Mental health stuck between intention and action

Even a year after her husband Vasanth (40) was diagnosed with schizophrenia, Bhagyamma is yet to find a reliable way to get the medication. The doctor at the local Public Health Centre needs to sign off on a form for her to get the prescribed tablets under the District Mental Health Program, but getting hold of him is a difficult task. “I have to visit the centre at least two to three times before I am able to get the tablets,” she says.

Vasanth’s diagnosis came after 10 years of uncertainty about the cause for his sudden bursts of rage and incoherence. He was taken to the Dharwad Institute of Mental Health and Neurosciences only after the situation escalated into violence, and Vasanth started to throw stones at passersby from the roof of his house at Harapanahalli in Vijayanagar.

“He got better after that,” Bhagyamma says, but Vasanth is not out of the woods yet. When he misses his medication, the fits of rage return. Covid-19 has made the situation worse, with doctors being unavailable for regular counselling, and requisitioning medication becoming tougher.

Read more: ‘I weep all the time’: Trauma lasts beyond India’s Covid peak

Such issues continue to dog people with mental health issues seeking help from the public health system, despite long-standing government programmes like the National Mental Healthcare Plan (NMHP) and the District Mental Health Program (DMHP).

Even in Karnataka, which is implementing the DMHP in all 30 districts and spent over 80% of the funds allocated under the programme, the challenge is formidable — the latest data from the National Crime Records Bureau (NCRB) ranks Karnataka fifth in the number of states that report the most suicides.

Across the country, the National Mental Health Survey of 2016 found that 10.6% of the country needed some form of intervention and access to mental healthcare facilities. And a vast majority of people — as high as 83% — are not able to access treatment.

Also read: ‘We need to link general healthcare and specialised services’

India loses about 1.39 lakh people by suicide in the year 2019, 67% of whom were young adults, that is between 18-45 years.

One of the primary reasons for this wide gap in treatment is an acute shortage of trained mental health professionals. “For a population of over 1.3 billion we have psychiatrists only in the thousands,” says Dr Pratima Murthy, director of the National Institute of Mental Health and Neurosciences (NIMHANS).

India has 9,000 psychiatrists — only 0.75 psychiatrists for one lakh of people, while the requirement is three psychiatrists per lakh. Estimates from World Health Organisation in 2017 show that the country has only 0.15 psychologists per lakh.

The Mental Healthcare Act, 2017 set up provisions to maintain a national register for clinical psychologists, mental health nurses and psychiatric social workers based on information provided by all state authorities.

However, in February this year, Minister of State for Health and Family Welfare Ashwini Choubey said, “The data regarding the number of clinical psychologists was not maintained centrally.”

Bridging the gap

In 1985, NIMHANS implemented the NMHP at the district level in Ballari on an experimental basis to see if mental healthcare could be decentralised to help people in rural areas better access to services.

The team contained a psychiatrist, a clinical psychologist, a psychiatric social worker and a clerk. “The model was successful and was approved to be implemented across India in select districts after 1997,” says Dr Suresh Badamath, Professor of Psychiatry at NIMHANS. Now, over 600 districts across India replicated the 'Ballari model' and implemented the DMHP, though with varying levels of success.

Karnataka has also moved to the ‘Thirthahalli model’ which works at the taluk level. Running in Thirthahalli and Turvekere taluks on an experimental basis for the past decade, the programme has received approval to be implemented in 10 more taluks.

Under DMHP, general healthcare workers are trained to diagnose mental illnesses and provide the first line of care at primary health centres (PHC) through medication or to refer cases to district hospitals if a more serious illness is observed.

In Karnataka, over 68,285 people, including health professionals, paramedical staff, AYUSH, ASHAs, faith healers and police personnel, have been trained, according to data from the Department of Health and Family Welfare.

In 2019 - 20, the state also saw 10.63 lakh people seek consultations under the DMHP, up from the 32,333 patient consultations in 2015 - 16.

Still, there are many challenges that impede DMHP’s reach. To begin with, doctors are usually trained for a period of two to three days.

“There is a range of mental illnesses that need to be identified and treated, unlike other single communicable illness programmes. Further, they are expected to do primary prevention such as school mental health, suicide prevention and anti-substance abuse programmes. The doctors cannot be trained to learn all these mental illnesses and prevention programme given the amount of time spent on training and the enormous expectations in them. They will have to take a three-year course then,” says Dr Suresh Badamath, Professor of Psychiatry at NIMHANS.

The supply of medication at the PHC level also may be irregular given the range of illnesses. Then, there is the need to follow up on the medication with frequent counselling. Like in Vasanth’s case, sometimes treatment can take over a year, if not several years, and patients may lose patience, with some studies indicating that over 30 - 40% patients drop out of the programme.

Recruiting mental health professionals is also often a problem as many are reluctant to work in rural areas.

Staff shortage

Along with a shortfall of 22% to 30% of PHCs and community care centres, close to 60% of centres have only a single doctor, and 5% have none. In 2018, out of 2,359 PHCs in Karnataka, 1,973 had just one doctor. Already faced with a shortage of staff, these additional responsibilities may overburden the doctors, explains Dr Murthy.

At a public healthcare centre in Mysuru district, a doctor on the condition of anonymity says that Covid-19 testing and immunisation programmes have occupied the staff for over a year. “In the past, we were able to give basic counselling support and medication when required to people who would come in. We have also noticed an increase in the number of people seeking support. Right now we have too much to do,” he says.

Another major hurdle is encouraging people to reach out to PHCs or district hospitals when they notice an issue with their mental well-being. The stigma surrounding mental health is enough to scare off many from visiting centres even in case of serious mental illness.

Chinnammakka, a social worker from the Jagrutha Mahila Sammilana, explains that she encounters many people in rural Karnataka suffering from substance abuse, anxiety and depression-related issues. “We try to counsel people by visiting their homes. If we tell them we’ll take them to a doctor because of a mental illness, they will start avoiding us,” she says.

Review boards

A cornerstone of the Mental Healthcare Act is the setting up of the Mental Health Authority at the Centre and state level, along with the Mental Health Review Board.

The State Mental Health Authority (SMHA) registers and maintains records of all mental health practitioners, support staff, institutions and patients in the state. It trains the relevant stakeholders and also advises the government on matters of mental health.

Section 45 of the Mental Healthcare Act mandates that the SMHAs have to be set up within nine months of the law being passed. As of March last year, just 19 states had set up SMHAs.

In Karnataka, the High Court pulled up the government several times before the SMHA was finally functional in April 2020. “Really, I would give full credit to the High Court for the SMHA being constituted,” says one senior official.

But problems persist: the Act mandates the SMHA should meet four times in a year, but the pandemic has meant that the SHMA has only met once, in October 2020.

More disconcerting is the absence of the Mental Health Review Board, which has the important role of safeguarding the rights of mental health patients and addressing their grievances.

Except for Tripura, no other state has set up this judiciary body.

Last year, the Karnataka High Court had directed the state government to constitute the mental health review board as per the Act but so far, no review board has been set up.

The review boards become important when a person with mental illness is admitted without consent, explains Dr Jagadisha Thirthalli, Psychiatry Professor, NIMHANS. A family member, a relative or a nominated representative can sign for admission when the patient lacks capacity to consent but if the patient has a grievance against this, they may approach the review boards, he says.

“Right now, though we are under the new Act, since there is no review board constituted yet, there is some degree of confusion in this regard,” he adds.

Dr Chandrashekhar, Medical Advisor, KSHMA says that five review boards have been planned in the state — two in Bengaluru and one each in Mysuru, Kalaburagi and Belagavi.

Dr K Sudhakar, the state health minister, says, “We will set up the Mental Healthcare Review Board soon with additional scope based on the suggestions provided Dr Devi Shetty’s report.”

While the NMHP and the Mental Healthcare Act are ambitious in their goal of trying to provide a minimum level of mental healthcare to everyone, many states have demonstrated a “tremendous lack of will in implementing the Act,” says Dr Pathare.

“We are on the right path. We need to understand how closely linked our physical health is with our mental health and give it the attention it deserves,” he says.

(With inputs from Prajwal Suvarna)