KATHMANDU, Nepal — For the past 20 years, Geeta tried everything to cure her son. She sold precious family ornaments and her prized gold chain; she took him to faith healers, temples, and astrologists across India; and she even married him off.
But nothing worked. Ramash,* 45, continued to remain elusive: He talked no one but himself; he was socially withdrawn; and was often delusional, seeing things that no one else could.
“I tried everything but nothing worked,” said Geeta, who lives in rural Bangalore, the capital city of Karnataka, a state in southern India. “I felt that an evil spirit had done black magic on him. I was fearful of being at home with just him. It’s very sad because the community treats us badly.”
But earlier this year, Geeta and Ramesh finally got some answers. Ramesh was diagnosed with chronic schizophrenia and put on antipsychotic medication. Ramesh was connected with the public health care system after a community health worker recognized his symptoms. She referred him to a nearby primary health care center, eventually connecting him with a psychiatrist.
It was not an easy task. Nagaveni, a community health worker, recalled visiting the family “four or five times because they believed it was black magic.”
“They weren’t having any success with faith healers so they agreed.”
But while it’s early days, the intervention seems to have hit its mark. After all her efforts failed, Geeta said she is hopeful the medication will help her son. “He’s my only son, I’m worried about the future. I want him to get better.”
Mental health neglected
An estimated 150 million people across India are in need of mental health care interventions, both short and long-term, according to India’s latest National Mental Health Survey 2015-16. The survey, which was carried out across 12 states, found that the overall prevalence for current mental health morbidity was 10.6 percent.
Despite the high number of people who need care, mental health has been sorely neglected in India, rooted in stigma, taboo, and myths.
Poor awareness about the symptoms of mental illness, stigma and the lack of mental health services available has resulted in a massive treatment gap, with inadequate numbers of trained mental health care professionals. The survey found that, depending on the state, between 70 and 92 percent of those in need of mental health care failed to receive any treatment.
There are just 0.3 psychiatrists, 0.07 psychologists and 0.07 social workers per 100,000 people in India. To compare, the ratio of psychiatrists in developed countries is 6.6 per 100,000 and the average number of mental hospitals globally is 0.04 per 100,000 while it’s only 0.004 in India.
Community mental health care
The lack of mental health care workers is hardly a new, or ignored, issue. In 1982, the government of India began implementing its National Mental Health Program with the broader aim of integrating mental health care with general care. Fourteen years later, the program expanded to the district level with the vision that each of India’s 630 districts would have a District Mental Health Program by 2025.
The objective of the DMHP is to provide community mental health services at the primary health care level by training a mental health team comprised of a psychiatrist, psychologist, psychiatric social workers, and nurses in each district, along with increasing awareness and reducing stigma.
But rollout has been slow. As of 2015, nearly two decades after the program launched, it was only prevalent in 27 percent of districts. The DMHP has also been plagued by inaccessible funding and administrative and programmatic problems such as poor governance, unrealistic expectations from low paid and poorly motivated health care workers, and a lack of understanding of ground realities.
But perhaps the chief shortfall has been its inability to fill the required number of professionals required in each district.
Recognizing this, staff from the National Institute of Mental Health and Neuro Sciences and the government of Karnataka, in southwest India, realized that community health workers, better known as Accredited Social Health Activists, or ASHA workers, presented a unique opportunity to fill the gap. Starting in 2016, they began giving the workers extra training in identifying and dealing with mental health issues.
There are more than 800,000 ASHA workers across India who act as interface between the community and public health system. The workers are specially trained local women, selected from those between the ages of 25 and 45 who have completed 10th grade schooling. Based in villages, their roles include counselling women on pregnancy, safe delivery, and breastfeeding, facilitating immunizations, and diabetes checks amid other health-related services.
“We have thirty districts in Karnataka and apart from the urban areas, we won’t find psychiatrists, psychologists or any other mental health professionals,” said Anish Cherian, from the department of psychiatric social work at NIMHANS, who is involved with the program. “There’s a huge skill shortage and the distribution of professionals hasn’t been even.”
“ASHA workers are very trusted members of the community — they’re known in every household,” Cherian said.
As a result, Karnataka has trained more than 22,000 workers on basic mental health in the last year alone. The training is just one day, and is carried out by each district’s DMHP and then continued one day per month by medical officers.
The ongoing training includes teaching ASHA workers how to recognize common to severe mental health problems like schizophrenia, anxiety, depression, and alcohol abuse along with teaching them how to refer patients to a professional at the primary health care level and also to provide basic counselling.
Cherian explained that because most cases require basic interventions such as listening, talking, and minor lifestyle changes, he said ASHA workers were in a unique position to offer such services in a supportive way.
“Most cases need basic interventions. Many people have tension, fatigue, and body aches and pains. They just need someone to talk to, to sit with them and support them,” he said.
A psychiatrist for Bangalore DMHP, Dr. Chetan Kumar, said utilizing ASHA workers was about strengthening the system rather than creating a new one.
“Increasing the number of psychologists and psychiatrists alone won’t help — that would take another 150 years to fill the gap,” he said.
But for patients with more severe mental health illnesses like Ramesh, linkage to care is a long road because of the lack of providers. Patients in rural areas who need care often have to travel more than 100 kilometers to see a psychiatrist, Cherian said.
The use of ASHA workers for India’s mental health response is not just confined to Karnataka.
In the northern Indian state of Madhya Pradesh, ESSENCE, a five-year research project that began last year by Harvard Medical School and Sangath, an NGO in south India in partnership with the state government, is evaluating the use of technology interventions to train and support ASHA workers to deliver therapy for depression.
Such efforts are part of India’s broader plan to implement its first ever National Mental Health Policy which was launched in 2014. The policy aims to provide universal access to mental health care by enhancing understanding of mental health. The policy called for increased funding along with an increased number of professionals to be trained on all levels from the community to specialized psychiatrists.
Much of the policy is reliant on individual states to implement it effectively. It is widely acknowledged that southern states like Karnataka are more likely to spend funds more efficiently on district-level programs than relatively poorer and more populous states in the north.
Greg Armstrong, research fellow at the Centre for Mental Health at the University of Melbourne, Australia, said the use of ASHA workers to provide basic mental health care was encouraging as it signaled India was moving closer to being able to fulfil the human right of access to mental health treatment.
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Last year, the country passed the Mental Health Care Act 2017, which looks to empower people suffering from mental illness and to safeguard their rights and access to treatment without discrimination, amid other clauses.
Armstrong stressed that while ASHA workers could fill a gap in the system, they were simultaneously creating demand for treatment when specialized supply was not yet fully available.
“ASHAs have to do everything and now we’re getting them to do mental health care. It’s not a bad thing but it creates a lot of pressure when the nearest psychiatrist might be six hours away,” he said. “We need to consider the whole mental health system on a region-by-region or district-by-district basis.”
So, while on paper 27 percent of India’s districts have a district mental health program, many are lacking a fully equipped team.
To this end, Armstrong highlighted that many mental health problems including depression may in many cases be strongly intertwined with major structural and social issues such as entrenched poverty, domestic violence, and early marriage. Armstrong said this meant there was an imperative to not to drop vigilance in addressing broader issues in India.
Looking ahead, experts are encouraged that momentum is building in India to provide better care and combat stigma. But it’s a long road.
“It’s a mammoth task,” Dr Kumar said. “Indians aren’t immune to mental health illnesses but they don’t believe they suffer from it.”
* Names have been changed for anonymity purposes.