The 2014 WHO report stated that India had the most deaths by suicide worldwide; 258 000 of 804 000 deaths reported in 2012. The country’s suicide rate was 21 suicide deaths per 100 000 people which is almost twice the world average.

The high number of suicides is just one indicator of India’s mental health burden and poor state of mental health care (India has just 3500 psychiatrists, most of whom are working in urban areas) but clear disparities exist between the different states throughout India, as shown below there are large swaths of the country in critical need of sufficient personnel.

 

India has just 3500 psychiatrists, most of whom are working in urban areas #fact Click To Tweet

 

The high number of suicides is just one indicator of India’s mental health burden and poor state of mental health care (India has just 3500 psychiatrists, most of whom are working in urban areas) but clear disparities exist between the different states throughout India, as shown below there are large swaths of the country in critical need of sufficient personnel.

The situation is not unknown in terms of lack of support for infrastructure and delivery but these figures highlight something that is maybe deeper and needs attention. Indeed previously it was believed that the types and manifestations of mental illness in the developing world were different from those of the Western world. However, Indian epidemiological studies, including the WHO multicentre collaborative study—the international pilot study of schizophrenia (WHO, 1974)—have suggested quite the opposite. Indian patients experience and exhibit similar psychopathology to patients anywhere else. It is true, however, that psychopathology may be modified by cultural influences. A rural patient, for example, may implicate witchcraft or evil spirits rather than alien forces in his paranoid delusion.

Similarly, dissociative and conversion forms of hysteria are still commonly described in India (in Western cultures hysteria has either disappeared or been replaced by other disorders). The causes of mental illness are explained in many different ways in Indian culture. A very common explanation in tribal and rural societies is supernatural visitation. Another is sudden environmental shock. It is commonly 

believed that one’s karma, or actions in a past life, determine our present lives’ successes, failures and illnesses. Thus, a severe illness may be perceived as punishment for past wrongdoings.

2015 and the year for New Legislation

The National Mental Health Programme (NMHP) was implemented since 1982. Under the NMHP, community mental health services are provided through the District Mental Health Programme (DMHP) by integrating mental health care, at the primary care level, with supervision and support from a mental health team at the district level (in total 182 districts were enrolled). It was stated that the government also supported a raft and infrastructure upgrades, development of post-graduate departments in mental health specialities, better communication and education and strengthening the State and Central Mental Health Authority for improved monitoring and evaluation. There were further efforts to consolidate and address any inadequacies through the 1987 Mental Health Act made better provision with respect to their property, personal affairs and rights.

A new document recently launched set out to drive universal access to mental health care and protection of all rights of people who are mentally ill. The policy seeks to “promote mental health, prevent mental illness, promote destigmatisation and desegregation, ensure socioeconomic inclusion of persons with mental illness by providing accessible, affordable and quality health and social care to all persons through their lifespan, within a rights-based framework. It calls for an enhanced understanding of mental health and strengthening of leadership in the mental health sector at all levels to achieve universal access to mental health care.

This has been broadly welcomed by experts and patient groups, the policy for two of its key features; a rights-based approach to mental health and recognition of the close inter-relationship between social disadvantage and mental health. It also enables a much stronger commitment to an inclusive approach to mental health, acknowledging a wide range of mental health goals from promotion of mental health to long-term needs of persons with enduring mental health problems. As a first step to implement the new policy, DMHP will have to be expanded to all 648 districts from the present 182. This plan, however, will need additional funding. Simultaneously, teaching programmes for mental health professionals such as psychiatric nurses will have to be scaled up. However, as this is a great advancement and recognition of the issues; questions still remain on the implementation of such legislation.

eMental Health

Coupled with these changes on a national level, significant change is already being driven through digital drivers, which are acting as a supporting mechanism, driving awareness and also enabling education to a broad populous. The use of digital technology to improve health outcomes has the potential to transform the face of the healthcare, with mobile density throughout India now exceeding 90%. Indeed as technology advances the telehealth market is expected to grow 15% CAGR for the next decade.

The current manifestation digital technology is still in its infancy for supporting mental health globally. However, there is a clear appetite to incorporate this into local and sustained care to transform the way people look after their mental health, and transform the way the national/regional bodies deliver mental health services. There is considerable support among mental health services, and the public, to make greater use of technology in this way. Indeed, pressure on resources across public services creates a powerful incentive for developing new ways of delivering care and support

There is however, more potential for growth of digital technology and online resources to improve overall public mental health. In principle, everyone should be able to access reliable information about mental health and wellbeing online, and through such portals access help and advice anonymously in a variety of ways (live chat, email, text and phone).

What Technology?

Digital technology offers many opportunities. Most applications range from enabling existing tasks and practices to be carried out in a more efficient way, to transforming the nature of mental healthcare itself. A few offer radically new models of care that put more emphasis on social healthcare models. There are a variety of approaches currently being applied that are shown below;

Enabling Technology  This details product and/or services that enable existing tasks and practices to be conducted in a more efficient way. It comprises of applications and programs that monitor mood or medication compliance. These can be either for individual use or for use alongside a clinician and are commonly commercially produced.

There are approximately 100,000 health apps available in major app stores, and it is said that the top ten mobile health apps generate more than 3 million US downloads on IOS alone. Interest has been increasing in the delivery of therapeutic interventions online that include cognitive behavioral therapy (c-CBT). There is also the potential for live, online, one-to-one psychological therapy, using text, audio or video. These applications are already being trailed and tested in the UK in the NHS with some success where they are delivered as part of an incorporated treatment regimen in a broad program rather than a standalone treatment.

Transformative Technology This comprises applications that transform the nature of mental healthcare. This is dependent on the participant and can include programs that educate and inform people to enable them to take care of their own mental health and wellbeing, platforms for peer support, and innovations that transform the delivery of care.  This can include telehealth whereby it offers the opportunity to provide health services at a distance using a range of technologies. For people with long-term conditions, this can include monitoring symptoms and vital signs from home, as well as the delivery of health education and information to help people manage their condition more effectively.

There are several examples of support programs such as the Bosch Health Buddy System (www.bosch-telehealth.com) that is a patient support program with education and motivational notes with clinical details enabling the multi-disciplinary team to keep track of ongoing care. In addition, social media offers some opportunity as a vehicle to educate and provide supportive care. This has been achieved through peer support, providing information and notification of local support groups.

In conclusion

There is a growing change in the way mental health is approached through India. From supportive mental health services and scale up to understanding the issues that need to be addressed. With these growing needs, the enabling of technology can facilitate and support ongoing programmes that help care providers and support patients and their families in ongoing care. This means supporting cultural change, empowering service users to exercise greater choice and control in their own care, as well as making the most of the opportunities provided by technology to change the way existing mental health services are designed and delivered