The strange mindset that is trying to treat mental health
PremiumIt’s an example of how policies made without stakeholder inputs yield suboptimal outcomes
India observes 10 October as World Mental Health Day every year. The day is significant because mental health issues have remained under-invested and under-appreciated. Untreated mental health problems have severe repercussions for society and for the economy. The World Health Organization (WHO) estimates that unaddressed mental health issues could force India to incur an economic loss of over $1 trillion between 2012 and 2030. But, as with all such occasions, 10 October has turned into yet another day for boiler-plate statements and hand-wringing. The problems run deep and remain overlooked.
The significance of mental health issues is percolating into the general consciousness at a glacial pace. The spectre of social stigma is still a formidable barrier, even among the young. For example, the flagship survey of Unicef has found that only 41% of people between 15 and 24 years of age in India appreciated seeking help for mental health issues, compared with 83% elsewhere in the world. This may not be a truly representative sample, but does provide an insight into the national psyche.
The hesitation gets worrisome when juxtaposed against the severity and prevalence of mental health issues. A 2020 study in The Lancet shows that over 197 million Indians suffered from mental disorders in 2017 (amounting to over 15% of India’s population) and included over 45 million with depressive disorders and another 45 million with anxiety disorders. The report also states that the proportion of mental disorders to the total disease burden in India has almost doubled since 1990. This number would have grown over the past 18 months, especially among those who have lost close ones to covid or suffered job losses.
The Indian government has recognized the growing risk of mental health problems and has drafted necessary legislation and policies. For example, The Mental Healthcare Act was passed in 2017, which superseded the Mental Health Act, 1982. A raft of policy documents has also been authored over the past few years, but much of that has stayed mostly on paper. For example, the Act had specified that each state must set up its own mental health authority by 2019, but that is still work in progress. That is not all; the thicket of policies and rules has created a conflicting structure.
This asymmetry is evident in the structure of trained mental healthcare professionals. The rising incidence of mental health issues requires a deployment of trained first-responders and professionals, but that is where the slips start showing. According to the WHO’s mental health atlas for India, there were only 0.07 psychologists per 100,000 people in 2017. The next level is only marginally better: there were only 0.29 psychiatrists (those who have medical degrees and can prescribe medicines). Many developed economies, especially the US, have more psychologists than psychiatrists, with counselling and therapy preceding medical intervention. Tragically, India’s entrenched system, especially a crimped pipeline for trained psychologists, is likely to perpetuate this skew.
Psychologists need a licence to practice in India that can be obtained only by acquiring a two-year M-Phil degree. But, and herein lies the rub, the degree can only be obtained from a few select institutions hand-picked by the Rehabilitation Council of India (RCI), a statutory body set up to “regulate and monitor services given to persons with disability, to standardise syllabi and to maintain a Central Rehabilitation Register of all qualified professionals and personnel working in the field of Rehabilitation and Special Education."
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Two oddities spring up here. One, the RCI still insists on an M-Phil degree even when the National Education Policy has abolished it. Second, the RCI is part of the ministry of social justice and empowerment, while mental health is clearly under the health ministry’s jurisdiction.
There are other disturbing imbalances. The RCI, run by bureaucrats in Delhi, rations out permissions for conducting M-Phil programmes to only a handful of different institutions every year, which automatically limits the number of psychologists qualifying each year. The basis for selecting these institutions is not transparent and Delhi-based bureaucrats rationing professional licences is an uncomfortable throwback to a long-forgotten era. The selected institutions conduct entrance exams that are not standardized, with each institution pulling in a different direction. For example, these institutions conducted in-person exams even during the pandemic and forced students to travel to various cities. These exams are fashioned on the multiple-choice-question format, which, instead of testing students’ knowledge of mental health theories and practices, assesses their ability to game exams.
Here is another skew. India specifies mental illnesses on the basis of the WHO’s International Classification of Diseases, but, ironically, all Indian post-graduate institutions use a different norm in their pedagogy because neither the RCI nor the health ministry has any clarity on textbooks. There is one unsavoury upshot from all this: multiple charlatans have emerged who are practising without proper qualifications or licences, often gaining their knowledge from spurious video-tube instructions.
Sadly, mental health authorities seem to have missed the memo on how policy frameworks devoid of stakeholder inputs always lead to sub-optimal outcomes.
Rajrishi Singhal is a policy consultant, journalist and author. His Twitter handle is @rajrishisinghal
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