (psychiatrists, clinical psychologists and psychiatric social workers (existing ones are also mostly in urban areas)) has been one of the barriers in providing essential mental health care to all. Information on core mental health personnel and supportive service providers from the private sector was not readily available.
Despite the acceptance of the fact that primary and community care is the need of the hour, some patients need institutional mental health care and rehabilitative services. There was at least one mental hospital in all the surveyed states, except in Manipur; all states have medical colleges with a psychiatric department, general hospitals with a psychiatric unit and a few have de-addiction centres. Apart from the major mental health facilities, there were 450 mobile mental units and 249 de-addiction centres providing mental health services in the 12 states. However, the existing facilities had inter-state variations, were inadequate and unevenly distributed thereby resulting in limited care accessibility.
Information on private mental health facilities was limited. As India moves beyond mental hospitals, it is important to increase the role of medical colleges and district hospitals in delivering mental health care. Outreach facilities should be initiated to cover not only care, but also mental health promotion and rehabilitation services. Private sector institutions should also actively engage themselves. The need for clear guidelines to achieve these aims cannot be over-emphasised.
There is a paucity of mental health professionals (psychiatrists, psychologists and psychiatric social workers) in India. This necessitates the engagement of nonspecialist professionals for mental health care. The health workforce density (per lakh population) across states ranged from 146 in Uttar Pradesh to 995 in Kerala. In five states (Kerala, Manipur, Punjab, Rajasthan and Tamil Nadu), the density of the health workforce was relatively higher. The doctor (MBBS) density (per lakh population) varied widely across states from 64.4 in West Bengal to 5 in Chhattisgarh.
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