• Users Online: 591
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 4-12

Analyzing Indian mental health systems: Reflecting, learning, and working towards a better future

Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission18-May-2019
Date of Acceptance20-May-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Preetam B Mahajan
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_21_19-

Rights and Permissions

Mental health has been long neglected. Even though it causes substantial loss of disability-adjusted life years, it does not receive proportionate funding. India spends <2% of its annual health budget on mental health. India has been witnessing a great push for mental health. A number of policy-level reforms have been undertaken, and efforts are on to tackle this issue in a better way. In this study, we have reviewed various factors contributing towards policy, implementation, and utilization gaps based on published studies and Mental Health Survey reports and suggested ways to address these. Bottleneck analysis reveals that interventions to improve mental health scenario extend beyond the ambit of the National Mental Health Policy and requires strong policy negotiations and reforms to resuscitate the dying public health-care system of India.

Keywords: Bottleneck analysis, health systems strengthening, mental health, patient care pathway

How to cite this article:
Mahajan PB, Rajendran PK, Sunderamurthy B, Keshavan S, Bazroy J. Analyzing Indian mental health systems: Reflecting, learning, and working towards a better future. J Curr Res Sci Med 2019;5:4-12

How to cite this URL:
Mahajan PB, Rajendran PK, Sunderamurthy B, Keshavan S, Bazroy J. Analyzing Indian mental health systems: Reflecting, learning, and working towards a better future. J Curr Res Sci Med [serial online] 2019 [cited 2023 May 31];5:4-12. Available from: https://www.jcrsmed.org/text.asp?2019/5/1/4/260634

  Introduction Top

The World Health Organization (WHO) defines mental health as “a state of wellbeing in which every individual realizes his/her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community."[1] Disturbance to this Mental State, compromises individual capacity, and their level of functioning leading to welfare losses to self, their household and society at large.

In 2004, Mental Disorders accounted for 13% of global disease burden. About a third of this disease burden (i.e. overall 4.3%) was due to depression, which alone is expected to be No 1 contributor to disease burden by 2030. If one had to factor only the disability component, mental disorders would account for 25.3% and 33.5% of all years lived with a disability in low- and middle-income countries, respectively.[2] In terms of economic output, mental disorders would result in losses of 16 trillion US$ by 2030.[3] Mental health-related issues have long been neglected.[4] Most nations (low and middle income) spent <2% of health budget to the treatment and prevention of mental disorders. More than 80% of these are spent on mental hospitals.[5]

The WHO for thefirst time adopted a comprehensive mental health action plan (MHAP) 2013–2020 that called for change in attitudes that perpetuated stigma, expansion of services, and efficient use of scarce resources in promoting mental well-being, preventing mental disorders, and protecting rights of people suffering from mental illnesses. It focused on four key objectives: “to strengthen effective leadership and governance for mental health; provide comprehensive, integrated, and responsive mental health and social care services in community-based settings; implement strategies for promotion and prevention in mental health; and strengthen information systems, evidence, and research for mental health."[6],[7] Amid some progress, many challenges and barriers are yet to be surmounted. There is a renewed agenda for achieving global mental health[8] with considerable global and national responses.

India was one of thefirst countries in developing world to have adopted a Mental Health Program (MHP) in 1982.[9] A series of setbacks and implementation failures collectively led to its underperformance.[10] However, interest of multiple stakeholders got reignited after the WHO called for scaling up action against mental illnesses in 2013. Since then, India has been witnessing a great push for mental health[11] with revamping of its MHP,[12],[13] framing of itsfirst mental health policy[14] fully in line with human rights covenants,[15] and enactment of mental health legislation.[16] Underlying principles of newly rolled out District MHP (DMHP) was based on six key perspectives, namely life course, recovery, equity, evidence based, health systems, and right based.[13]

It's time we review our current mental health scenario, identify various policy implementation gaps, learn from success stories in other resource-constrained settings, and accordingly, shape mental health-care services, which is the primary focus of this review article.

  Mental Health-Care Scenario in India Top

Baxter et al.[17] modeled prevalence estimates of mental, neurological, and substance use (MNS) disorders in India but cautioned about generalizability citing inadequate underlying population-based data. Depression and anxiety were the most common. They predicted a 23% rise in burden between 2013 and 2025.[18] There was a strong recommendation for developing effective surveillance programs to capture trends; understanding of local context; to inform local area needs assessment and workforce requirements; urgent prioritization of interventions focused on targeted prevention, early identification, and effective treatment; and monitoring and evaluation of mental health services.[19]

In 2016, India carried out the National Mental Health Survey (NMHS-2016) in 12 states (first phase).[20] Lifetime prevalence and current prevalence for number of MNS disorders were provided for individuals >18 years of age (57%–68% of total population) and a subsample of 13–17 years in four states. In addition, treatment gaps, health-care utilization patterns, disability status of mentally affected individuals, and impact on individual and their family in the surveyed population were systematically assessed. They also assessed the mental health systems, services, and resources in different states. This could guide context-specific planning of health-care services at state level and strengthen mental health systems in the country.

It appeared that nearly 150 million Indians (urban > rural) were in need of active interventions posing a formidable challenge to our insufficient, inequitably distributed, and inefficient mental health system. The overall weighted lifetime prevalence and current prevalence for any mental morbidity were 13.7% and 10.6%, respectively. People from 40 to 49 years were predominantly affected (psychotic disorders, bipolar affective disorders (BPADs), depressive disorders, and neurotic and stress-related disorders). The prevalence of substance use disorders was highest among 50–59 years (29.4%).

Treatment gap for mental disorders ranged between 70% and 92% for different disorders: common mental disorder – 85.0%, severe mental disorder – 73.6%, psychosis – 75.5%, BPAD – 70.4%, alcohol use disorder – 86.3%, and tobacco use – 91.8%. The median treatment delay varied from 2.5 months for depressive disorder to 12 months for epilepsy. Government facility was the most common source of care. The median monthly amount spent for care and treatment varied between disorders: alcohol use disorder – ₹2250, schizophrenia and other psychotic disorders – ₹1000, depressive disorder – ₹1500, neurosis – ₹1500, and epilepsy – ₹1500. This was sufficient enough to plunge many families into poverty spirals.

A detailed report about health system assessment is available.[21] A systems approach is crucial to identify various bottlenecks within health systems and facilitate effective implementation of simple as well as complex mental health interventions in real-world settings. Before this attempt, a number of other evaluations[22],[23],[24],[25],[26],[27],[28],[29] were carried out uncovering various implementation issues and possible solutions, but none of these had a systems approach.

DMHP gradually increased its coverage over three decades after its launch, but its implementation and community integration always remained a weak link.[30] Toward beginning of the 12th 5-year plan in 2012, a policy group was constituted to review the existing situation and then play a crucial role in revamping the DMHP and lay foundation toward the development of Mental Health Policy.[13] At present, the availability of health system assessment (NMHS-2016) report[21] could prove crucial to further strengthen implementation steps. It would also serve as an interim assessment of the progress made since major mental health reforms in India after 2012 and allows midcourse correction or at best serve as a benchmark for future comparisons.

From [Figure 1], it becomes evident that states with a higher prevalence of mental morbidities suffer from poor coverage by DMHP.[21] It was found that Tamil Nadu (TN) and Kerala (KL) had the highest number of mobile mental health units (432 and 22, respectively); day-care centers (137 and 43, respectively); and de-addiction centers (120 and 66, respectively). While TN had 43 residential halfway homes, KL had 146 long-stay homes. An adequate number of these facilities were lacking in other states which are prerequisites for successful implementation of community-based mental health-care services. For every one lakh population, KL and Manipur had the highest density of psychiatrist (1.2 and 0.56, respectively); nonspecialist medical doctors trained in mental health (2.75 and 9.73, respectively); clinical psychologists (0.63 and 0.49, respectively); rehabilitation workers; and special education teachers (10.26 and 5.99, respectively); and psychosocial counselors (2.79 and 61.42 respectively). It appears that there is gross inadequacy and inequity in terms of availability of mental health resource personnel and health facilities that could provide appropriate care at different levels and need urgent attention in coming years.
Figure 1: Comparison of population covered by the District Mental Health Program and prevalence of mental morbidity in surveyed states of India (National Mental Health Survey-2016)

Click here to view

Except Gujarat (GJ) and KL, no other surveyed state has a stand-alone state mental health policy, and this could be a hindrance in developing context- and culture-specific MHAPs. It was also observed that state mental health coordination for implementation of DMHP was weak and needed reforms.

At present, India spends 1.3% of its total health budget on mental health.[15] This is grossly less as compared to other nations and a proxy indicator of low priority on health agenda. This could probably be due to the absence of groundswell of public opinion on mental health-related issues that would compel higher fund allocations.[31] Further, this meager amount is not fully utilized due to issues related to untimely distribution, lack of clarity on utilization mechanisms, etc. Most of what is available is spent toward upgrading hospitals, salaries of staff, or procuring medicines. In 2015, 16% of total inpatients were being institutionalized for >5 years, an indicator of poor availability of community-based rehabilitative and homestay services. The quantum of expenditure needs to tilt toward community-based services but is perhaps possible with an increase in budgetary allocation.[31] Funds allocated specifically to mental health has been ringed-fenced (i.e. cannot be utilised elsewhere). Additionally Mental health has also been included under Non-communicable disease (NCD) flexipool budget. These are welcome initiatives.

Health-care utilization depends on robust information, education, and communication (IEC) efforts. However, IEC activities were merely restricted to preparing posters and distributing pamphlets at most places, rather than being population centric, targeted toward local situation, uniform in coverage, highly visible, and continuous over time. Thus, stigma prevailed resulting in poor utilization of whatever services available and perpetuating problems. This has to change followed by more effective engagement of community in health seeking and utilization of services. This is where civil society could play a major role. At present, 69 such organizations are prominently functioning in mental health, and there is a need for more that could contribute in mental health advocacy, service delivery, and research.[21]

With regard to availability of drugs, most primary health centers across country had poor state of affairs narrowing down to availability of benzodiazepines alone, while private pharmacy had adequate stock of most essential drugs. This could trigger an increase in out-of-pocket expenditure, leading to either poverty or discontinuation of care and defeating the very purpose of making services accessible at community level. This happens due to delay in receipt of funds, tendering issues, inventory control, etc., This is mainly a health management-related issue that needs separate attention.

With regard to the Health Management Information System (HMIS), only 33% of surveyed states had mental health included in their HMIS. This means that one could anticipate a delay in monitoring and evaluation activities in most places. Without robust HMIS, it would be difficult to plan and provide services.

[Box 1] summarizes the implications of health system evaluation[21] and in next section leads us toward discussion of why some of these gaps exist and what could possibly be adopted from lessons learned elsewhere and work toward more effective implementation of MHAP in future.

  Recognizing Policy Planning, Implementation, and Utilization Gaps and Planning Future Course Top

The gaps appear to be operational at policy, implementation, and utilization level. To better conceptualize the implications of these gaps, we have shown disease progression and patient care pathways in [Figure 2] and [Figure 3], respectively. We have also demonstrated an interplay of various risk factors[32] and intermediary outcomes along this pathway. Delay in diagnosis and treatment often results in poor mental health outcomes.
Figure 2: Disease progression pathway in a patient with mental illness and possible modes of intervention

Click here to view
Figure 3: Patient care pathway in mental illness in India

Click here to view

Most of these gaps have been operational even at the time of revamping of DMHP in 2012 as pointed out by the mental health policy group,[13] and some continue to exist even today [Box 1].[21] Since the underlying strategy of DMHP was to integrate mental health with general/primary health-care services, it invariably inherited various barriers/gaps of the existing primary health-care system besides having its own.[31],[33] With lack of supervision, lack of follow-up to check the effectiveness of training of primary care workers in mental health, and frequent drug shortages, integration of mental health services with primary health care is bound to pose unsurmountable challenge.[31] Similar situations exist in other low-income countries as well.[34] Cross-cultural learning and sharing of solutions could be a worthwhile exercise.

At present, riding on the highest possible political commitment, India seems to be at the crossroads of witnessing a major transformation in health-care delivery (Ayushman Bharat [AB]) through Health and Wellness Centers (HWCs) that are being hoped to address all the bottlenecks discussed earlier.[35] Mental health care is being projected as one of the key components of comprehensive care strategy of HWCs. However, careful scrutiny of operational guidelines of AB[36] suggests that mental health care has been identified under additional skills offirst-line workers (FLWs), which could be read as desired skills, and so could variably get compromised at different centers. There is a need for shifting these to core skill sets to acquire prompt attention. Second, there is no plan to immediately adopt mental health-related indicators in HMIS, which can only delay progress in this important area. These things require urgent policy negotiations for effective integration. Situation analysis[37] should be followed by policy reforms to strengthen this weak link.

In [Figure 4], we have shown primary mechanisms leading to unfavorable outcomes using red arrows and other secondary mechanisms using black arrows. The picture is an inverted bottle with health system factors at its neck. Some of these are nonmodifiable, especially under the mental health policy framework, thus perpetuating unfavorable outcomes. The existing primary health-care systems are plagued with issues[38] such as inadequate workforce, substandard quality of care, inequitable distribution of health facility, inaccessibility, and ineffective private sector engagement through safety nets of health insurance. These serve as bottleneck [Figure 4] in effective implementation of MHAP at district levels. Mental health advocates have an additional responsibility of holding policy cross talks at various levels to circumvent these issues. MHAP[39] will have to be more articulate to push for reforms such as increased allocation of funds, leverage to improve quality of care, and effective engagement of civil society.
Figure 4: Bottleneck analysis of factors hampering effective implementation and integration of the District Mental Health Program with primary health-care services

Click here to view

The major drawback of DMHP is diagnostic and treatment delay besides delay in seeking care. The reasons are manifold [Figure 3] and [Figure 4]. Caregivers of people suffering from psychotic illness are more likely to face stigma. These can delay treatment and further worsen the situation both for patients and caregivers.[40],[41] Sometimes, simple messages can be very powerful in gathering empathy of community members, as shown by Koschorke et al.,[42],[43] and hence, stigma reduction measures should be culture and context specific.[44] Faith healing is a very common cause of treatment delay. Very interesting models have risen from GJ[21] and TN,[45] where health systems collaborated with faith healers to tap patients with mental illnesses early and provide evidence-based treatments with successful outcomes. This is worth a try in other states as well.

Patients reporting to health facilities may not get quality care. The WHO has done a pioneering job in preparing various guidelines[46] and testing cost-effective interventions[47] that can be used in resource-poor settings to improve the quality of services. Training health workforce in mental health continues to be Achilles heel. Institutes such as National Institute of Mental Health and NeuroSciences in India along with Central Institute of Psychiatry, Ranchi, have started training members of health team in community mental health in bid to exponentially increase the capacity to provide quality care in mental health and substance use disorders.[48] Efforts are on to provide standard simple diagnostic and therapeutic algorithms that can be used in primary health centers.[49.50] E-videos are also available that can support on-site learning.[51] Posttraining on-site support by a specialist is essential to optimize case detection and management. NIMHANS has been attempting this, and its impact will be clear in due course of time.[52] Trainings can be made more effective using Kirkpatrick models.[53]

Some models have demonstrated the success of engaging grassroots workers/FLWs to screen individuals with mental disorders and decrease treatment delays.[54] There are challenges involved as India is a multicultural society, and screening tools need to be cross-culturally adapted for this purpose. They are also expected to participate in IEC activities to improve care-seeking practices. More studies are needed to demonstrate successful ways of engaging FLWs in real-life settings as very often there are competing priorities to fulfill requirements of other national programs leading to opportunity costs. In fact, India needs to seriously consider increasing the number of FLWs at village levels and the economics of doing so needs to be worked out keeping in mind overall gain in health achieved by doing so.

There is a need to engage both service users[55] and caregivers in planning and utilization of services. However, there is a lack of high-quality research about successful ways of engaging these community resources.[56] Community volunteers (nonhealth sector) can also be potential partners in delivering mental health care, as shown in Maharashtra[57] and Goa.[58] Another review explores different ways of addressing barriers to treatment access.[59]

The management of mental illness includes drug management and psychosocial interventions (PSIs). There are some models of successful applications of these PSI[60] and community-based models of rehabilitation that can with little application scaled up at district levels.[61] PSI includes psychoeducation of patients and their caregivers, muscle relaxation techniques, counseling support, and mind relaxation techniques, and their administration requires certain special skills. The workforce available for these is already scarce and often used for other administrative works in overburdened PHCs again leading to opportunity costs. One of the PSIs is meditation[62],[63] that has no religious connotations but often underutilized due to unawareness and unavailability of trainers. Many organizations are active in promoting meditation practice in India.

Patients with a severe illness often need referral and inpatient support, but patients are unwilling to stay longer due to poor finances. Newer models are emerging that holds promise (more studies needed) in integrating ideas of day-care hospitals[64] as part of holistic mix of services for unwilling patients to reduce utilization gaps.

DMHP is the primary fulcrum for planning and delivering services at primary level of care. Integration of mental health service with general health is easier said than done given various bottlenecks and limiting factors. However, there are some interesting steps outlined by Hanlon et al.[65] for integrating mental health care in general health services. Very often, we fail to follow the implementation process of public health interventions that have shown a demonstrable success. We know what works, but we should also know how it worked? A very interesting article highlights the processes in one such model in Sehore, Madhya Pradesh. Here, theory of change[66] workshops and mixed methods were used for developing a Mental Healt Care Policy/Program that comprised three enabling packages (program management, capacity building, and community mobilization) and four service delivery packages (awareness for mental disorders, identification, treatment, and recovery).[67] There were some interesting lessons learned, and it pointed toward the need for developing capacity of dedicated district-level mental health coordinator in public health skills for successful implementation of MHCP using a standard approach. It would be prudent to follow similar steps in every district of India to contextualize culture-specific interventions. The Indian Association of Preventive and Social Medicine[68] and the Indian Psychiatric Society[69] state that chapters could gainfully contribute in this endeavor and join hands with other stakeholders in devising ways to continuously support activities of DMHP.

It is well accepted that designing effective community-based mental health services has culture- and context-specific challenges. There is no one-size-fits-all formula. However, there are some basic steps that need to be followed which have also been explained by Ng et al.[70] Few reports/reviews[71],[72],[73],[74] are available that provide deeper insights into basic models that have been tested and could possibly be adapted to one's local settings. Of course, policy reforms should also happen simultaneously.[75]

In this review, we looked at care pathways, factors resulting in gaps in health care. We also looked at the availability of evidence-based interventions/health-care delivery models that could possibly be adopted while designing and scaling up culture- and context-specific MHAPs across different states of India. A few research gaps do exist posing grand challenges to global mental health. This has been highlighted elsewhere, and more research in this direction is needed.[76] Answers to these could possibly provide the final push to achieve mental well-being in years to come. Scaling up community-based mental health services require a systems approach.[77],[78],[79] Most importantly, reflecting on the mistakes of the past,[80],[81] learning from the present, and striving for a better future are what will help us achieve desired outcomes. Now, only time and untiring efforts of all concerned will hold the key.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Promoting Mental Health: Concepts, Emerging Evidence, Practice. Geneva: World Health Organization; 2004. Available from: https://www.who.int/mental_health/evidence/en/promoting_mhh.pdf. [Last accessed on 2019 May 02].  Back to cited text no. 1
World Health Assembly 65. Global Burden of Mental Disorders and the Need for a Comprehensive, Coordinated Response from Health and Social Sectors at the Country Level: Report by the Secretariat. World Health Organization; 2012. p. 4. Available from: http://www.who.int/iris/handle/10665/78898. [Last accessed on 2019 May 03].  Back to cited text no. 2
The Global Economic Burden of Non-Communicable Diseases. A report by the World Economic Forumand the Harvard School of Public Health; 2011. p. 48. Available from: https://apps.who.int/medicinedocs/en/m/abstract/Js18806en/. [Last accessed on 2019 May 03].  Back to cited text no. 3
Horton R. Launching a new movement for mental health. Lancet 2007;370:806.  Back to cited text no. 4
World Health Organzation. Mental Health Atlas 2017. World Health Organzation; 2019. p. 68. Available from: https://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/. [Last accessed on 2019 May 03].  Back to cited text no. 5
World Health Organzation. Comprehensive Mental Health Action Plan 2013–2020. World Health Organzation; 2015. Available from: https://www.who.int/mental_health/action_plan_2013/en/. [Last accessed on 2019 Apr 22].  Back to cited text no. 6
Saxena S, Funk M, Chisholm D. World health assembly adopts comprehensive mental health action plan 2013-2020. Lancet 2013;381:1970-1.  Back to cited text no. 7
Patel V, Boyce N, Collins PY, Saxena S, Horton R. A renewed agenda for global mental health. Lancet 2011;378:1441-2.  Back to cited text no. 8
Wig NN, Murthy SR. The birth of national mental health program for India. Indian J Psychiatry 2015;57:315-9.  Back to cited text no. 9
[PUBMED]  [Full text]  
Goel DS. Why mental health services in low- and middle-income countries are under-resourced, underperforming: An Indian perspective. Natl Med J India 2011;24:94-7.  Back to cited text no. 10
Patel V, Copeland J. The great push for mental health: Why it matters for India. Indian J Med Res 2011;134:407-9.  Back to cited text no. 11
[PUBMED]  [Full text]  
National Mental Health Programme. National Health Portal of India. Available from: https://www.nhp.gov.in/national-mental-health-programme_pg. [Last accessed on 2019 May 04].  Back to cited text no. 12
Policy Group. XIIth Plan District Mental Health Programme. New Delhi; 2012. Available from: https://mhpolicy.files.wordpress.com/2012/07/final-dmhp-design-xii-plan2.pdf. [Last accessed on 2019 May 07].  Back to cited text no. 13
Ministry of Health & Family Welfare G of I. New Pathways New Hope-National Mental Health Policy of India. New Delhi: Ministry of Health & Family Welfare G of I; 2014. Available from: https://www.nhp.gov.in/sites/default/files/pdf/nationalmentalhealthpolicyofindia2014.pdf. [Last accessed on 2019 May 04].  Back to cited text no. 14
World Health Organization. Mental Health ATLAS 2017. World Health Organization; 2019. Available from: https://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/. [Last accessed on 2019 May 07].  Back to cited text no. 15
Ministry of Law and Justice. The Mental Healthcare Act, 2017; 2017. Available from: https://www.prsindia.org/uploads/media/MentalHealth/MentalHealthcareAct, 2017.pdf. [Last accessed on 2019 May 04].  Back to cited text no. 16
Baxter AJ, Charlson FJ, Cheng HG, Shidhaye R, Ferrari AJ, Whiteford HA. Prevalence of mental, neurological, and substance use disorders in China and India: A systematic analysis. Lancet Psychiatry 2016;3:832-41.  Back to cited text no. 17
Charlson FJ, Baxter AJ, Cheng HG, Shidhaye R, Whiteford HA. The burden of mental, neurological, and substance use disorders in China and India: A systematic analysis of community representative epidemiological studies. Lancet 2016;388:376-89.  Back to cited text no. 18
Liu S, Page A. Reforming mental health in China and India. Lancet 2016;388:314-6.  Back to cited text no. 19
Gururaj G, Varghese M, Benegal V, Rao G, Pathak K, Singh L, et al. National Mental Health Survey of India, 2015-16 Prevalence, Pattern and Outcome. Bengaluru; 2016. Available from: http://www.nimhans.ac.in/sites/default/files/u197/NMHSReport%28Prevalencepatternsandoutcomes%291.pdf. [Last accessed on 2019 May 06].  Back to cited text no. 20
Gururaj G, Varghese M, Benegal V, Rao G, Pathak K, Singh L, et al. National Mental Health Survey of India, 2015-16 Mental Health Systems. Bengaluru; 2016. Available from: http://indianmhs.nimhans.ac.in/Docs/Report1.pdf. [Last accessed on 2019 May 06].  Back to cited text no. 21
Evaluation of District Mental Health Programme Final Report 2008. Available from: https://mhpolicy.files.wordpress.com/2011/05/evaluation-of-dmhp-icmr-report-for-the-ministry-of-hfw.pdf. [Last accessed on 2019 May 07].  Back to cited text no. 22
Jain S, Jadhav S. A cultural critique of community psychiatry in India. Int J Health Serv 2008;38:561-84.  Back to cited text no. 23
Murthy RS. Mental health initiatives in India (1947-2010). Natl Med J India 2011;24:98-107.  Back to cited text no. 24
Desai NG, Tiwari SC, Nambi S, Shah B, Singh RA, Kumar D, et al. Urban mental health services in India: How complete or incomplete? Indian J Psychiatry 2004;46:195-212.  Back to cited text no. 25
[PUBMED]  [Full text]  
Report of Evaluation of District Mental Health Programme. Bengaluru; 2003. Available from: https://mhpolicy.files.wordpress.com/2011/05/nimhans-report-evaluation-of-dmhp.pdf. [Last accessed on 2019 May 07].  Back to cited text no. 26
Bakre RH, Chandra V, Saxena S. WHO-AIMS Report on Mental Health System in Gujarat (India). New Delhi; 2006. Available from: http://www.who.int/mental_health/evidence/WHO-AIMS/en/index.html. [Last accessed on 2019 May 07].  Back to cited text no. 27
Jha D, Sahni T, Chandra V, Saxena S. WHO-Aims Report On Mental Health System In Uttarkhand, India. New Delhi; 2006. Available from: https://www.who.int/mental_health/uttarkhand_who_aims_report.pdf?ua=1. [Last accessed on 2019 May 07].  Back to cited text no. 28
Report of Evaluation of District Mental Health Programs Tamil Nadu, Karnataka, Andhra Pradesh and Maharashtra. Bengaluru; 2011. Available from: https://mhpolicy.files.wordpress.com/2011/05/dmhp-evaluation-final-report-2011.pdf. [Last accessed on 2019 May 07].  Back to cited text no. 29
van Ginneken N, Jain S, Patel V, Berridge V. The development of mental health services within primary care in India: Learning from oral history. Int J Ment Health Syst 2014;8:30.  Back to cited text no. 30
Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 2007;370:1164-74.  Back to cited text no. 31
WHO Secretariat for the Development of a Comprehensive Mental Health Action Plan. Risks to Mental Health: An Overview of Vulnerabilities and Risk Factors; 2012. Available from: https://www.who.int/mental_health/mhgap/risks_to_mental_health_EN_27_08_12.pdf. [Last accessed on 2019 May 17].  Back to cited text no. 32
Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and inefficiency. Lancet (London, England) 2007;370:878-89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17804062. [Last accessed on 2019 May 17].  Back to cited text no. 33
Jenkins R, Othieno C, Okeyo S, Aruwa J, Kingora J, Jenkins B. Health system challenges to integration of mental health delivery in primary care in Kenya – Perspectives of primary care health workers. BMC Health Serv Res 2013;13:368.  Back to cited text no. 34
Ved RR, Gupta G, Singh S. India's health and wellness centres: Realizing universal health coverage through comprehensive primary health care. WHO South East Asia J Public Health 2019;8:18-20.  Back to cited text no. 35
AYUSHMAN BHARAT Comprehensive Primary Health Care through Health and Wellness Centers Operational Guidelines. New Delhi; 2018. Available from: http://nhsrcindia.org/sites/default/files/Operational. GuidelinesForComprehensivePrimaryHealthCarethroughHealthand WellnessCenters.pdf. [Last accessed on 2019 May 07].  Back to cited text no. 36
Upadhaya N, Jordans MJ, Abdulmalik J, Ahuja S, Alem A, Hanlon C, et al. Information systems for mental health in six low and middle income countries: Cross country situation analysis. Int J Ment Health Syst 2016;10:60.  Back to cited text no. 37
Balarajan Y, Selvaraj S, Subramanian SV. Health care and equity in India. Lancet 2011;377:505-15.  Back to cited text no. 38
Mental Health Action Plan 365. New Delhi; 2014. Available from: https://facemindia.files.wordpress.com/2014/08/mental-health-action-a4.pdf. [Last accessed on 2019 May 16].  Back to cited text no. 39
Mestdagh A, Hansen B. Stigma in patients with schizophrenia receiving community mental health care: A review of qualitative studies. Soc Psychiatry Psychiatr Epidemiol 2014;49:79-87.  Back to cited text no. 40
Lauber C, Rössler W. Stigma towards people with mental illness in developing countries in Asia. Int Rev Psychiatry 2007;19:157-78.  Back to cited text no. 41
Koschorke M, Padmavati R, Kumar S, Cohen A, Weiss HA, Chatterjee S, et al. Experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in India. Soc Sci Med 2017;178:66-77.  Back to cited text no. 42
Koschorke M, Padmavati R, Kumar S, Cohen A, Weiss HA, Chatterjee S, et al. Experiences of stigma and discrimination of people with schizophrenia in India. Soc Sci Med 2014;123:149-59.  Back to cited text no. 43
Ng CH. The stigma of mental illness in asian cultures. Aust N Z J Psychiatry 1997;31:382-90.  Back to cited text no. 44
Dawa-Dua: How Medical Treatment Complements Prayer for People with Mental Illness in India. End Poverty in South Asia; 2016. Available from: https://blogs.worldbank.org/endpovertyinsouthasia/dawa-dua-how-medical- treatment-complements-prayer-people-mental-illness-india. [Last accessed on 2019 May 16].  Back to cited text no. 45
World Health Organization. Mental Health Evidence and Research (MER). World Health Organization; 2018. Available from: https://www.who.int/mental_health/evidence/en/. [Last accessed on 2019 May 16].  Back to cited text no. 46
World Health Organization. WHO Mental Health Gap Action Programme (mhGAP). World Health Organization; 2019. Available from: https://www.who.int/mental_health/mhgap/en/. [Last accessed on 2019 May 16].  Back to cited text no. 47
NIMHANS Digital Academy: Translating “Best Practice Care"; – Initiative under Mental Health Informatics, Dept of Psychiatry. Available from: http://nimhansdigitalacademy.in/. [Last accessed on 2019 May 16].  Back to cited text no. 48
NIMHANS. Manual for Medical Officers- Assessment and Management of Mental Health Problems in General Practice. Available from: https://drive.google.com/file/d/1VEXSmA0dTGvKcM7Sb7ylfxE80aeIz-X9/view. [Last accessed on 2019 May 16].  Back to cited text no. 49
NIMHANS. Clinical Schedule Primary Care Psychiatry Version 2.1; 2017. p. 8. Available from: https://drive.google.com/file/d/1Oxmk7Zn24mJ16R2A8775a3C9B72FmgdS/view. [Last accessed on 2019 May 16].  Back to cited text no. 50
Learning Videos – Virtual Knowledge Network Nimhans. Available from: http://vlc.nimhans.ac.in/?page_id=4558. [Last accessed on 2019 May 16].  Back to cited text no. 51
e-Consult – Nimhans Digital Academy: Translating “Best Practice Care". Available from: http://nimhansdigitalacademy.in/e-consult/. [Last accessed on 2019 May 16].  Back to cited text no. 52
Kirkpatrick Model: Four Levels of Learning Evaluation – Educational Technology. Available from: https://educationaltechnology.net/kirkpatrick-model-four-levels-learning-evaluation/. [Last accessed on 2019 May 16].  Back to cited text no. 53
Shidhaye R, Murhar V, Gangale S, Aldridge L, Shastri R, Parikh R, et al. The effect of VISHRAM, a grass-roots community-based mental health programme, on the treatment gap for depression in rural communities in India: A population-based study. Lancet Psychiatry 2017;4:128-35.  Back to cited text no. 54
Katontoka S. Users' networks for Africans with mental disorders. Lancet 2007;370:919-20.  Back to cited text no. 55
Semrau M, Lempp H, Keynejad R, Evans-Lacko S, Mugisha J, Raja S, et al. Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: Systematic review. BMC Health Serv Res 2016;16:79.  Back to cited text no. 56
Shields-Zeeman L, Pathare S, Walters BH, Kapadia-Kundu N, Joag K. Promoting wellbeing and improving access to mental health care through community champions in rural India: The Atmiyata intervention approach. Int J Ment Health Syst 2017;11:6.  Back to cited text no. 57
Patel V, Weobong B, Weiss HA, Anand A, Bhat B, Katti B, et al. The healthy activity program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: A randomised controlled trial. Lancet 2017;389:176-85.  Back to cited text no. 58
Patel V, Chowdhary N, Rahman A, Verdeli H. Improving access to psychological treatments: Lessons from developing countries. Behav Res Ther 2011;49:523-8.  Back to cited text no. 59
Chatterjee S, Naik S, John S, Dabholkar H, Balaji M, Koschorke M, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): A randomised controlled trial. Lancet 2014;383:1385-94.  Back to cited text no. 60
Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 2007;370:991-1005.  Back to cited text no. 61
Potes A, Souza G, Nikolitch K, Penheiro R, Moussa Y, Jarvis E, et al. Mindfulness in severe and persistent mental illness: A systematic review. Int J Psychiatry Clin Pract 2018;22:253-61.  Back to cited text no. 62
Thimmapuram J, Pargament R, Sibliss K, Grim R, Risques R, Toorens E. Effect of heartfulness meditation on burnout, emotional wellness, and telomere length in health care professionals. J Community Hosp Intern Med Perspect 2017;7:21-7.  Back to cited text no. 63
Marshall M, Crowther R, Almaraz-Serrano A, Creed F, Sledge W, Kluiter H, et al. Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care. Health Technol Assess 2001;5:1-75.  Back to cited text no. 64
Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin G, et al. Challenges and opportunities for implementing integrated mental health care: A district level situation analysis from five low- and middle-income countries. PLoS One 2014;9:e88437.  Back to cited text no. 65
De Silva MJ, Breuer E, Lee L, Asher L, Chowdhary N, Lund C, et al. Theory of change: A theory-driven approach to enhance the medical research council's framework for complex interventions. Trials 2014;15:267.  Back to cited text no. 66
Shidhaye R, Shrivastava S, Murhar V, Samudre S, Ahuja S, Ramaswamy R, et al. Development and piloting of a plan for integrating mental health in primary care in Sehore district, Madhya Pradesh, India. Br J Psychiatry 2016;208 Suppl 56:s13-20.  Back to cited text no. 67
Indian Association of Preventive and Social Medicine. Available from: http://iapsm.org/. [Last accessed on 2019 May 17].  Back to cited text no. 68
Indian Psychiatric Society. Available from: http://www.indianpsychiatricsociety.org/index.php. [Last accessed on 2019 May 17].  Back to cited text no. 69
Ng C, Chauhan AP, Chavan BS, Ramasubramanian C, Singh AR, Sagar R, et al. Integrating mental health into public health: The community mental health development project in India. Indian J Psychiatry 2014;56:215-20.  Back to cited text no. 70
[PUBMED]  [Full text]  
Smith-Merry J, Mellifont D, Gillespie J, Luis SC, Salvador L. Recovery-Oriented Community Mental Health Models; 2017. Available from: http://www.saxinstitute.org.au. [Last accessed on 2019 May 17].  Back to cited text no. 71
van Ginneken N, Maheedhariah MS, Ghani S, Ramakrishna J, Raja A, Patel V. Human resources and models of mental healthcare integration into primary and community care in India: Case studies of 72 programmes. PLoS One 2017;12:e0178954.  Back to cited text no. 72
Mental Health Innovation Network. A Global Community of Mental Health Innovators. Available from: https://www.mhinnovation.net/. [Last accessed on 2019 May 17].  Back to cited text no. 73
Thornicroft G, Deb T, Henderson C. Community mental health care worldwide: Current status and further developments. World Psychiatry 2016;15:276-86.  Back to cited text no. 74
DeSilva M, Samele C, Saxena S, Patel V, Darzi A. Policy actions to achieve integrated community-based mental health services. Health Aff (Millwood) 2014;33:1595-602.  Back to cited text no. 75
Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS, et al. Grand challenges in global mental health. Nature 2011;475:27-30.  Back to cited text no. 76
Semrau M, Evans-Lacko S, Alem A, Ayuso-Mateos JL, Chisholm D, Gureje O, et al. Strengthening mental health systems in low- and middle-income countries: The emerald programme. BMC Med 2015;13:79.  Back to cited text no. 77
Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet 2011;378:1592-603.  Back to cited text no. 78
Petersen I, Marais D, Abdulmalik J, Ahuja S, Alem A, Chisholm D, et al. Strengthening mental health system governance in six low- and middle-income countries in Africa and South Asia: Challenges, needs and potential strategies. Health Policy Plan 2017;32:699-709.  Back to cited text no. 79
Maj M. Mistakes to avoid in the implementation of community mental health care. World Psychiatry 2010;9:65-6.  Back to cited text no. 80
Thornicroft G, Alem A, Antunes Dos Santos R, Barley E, Drake RE, Gregorio G, et al. WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care. World Psychiatry 2010;9:67-77.  Back to cited text no. 81


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
1 Clinical Profile of Patients Visiting a Private Child and Adolescent Psychiatric Clinic in Delhi
Deepak Gupta, Nabanita Sengupta
Journal of Indian Association for Child and Adolescent Mental Health. 2023; : 0973134223
[Pubmed] | [DOI]
2 The Design, Development, and Implementation of a Web-Enabled Informatics Platform to Enhance the Well-being of Individuals Aged 18-24 Years: Protocol for an Experimental Study
Bhavya Malhotra, Jagannath Sahoo, Mansi Gupta, Ashish Joshi
JMIR Research Protocols. 2023; 12: e38632
[Pubmed] | [DOI]
3 Mental Health Interventions among Adolescents in India: A Scoping Review
Devika Mehra, Theophilus Lakiang, Nishtha Kathuria, Manish Kumar, Sunil Mehra, Shantanu Sharma
Healthcare. 2022; 10(2): 337
[Pubmed] | [DOI]
4 Whose responsibility? Part 2 of 2: views ofpatients, families, and clinicians about responsibilities for addressing the needs of persons with mental health problems in Chennai, India and Montreal, Canada
Srividya N. Iyer, Ashok Malla, Megan Pope, Sally Mustafa, Greeshma Mohan, Thara Rangaswamy, Norbert Schmitz, Ridha Joober, Jai Shah, Howard C. Margolese, Padmavati Ramachandran
International Journal of Mental Health Systems. 2022; 16(1)
[Pubmed] | [DOI]
5 India's policy and programmatic response to mental health of young people: A narrative review
Bhushan Girase, Rachana Parikh, Samica Vashisht, Anushka Mullick, Vaibhao Ambhore, Sudhir Maknikar
SSM - Mental Health. 2022; : 100145
[Pubmed] | [DOI]
6 Reimagining Community Mental Health Care Services: Case Study of a Need Based Biopsychosocial Response Initiated During Pandemic
Poornima Sunder, Anu Sonia Vincent, Meenu K. Saju, Anu S. Moorthy, Godson Paulose, Roshni Robins, Anupama V. Prabhu, M. Arun, Anita Rajah, Chitra Venkateswaran
Frontiers in Psychiatry. 2021; 12
[Pubmed] | [DOI]
7 Effectiveness of Psychological Intervention by Videoconference for Family Members with Depression of Farmers Who Have Committed Suicide
Raghavendra B. Nayak,Triptish Bhatia,Mahesh Mahadevaiah,A. Bheemappa
Indian Journal of Psychological Medicine. 2020; 42(6_suppl): S46
[Pubmed] | [DOI]
8 Mental Health and Psychosocial Aspects of COVID-19 in India: The Challenges and Responses
Shankar Das
Journal of Health Management. 2020; 22(2): 197
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Mental Health-Ca...
Recognizing Poli...
Article Figures

 Article Access Statistics
    PDF Downloaded1558    
    Comments [Add]    
    Cited by others 8    

Recommend this journal