Health

As State Elections Approach, It’s Time to Prioritise Mental Health

Where do Punjab, Uttar Pradesh and Manipur stand in terms of mental healthcare? And why is it necessary for politicians to take the issue more seriously?

A woman looks out of the window at a mental health facility. Credit: Shazia Yousuf/IPS/Files

A woman looks out of the window at a mental health facility. Credit: Shazia Yousuf/IPS/Files

Mental disorders have long been plagued with stigma due to lack of awareness and preconceived notions. This has prevented mental health from getting the same degree of attention as other health issues. Shockingly, the Millennium Development Goals almost entirely ignored any form of mental disorders, despite 10% of the global population being affected by some form of mental illness at any given time. According to the National Mental Health Survey (NMHS), the same figure for India was 10.6%, higher than the global average.

The economic burden associated with global mental disorders between 2011-2030 was estimated to be around $16.3 million. Therefore, mental disorders affect not just individual health but the overall health of a community and country. This has finally been recognised by world leaders who dedicated target 3.4 and 3.5 of the Sustainable Development Goals to the promotion of mental health and prevention and treatment of substance abuse.

Bearing 15% of the disease burden of global mental, neurological and substance use disorders, India is the second largest global contributor to mental disorders. Therefore, India plays a key role in bringing down the global rate. In order to address these challenges, India began framing the National Mental Health Policy (NMHP) in 2011. This was adopted in 2014 and each state was expected to either adapt the NMHP or create their state specific-policy. Among the 12 states covered by the NMHS, Uttar Pradesh, Manipur and Punjab will hold elections in the coming month. This is an ideal time to focus on the condition of mental health in these states and urge the newly-elected governments to prioritise it in their health agendas. However, they have not yet formulated any state-specific action plan, but are reportedly following the NMHP.

The lifetime prevalence of mental morbidity, which includes schizophrenia and other psychotic disorders, mood disorders, neurotic and stress related disorders and substance use disorders (excluding tobacco use disorder), was 13.7% at an all-India level. According to the NMHS report, Manipur has the highest risk of mental morbidity in the country, closely followed by Punjab. UP has one of the lowest estimates of mental morbidity prevalence. Mental morbidity is 2-3 times higher in urban metros than in rural and non-urban centres due to a fast-paced lifestyle, stress, breakdown of support systems and so on. Given that urban centres are continuing to expand, this is expected to rise. In terms of gender, depression and anxiety seem to be 2-3 times higher in women than in men, whereas men have higher rates of substance abuse, addictions and psychopathic personality disorder than women. Prevalence of mental morbidity also peaked between the ages 30-49 years (productive population of society).

Despite having the highest mental morbidity in the country, Manipur does not yet have a hospital for the mentally ill. Surprisingly, the state houses the maximum number of trained medical officers (9.73 per 100,000 population) for treating people with mental illnesses at the primary health centre (PHC) level. Most other states, Punjab (1.37 per 100,000 population) and UP (0.11 per 100,000 population) included, have exceptionally low rates of such trained doctors. The number of psychiatrists is also very low in most states, except Kerala. High-income countries have a psychiatrist to patient ratio of 1-2 psychiatrists per 100,000 population, while in India the ratio is 0.3 psychiatrists per 100,000. For Manipur and Punjab, this number stands at 0.5 and for UP, a mere 0.15 per 100,000 population. The availability of medicines for treatment of mental and neurological disorders is varied across the 12 states. The table below shows the availability of drugs for mental and neurological disorders in Manipur, UP and Punjab at the PHC, sub-district and district hospital level.

According to the National Crime Records Bureau, suicide incidence for UP, Punjab and Manipur is relatively low (1.7, 2 and 3.3 per 100,000 population, respectively). However, the survey ranked Kerala, West Bengal, Manipur, Rajasthan and UP as the top five states with high risk of suicide (including ideation, preparation, attempts and repeated thoughts of suicide). UP and Manipur have very high rates of people at risk of suicide but very low actual number of suicides. This gap indicates a possibility of either reporting issues or suggests that people with suicidal tendencies did not act upon their thoughts, or other contextual factors. While men in the three states had an almost double suicide incidence rate, women were reportedly twice as likely to commit suicide than men. More than a fifth of India’s population is afflicted by some sort of substance use disorder, with tobacco-use disorders being the most prevalent. Among the 12 states covered by NMHS, alcohol-use disorder is reportedly 8% in the agrarian state of Punjab, making it second only to Madhya Pradesh. Prevalence of ‘other’ substance disorders in Punjab stands at 2.5% – over four times the average for the NMHS states. Punjab accounted for 25% of the total illicit opium and 43% of the illicit heroin seized in India. Up 1% and 40% of the population consumes opioids, cannabis, sedatives and inhalants. In UP, 5-65% of the population use ganja/bhang, while other common drugs include other forms of cannabis, opioids, heroin, etc. Cannabis, heroin, ganja and painkillers are the most commonly used drugs in Manipur. In general, drug abuse is more common among the youth and adults, while in Punjab, sedatives and prescription drugs are consumed largely by the elderly.

According to the findings, almost nine in ten people with mental health disorders do not receive evidence-based treatment. The table below shows the worrying treatment gap in Manipur, UP and Punjab. This is largest in Manipur for severe mental disorders such as schizophrenia, bipolar affective disorders and severe depression. This gap could partly be due to low spending on mental health disorders in the country, accounting for a mere 0.06% of the health budget. Other factors such as stigma and low awareness act as stumbling blocks for people seeking treatment.

Since a majority of patients access treatment from a highly unregulated private sector, enough data is not available on mental healthcare. Therefore, public-private partnerships as well as streamlined, state-specific mental health action plans are urgently required. Both inter-sectoral and intra-sectoral (law, civil society, education, employment etc.) collaboration are essential to promote long-term mental health awareness, treatment and rehabilitation. The Mental Health Care Bill passed in the Rajya Sabha in August 2016 is a step towards the protection of the rights of people with mental illnesses. This Bill intends to replace the Mental Health Act, 1987 and reform archaic laws such as criminalising suicide and the use of electro-convulsive therapy.

Given this urgent scenario, it still remains to be seen how far the newly-elected governments prioritise the issue of mental health in their respective states.

Priyanka Shah is a junior fellow at the Observer Research Foundation, New Delhi. Rhea Colaco is a researcher at the Observer Research Foundation, New Delhi.

  • method man

    Dear Authors

    I am a mental health professional, so I speak as an informed person with a specific interest in these matters. Firstly, thanks for putting this article together, because it must have taken a substantial amount of effort to collate data from a number of sources.

    However.

    This article has an acute lack of context, without which it is meaningless. Before going into the details, I would also like to ask why this is framed as an election issue. If your motivation is the drug dependence epidemic that claims both Punjab and Manipur amongst its victims, this article would have done well to include figures on the treatment of drug dependent subjects–these statistics are available from other sources, and are worth highlighting both for their virtues and their deficits (disclosure: the institution I work for is closely involved in the expansion of these services). The mental health concerns, on the other hand, are general, and not limited to these states.

    In terms of specifics.

    1. Manipur does not have a mental hospital. This has to do with a policy to move towards a community based treatment paradigm. In the very same table that you use as a basis for this data point, you would find that there are 5 in-patient units in general hospitals, and that the district mental health programme is being implemented in 5 (out of 8) districts in the state. This is very much in line with state policy. In fact, given that the national mental health programme has been a relative laggard, and covers hardly one-third of the 600-odd districts in the coutnry, these would be exemplary figures.

    2. Mental health manpower is “inadequate”. This is a statement I ought to welcome. And I would, if it wouldn’t deteriorate very quickly into a discussion of the lack of psychiatrists. In India, the figures on the number of psychiatrists (including that quoted by the latest version of the WHO’s mental health atlas) are based on some babu’s assessment of the numbers. There is no systematic data collection, there is no attempt to verify. The Indian psychiatric society (which is the national level professional association) itself contains 5000 members, which is far in excess of the official figure of 3000.

    More importantly, there is nothing to show that a mere quantitative increase in mental health manpower would be either cost effective, or even effective per se. We lag even further behind in terms of the availability of other professionals who are the mainstay of community mental health programmes in other parts of the world. Specifically, we have not yet come to include community psychiatric nurses or social workers (the usual “case managers” and first contact mental health practitioners who deal with patients in western systems) or even to train these professionals to work with patients with mental illness. What results is a top-heavy system that’s entirely built on a referral-and-admission paradigm.