NAMS task force report on mental stress

Models of stress

Importance of stress

Stress is a universal phenomenon. The global prevalence of stress among the general population during the COVID-19 pandemic has been observed to be around 36.5%, and that of psychological distress is around 50.0%.⁸ The studies available before the pandemic have shown that the prevalence of psychological distress in the general population varied from 5 to 27%, depending on the screening tool and the methodology used. The prevalence in certain special populations such as migrants, workers facing stressful work situations, and elderly who have faced neglect or abuse is even higher.⁹

The stressors can occur from various sources, such as environmental stressors, physical pain, circadian disruptions, and substance consumption. Also, stressors can differ significantly in their strength, ranging from mild to severe, and in terms of their duration or timing, spanning acute, chronic, or intermittent periods. It is also essential to acknowledge that not only do stressors come in a wide range, but an individual’s response to a stressor can also vary significantly based on various factors such as sociodemographic factors, personality factors, the presence of social support, and prevailing social norms.

Stress has been identified as a factor that can heighten the likelihood of various physical illnesses, and it may also worsen preexisting physical conditions. Similarly, stress can elevate the risk of mental illnesses, particularly depression, anxiety, and substance use disorders. Moreover, it has the potential to intensify the severity of preexisting mental health conditions, contributing to a decline in the overall quality of life and an increased risk of morbidity and mortality.

Given that mental stress is a widespread phenomenon affecting individuals across diverse backgrounds, it becomes imperative to comprehend the current situation of mental stress in our country. This article aims to provide an overview of the existing mental stress scenario, delineate the consequences of mental stress, highlight gaps in current policies and programs, and propose recommendations for enhancing the current situation.

Current situation in the country

Since the concept of mental stress has varied across the literature, the scales used to screen for mental stress, and the methodology used in the studies have also varied. As a result, the prevalence of psychological stress or distress in the general population has also varied across studies from 5 to 27%.⁹ In India, there has been no nationally representative study to find the prevalence of psychological stress in the general population, even though there are many studies that have tried to assess the prevalence of mental illness in the country.

In India, the total disease burden due to mental disorders has almost doubled since 1990.¹⁰ The National Mental Health Survey (NMHS) conducted in 2016 across 12 states found that the weighted prevalence for any mental illness in the lifetime was 13.7% and that for current mental illness was 10.6%. Apart from substance use disorders, mood disorders, and neurotic or stress-related disorders were found to be the most common mental disorders [Table 1].¹¹ The prevalence of mental health disorders according to global burden of disease study has been mentioned in Annexure.

Most studies in India that have tried to assess the prevalence of mental stress or psychological distress have focused on specific populations, such as adolescents and the elderly. There have been very few studies that have focused on the general population.

Some of the studies conducted in the general population have been listed below:

• A cross-sectional, community-based study conducted among 943 participants in a rural community among the adult population in India found the prevalence of psychological distress to be around 42.4 per thousand, around 0.04%. Being illiterate and being separated or divorced was found to be associated with psychological distress.¹²

• A meta-analysis of 21 cross-sectional studies during the COVID-19 pandemic in India found the overall prevalence of psychological distress among the general population was around 33%. There was significant heterogeneity across studies, with prevalence ranging from 2.4 to 84% depending on the scales and the methodology used.¹³

• A cross-sectional study to assess the psychological distress among healthcare workers in India during the COVID-19 pandemic found the prevalence to be around 52.9%, with the risk being significantly associated with longer hours of work, income, screening of patients, or contact tracing. Also, high emotional exhaustion and depersonalization were found to be associated with higher psychological distress.¹⁴

Consequences of Mental Stress

Some amount of stress is necessary to propel an individual to act or deal with the situation. The Yerkes–Dodson law, proposed in 1908, elucidated that the performance increased with stress or arousal only to some extent, beyond which it started declining. It further stressed that insufficient stress would lead to disinterest or boredom and decreased performance [Figure 2].

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Figure 2:

Yerkes–Dodson law.

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However, extreme or prolonged stress can have physiological, psychological, and social ramifications. A systematic review comprising 47 studies revealed that elevated stress reactivity in both the situationally accessible memory (SAM) system and the hypothalamic-pituitary-adrenal (HPA) axis was predictive of a heightened risk of cardiovascular diseases. Conversely, blunted stress reactivity was associated with an increased likelihood of future obesity, depression, anxiety, higher illness frequency, pains or aches, diminished cognitive ability, poor self-reported health, and disability.²⁵

Physiological effects: The hypothalamus is affected in the same manner by our internal anger, as well as our guilt and resentment toward other people and ourselves. But, we trap this tension inside where its consequences compound rather than letting it go. Research indicates that nearly every bodily system can be impacted by chronic stress. When chronic stress is not relieved, it hampers the immune system, leading to illnesses. Fortunately, in typical situations, 3 minutes after the cessation of a threatening scenario and the elimination of real or perceived danger, the fight-or-flight response diminishes. Consequently, the body relaxes and reverts to its usual state. During this period, several physiological functions such as heart rate, blood pressure, breathing, muscle tension, digestion, metabolism, and the immune system normalize. If stress persists beyond the initial fight-or-flight reaction, the body’s response progresses to a second stage.

Effect on physical health: Psychological distress is well known to lead to an increase in the risk of physical illness, as well as worsen the course of physical illness.

Stress and immune system: The harmful effects of chronic stress lead to dysfunction of the HPA axis, which in turn leads to impaired immune system, reduction in activity of the T-lymphocytes and natural killer (NK) cells, and predisposition to malignancies.

Stress and cardiovascular system: Stress, both acute and chronic, has a deleterious effect on the cardiovascular system, as it causes chronic activation of the autonomic nervous system, leading to vasoconstriction, atherogenesis, increase in blood pressure, and so on. A systematic review of 24 prospective studies found that psychological distress was associated with a significantly increased risk of recurrent cardiac events in patients with coronary artery disease.²⁶

Stress and Gastrointestinal (GI) system: Stress affects not only appetite but also the absorption process, intestinal permeability, mucus and stomach acid secretion, function of ion channels, and GI inflammation. Stress can also alter the functional physiology of the intestine. Many inflammatory diseases, such as Crohn’s disease and other ulcerative-based diseases of the GI tract, are associated with stress. Irritable bowel syndrome (IBS) is considered a functional disorder related to stress.

Diabetes: Higher levels of chronic psychological stress and, more importantly, a decreased stress-coping ability measured as a sense of coherence (SOC)²⁷ were associated with a greater risk of type 2 diabetes (T2DM) among Indians. A dysregulated HPA axis²⁸ driven primarily by arginine–vasopressin (AVP)²⁹ was observed to be the possible link in this association. A significant association of psychological stress with oxidative stress and inflammatory markers in the context of T2DM was also documented.³⁰ All these findings were novel and hitherto unreported in Indians.

Mortality: An individual participant pooled analysis of 10 prospective cohort studies among 68,222 individuals found a higher risk of all-cause mortality, deaths due to cardiovascular diseases and external causes.³¹

Effects on mental health: Stressful living circumstances increase the risk of mental illnesses, including depression and anxiety. Psychological stress has been associated with an increased risk of psychiatric disorders, especially depression, anxiety disorders, and substance use disorders. Apart from psychiatric disorders, psychological distress is also associated with an increased risk of sleep disorders, dementia, memory disturbances, eating problems, and so on.

Memory disturbances: Chronic stress leads to impairment of the HPA axis, leading to changes in the hippocampus that consist of a high density of cortisol receptors. This leads to impairment in memory and learning.

Depression: Depression is one of the most common mental health issues, with a prevalence rate of 5%.³² The relationship between stress and depression has long been studied. Initially believed to be unidirectional, recent studies on the stress–diathesis model indicated a bidirectional relationship. Recently, the focus has been shifted to the awareness that stressors during early developmental years, such as loss of parent(s) and bullying, as well as enduring or chronic stress, such as marital or occupational circumstances, are strong indicators of depression.^33,34 A recent key pursuit has been the investigation of accumulated stress (measured through allostatic load) and its influence on depression and other psychological issues. Biological components such as increased cortisol levels and dysregulation in the HPA axis have been implicated in both stress as well as depression.³⁵ In comparison to age- and gender-matched controls, a study of 13,006 Danish patients with initial psychiatric admissions diagnosed with depression showed higher instances of recent divorces, unemployment, and relative suicides. A serious medical diagnosis is often considered a severe life stressor and is frequently linked with elevated rates of depression. For instance, a review indicated that approximately 24% of individuals diagnosed with cancer experienced major depression.³⁶ Future research should enhance the specific factors influencing the relationship between stress and depression by employing reliable and consistent methodologies.

Anxiety and stress-related disorders: Anxiety serves as the physiological and psychological indicator that the body’s stress response has been activated. Unmitigated stress has been shown to precipitate the development of anxiety disorders as well as stress-related disorders such as acute stress disorder (ASD) and post-traumatic stress disorders (PTSD). Roughly 4.05% of the worldwide population, corresponding to around 301 million individuals, suffers from any anxiety disorder.³⁷ According to the NMHS conducted in India, the prevalence of any anxiety disorder was found to be 3.6%, and that of PTSD was found to be about 0.2%.¹¹ The prevalence of ASD is estimated between 5 and 20% following a traumatic or stressful event. Stress-induced changes in brain regions, such as shrinkage in hippocampal volume have been implicated in ASD as well as PTSD.

Sleep disorders: Sleep disorders have been reported in 25–30% globally.³⁸ The relationship between stress and sleep problems is a commonplace phenomenon. Recent research has shed light on the presence of a sleep-specific aspect of stress reactivity, and the phenomenon has been termed “Sleep reactivity.” Sleep reactivity has been understood as the individual variation in sleep disturbances in response to exposure to stress. Sleep disorders have been implicated in various physical and mental health issues, including cardiovascular diseases and depression. A recent meta-analysis indicated a moderate association between sleep quality, insomnia, and stress in undergraduate students.³⁹ On the other hand, sleep disorders also affect one’s capacity to tolerate stress as well as stress reactions.

Eating habits: Eating has frequently been associated with stress. Studies examining the relationship between stress and eating habits have predominantly evaluated stress by several methods, such as tallying life events, evaluating ongoing stress factors, or concentrating on daily hassles. It has been reported that high cortisol levels are associated with increased consumption of calories. Moreover, when stressed, people decrease their consumption of healthy foods. Evidence also points toward an association between stress and eating disorders, especially binge eating disorder. Research has been conducted primarily on the adult population to understand the relationship between stress and eating habits. Only a few studies have been conducted on young children and adolescents, which found a positive correlation. Potential mechanisms that explain the association between stress and eating habits include mood, negative automatic thoughts, coping, and hormonal changes.⁴⁰

Substance use and substance use disorders: Stress has been implicated in initiation as well as maintenance of substance use disorders. However, most studies were cross-sectional and did not allow us to infer cause-effect relationships. Longitudinal studies have reported that other factors such as poor family support, poor coping styles, stressful life events, migration, and gender also mediated the relationship between the two.⁴¹

Studies have found that populations that live in highly stressful environments tend to smoke heavily and experience higher mortality from lung cancers and cardiopulmonary diseases (COPD). Chronic, stressful conditions have also been linked to higher consumption of alcohol. Alcohol may also be used as self-medication for stress-related disorders. The correlation between acute and chronic stress and the desire to use addictive drugs is well documented in the literature. Many of the major theories of addiction have identified stress as an important cause of addiction processes. These range from psychological models of addiction that view drug use and abuse as a coping strategy to deal with stress and reduce tension to self-medicate and decrease withdrawal-related distress.

Numerous population-based and clinical investigations have found strong evidence for the link between psychosocial adversity, negative affect, chronic distress, and predisposition to addiction. Negative life experiences, including parent death, parental conflict and divorce, limited parental support, physical and emotional abuse and neglect, social isolation, and deviant affiliations, have all been linked to an increased likelihood of drug dependence. Additionally, there is overwhelming evidence linking childhood maltreatment, misuse of drugs, and abuse of sexual and physical abuse. After taking into consideration a variety of control factors, including race or ethnicity, gender, socioeconomic level, past drug misuse, the incidence of mental illnesses, family history of substance use, behavioral and conduct issues, and lifetime exposure to stressors, researchers have recently looked at the effect of cumulative adversity on addiction vulnerability. Even after considering control variables, the results showed that the total number of stressful episodes was a dose-dependent significant predictor of alcohol and drug dependency. Addiction susceptibility was strongly and independently impacted by both proximal and distal events. Even though there are many effective behavioral and pharmaceutical therapies for the treatment of addiction, recurrence rates of addiction are still very high. Exposure to stress can reinstate drug-seeking behavior in animals and increase relapse susceptibility in addicted individuals.

Stress and psychosomatic disorders: Many studies have indicated the strong link between stressful life events and IBS. In general, psychosocial factors are followed by the onset or exacerbation of GI symptoms (Lee OY, 2006).⁴² IBS is a functional disorder with an etiology that has been linked to both psychological stress and infection. It is characterized by an overactivation of the HPA axis and a proinflammatory cytokine increase. (Dinan TG et al., 2006).⁴³ Acute mental stress has a significant effect on the coronary artery blood flow that may be significant in patients with preexisting coronary disease.

Mental stress induces arterial endothelial dysfunction, with impaired vasodilatation and paradoxical vasoconstriction.

Current infrastructure and facilities

The government and other organizations have been providing community mental health services since the NMHP was established in 1981. The major aim of the NMHP is to deliver basic psychological health care at the grassroots level, as well as to ensure that services are available and accessible to the most vulnerable and underprivileged people. In India, government spending on mental health accounts for only 0.06% of the total health expenditure, which accounts for barely 4% of the national gross national product (GNP). In India, only 43 mental hospitals with 1.469/100,000 beds, 0.047/100,000 psychologists, and 0.301/100,000 psychiatrists exist. Qualified personnel are scarce. The availability of mental health nurses and social workers is 0.166/100,000 and 0.033/100,000, respectively. Mental health infrastructure is mostly restricted to huge, semi-permanent facilities which serve a small number of people. We are still in the early stages of completely allowing patients, families, and communities to fulfill the three goals of mental health, promotion, prevention, and treatment. The objectives of the District Mental Health Program (DMHP) as envisaged in the 12th 5-year plan were: To reduce mental illness-related distress, disability, and premature mortality, as well as to improve rehabilitation from a mental condition by assuring that psychiatric care is available and accessible to all, specifically the most marginalized and poor members of society. Other objectives were as follows: reduce stigmas, encourage community engagement, increase accessibility to preventative care for at-risk groups, safeguard persons with mental illness (PWMI) rights, and integrate mental health services with other programs such as rural and child health, motivate and empower employees, build administration, regulations, and accountability procedures to strengthen mental health service delivery infrastructure, develop awareness and information, and develop leadership, organizational, and accountability mechanisms. These goals are now being pursued through extending community services and improving community-based programs (satellite clinics, school counseling, workplace stress management, and suicide prevention), organizing community awareness camps with the assistance of local groups, increasing national involvement (through collaboration with conscience and caretaker organizations), forming public-private partnerships with designated financial cooperation, establishing a special 24-hour hotline number (e.g., to notify the public about urgent mental health services), assisting national and state mental health agencies in obtaining public funding, and so on. Hence, the concept of mental distress alleviation is being dealt with by not only psychiatrists but also a team of mental health professionals, including psychiatry social workers, mental health nurses, occupational therapists, psychologists, primary care physicians, Accredited Social Health Activists (ASHAs) workers, and volunteers from the community.

Application of technology in the alleviation of stress and mental health intervention: Technology creates opportunities for extending mental health services to remote areas. The use of technology in the field of mental health has given impetus at multiple levels.⁸⁵ Information and communication technologies have yielded positive results in mitigating stress. Innovative technology-based interventions have helped to reach out to various age groups and to reduce stigma.⁸⁶

Digital mental health interventions and technology interface: Digital mental health interventions (DMHI) have been categorized as “e-Health” through telemedicine or internet-based interventions and “m-Health” through mobile digital interventions such as smartphones or virtual and augmented reality applications.^87,88

1. Internet-based Interventions (IBIs) can be effective in promoting healthy behaviors

2. Smartphone Apps: Efficacy was examined by the meta-analysis conducted by Linardon et al.⁸⁹ (2019). It was noted that apps can be low-intensity, cost-effective, and easily accessible interventions for those unable to receive standard psychological treatment.

3. Virtual and Augmented Reality: Virtual reality is defined as “a collection of technologies that allow people to interact efficiently with 3D computerized databases in real-time using their natural senses and skills”.⁹⁰ It has been helpful for relaxation as well as for the treatment of social phobia, etc.

4. Artificial Intelligence–based technologies (e.g., machine learning, deep learning) may bring phenomenal changes in understanding and preventing the occurrence of stress-related psychological disorders.⁹¹

With respect to mental health concerns and stress-related disorders, availability and access of trained human resources remain a challenge.⁹² Stigma of seeking help, availability of trained human resources, and geographic and economic challenges are some of the issues that supplement and advocate the implementation of DMHI.⁹³ Systematic review and meta-analysis of DMHI to quantify the effectiveness of the interventions of DMHI revealed that they may be helpful if delivered under supervision and with active support.⁹⁴ Some of the challenges are adaptations of the psychological interventions into digital formats.

The DMHI (e.g., Internet-based interventions, smartphone apps, mixed realities – virtual and augmented reality) provides an opportunity to improve accessibility to intervention in stress-related disorders. Systematic reviews and meta-analyses found that DMHI is effective in mild mental disorders; however, in-person professional consultation is associated with greater effectiveness and lower dropout than fully automatized or self-administered interventions.⁹⁵

Tele-mental health: Tele-mental health involves technologies such as video-conferencing to deliver mental health services and education and to connect individuals and communities for healing and health. Tele-mental health is effective and increases access to care.⁹⁶ Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost. Technology adoption for combating stress during the pandemic has opened many options for interventions. Information dissemination and mental health interventions attained momentum during this period. It involved the dissemination of authentic information through reliable resources of government-aided platforms. Technology-based solutions, information management, and the use of technologies⁹⁷ were widely tried to alleviate distress. The stress mitigation initiatives through telework and online educational interventions are the key factors of an entirely new era of technology-based interventions in mental health. The primary advantage of these interventions is connectivity to remote locations where mental health interventions are not available for mitigating stress.

Tele-MANAS: The current National Tele-Mental Health Program (Tele Mental Health Assistance and Networking Across States [T-MANAS]) has been envisioned as the digital arm of DMHP as a further extension of the mental healthcare service in the country.

The Government of India introduced of the National Tele-Mental Health Program (T-MANAS) during the Union Budget 2022–23. The program was officially launched in October 2022. T-MANAS is a two-tier system comprising state T-MANAS cells, including trained counselors as first-line service providers at Tier 1 and mental health professionals at DMHP at Tier 2 to provide secondary-level specialist care. Referral services are also available for in-person consultations or audiovisual consultations through e-Sanjeevani, which is the national telemedicine initiative under the Ministry of Health and Family Welfare (MoHFW). The inclusion of tele-mental health services as a part of the mental healthcare deliverables is an expansion of digital mental health in the country.⁹⁸ Following are the objectives of Tele-MANAS:

1. To enhance health service capacity to deliver accessible and timely mental healthcare through a tele-mental health network support system.

2. To ensure a continuum of services in the community, including tele-mental health counseling.

3. To facilitate timely referral for specialist care and follow-up as appropriate.

4. To enhance mental healthcare capacity and networking at primary healthcare or health and wellness centers/district/state/apex institution levels.

The Ministry of Social Justice and Empowerment launched a helpline to offer mental health rehabilitation services with the objective of early screening, first aid, psychological support, distress management, promoting positive behaviors, and so on. The helpline is available in 13 languages and has 660 clinical or rehabilitation psychologists and 668 psychiatrists as volunteers. It is being coordinated by the National Institute for the Empowerment of Persons with Multiple Disabilities (NIEPMD), Chennai (Tamil Nadu) and the National Institute. It aims to cater to people in distress, people impacted by pandemic-induced psychological issues, and Mental Health Emergencies.

Mental well-being Apps: There are many apps available commercially but lack scientific validity. Under the mental health augmentation strategies, Sleep App, Mindfulness App, and Relaxation Apps are available. There is a strong need to regulate the practice of referring these apps for practice purposes. Content and standardization need to be regulated for the approval of the use of Apps in the mental health field for mitigating stress. In the pursuit of enhancement of positive mental health, scientific and evidence-based information is required to be curated for well-being apps. Mental Health and Normalcy Augmentation System Positive mental health App was developed based on robust scientific evidence in collaboration with National Institute of Mental Health and Neuro-Sciences, AFMC, and Centre for Development of Advanced Computing Bengaluru, under the Prime Minister Science and Technology Advisory Committee, Office of Principal Scientific Advisor to Government of India. The App focuses on the promotion of positive mental health.

Current Programs

Over the years, Government of India have launched various mental health programs to promote mental health and prevent mental illnesses [Figure 3].

1. National Mental Health Program

   The Government of India launched the NMHP in 1982, with the following objectives. As shown in Figure 4, NMHP has delineated various objectives to create an environment of awareness. It helped in promoting community participation in the mental health services and providing minimum healthcare available for all.

2. District Mental Health Program (DMHP)

   The DMHP is a government scheme launched in 1996 to provide mental health services at the district level and integrate mental health services into primary healthcare.

   The DMHP was initiated under NMHP in 1996 (during the IX 5-year plan). Modeled after the “Bellary Model,” DMHP encompasses the following components:

   1. Early detection and treatment

   2. Training: Providing short-term training to general physicians for the diagnosis and treatment of common mental illnesses and utilizing a limited range of drugs under specialist guidance. Health workers are also trained to identify individuals with mental illnesses.

   3. IEC (Information, Education, and Communication): Creating public awareness

   4. Monitoring: Primarily for straightforward record-keeping purposes

      DMHP addressed workplace stress management, life skill training, counseling in schools and colleges, and community awareness prevention and promotion at the district-level healthcare delivery system.

3. Ayushman Bharat - Health and Wellness Centers (AB-HWC)

   Ayushman Bharat – Health and Wellness Centers (AB-HWC) is a flagship program of the Indian government launched in 2018 intending to provide comprehensive primary healthcare services to all individuals. The program aims to establish 150,000 health and wellness centers across the country by 2022.

4. Atmanirbhar Bharat Abhiyan:

   The Atmanirbhar Bharat Abhiyan, launched in 2020, is a self-reliance program aimed at promoting economic growth and development in India. The program also focuses on addressing the impact of the COVID-19 pandemic on the mental health of individuals. The schemes have focused on integrating mental health services into the general healthcare system and promoting community-based mental health care. This further was envisaged to help reduce stigma and improve mental health.

5. Rashtriya Kishor Swasthya Karyakram:

   Rashtriya Kishor Swasthya Karyakram (RKSK) is a national program launched in 2014 to improve the health and well-being of adolescents in India, including their mental health.

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Figure 3:

Initiatives by government of India.

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Figure 4:

Objectives of National Mental Health Program (NMHP).

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Budget allocation

The optimum level of training of mental health professionals will take decades to reach the ideal number of Mental healthcare professionals training in the country.

Out of the total ₹86,200 allocated last year, the budget for mental health was ₹791 crores, which was 0.92% of the total health budget. This year, it has marginally increased to 1.03% and as per Table 2, it amounts to 919 crores out of 89165 crores allotted for health. In this year’s budget, the line item of NMHP under tertiary activities has been used as the Tertiary Care Program. The tertiary components of the NMHP are mandated for strengthening Post Graduate Training Departments of mental health specialties, establishing Centers of Excellence and modernizing state-run mental health hospitals.

Recommendations made to bridge the critical gaps and deficiencies in this aspect

Bridging the critical gaps in mental health services in India requires a comprehensive and multifaceted approach that addresses various challenges.

1. Increased funding and resource allocation

   The first step to improvement is having money for it. Most of the above issues require the allocation of funds by the government. Presently, mental health gets a meagre share of the budget, compared to the disability-adjusted life years (DALYs) and YLDs it is relatively responsible for. The effects of mental health disorders are not as overtly visible as those of physical disorders. Perhaps this reduces the urgency for it in the minds of decision-makers. Also, awareness of this silent epidemic, which is making its way, is poor at all levels.

   The allocation of a higher proportion of the healthcare budget to mental health services to address resource shortages and enhance the quality of care is of paramount importance. The funds are required for enhancing the medical services, training of PHC and community health center (CHC) staff, procurement of ample amounts of medications, increasing community awareness, school mental health literacy, deaddiction campaigns, research, and so on. The list is too long, as most of these areas are poorly addressed. For the financial year 2023–24, BE for mental health is just above 1% of the BE of the MoHFW. The government has increased its budget for T-MANAS, showing its commitment to digital mental health programs. However, elsewhere, there is a substantial lack of funds.

   The mental health atlas by WHO also reiterates the above allocation and points out that most of the allotted budget is used for in-patient treatment, leaving even lower financial aid for community psychiatry, literacy, and so on.

2. Workforce development

   The second step after the allocation of funds is to have trained manpower to address the issues. Thus, the government should aim to train and increase the number of mental health professionals, including psychiatrists, psychologists, counselors, and psychiatric nurses, to ensure adequate coverage. As stated above, the national averages for the above are far below the international standards, which causes an increased prevalence of mental health issues and is an economic burden. At the current pace of training, we are not looking at less than three decades to fill our cup.

   Thus, the way forward is to train the existing medical workforce until we can upgrade our infrastructure.

   1. Increase psychiatry training at the graduate level: Since the training in Psychiatry at MBBS and equivalent levels is poor, the Medical Officers manning the health centers are unaware of how to recognize and manage basic mental health issues. Thus, Psychiatry should be taught as a full, separate subject in MBBS, in the final professional examination, and simultaneously, the Internship in Psychiatry should be increased from 2 to 4 weeks. This amount of exposure in both theoretical and practical training is vital for improved knowledge and skill development. This training will also assist the specialist doctors in recognizing mental health issues in their clinics, as these issues, although having a very high prevalence in almost all chronic illnesses, go undetected. Thus, mental health components should be included in the training of primary care physicians and other healthcare professionals.

   2. Increase training programs and capacity: Medical and paramedical staff already employed can undergo short capsules of training in mental health with a refresher training every 5 years. This will ensure the staff is sensitized to mental stress recognition and management. These capsules can be run by the district hospitals or medical colleges.

   3. Increase trained psychologists: Increasing the seats for Psychology training helps fill the gap. Further, training of medical and nursing undergraduates should include Psychology as a subject, which would increase the mental health workforce.

   4. Provide supervision and mentorship: Establish mentorship programs for new mental health professionals, allowing them to learn from experienced practitioners. Regular supervision can help professionals improve their skills and ensure high-quality care. These can be arranged between CHC and tertiary care centers, such as medical colleges.

   5. Incentives and scholarships: Offer scholarships, grants, and financial incentives to attract individuals to mental health professions. Create initiatives to support mental health professionals working in underserved areas or with vulnerable populations.

   6. Enhance tele-health training: This is particularly useful for covering remote areas with geographical difficulties and has the advantage of real-time assistance.

   7. Develop a cadre of mental health professionals trained to work within the primary care system.

3. Awareness and stigma reduction

   Improving mental health literacy. Reducing stigma against mental health in India requires a multifaceted approach that involves raising awareness, education, advocacy, and fostering open conversations about mental health.

   1. Public awareness campaigns: Launch nationwide campaigns that provide accurate information about mental health, debunk myths, and challenge stereotypes. Various media platforms, including TV, radio, social media, and print, to reach a wide audience are required. The success of Polio immunization and TB or HIV awareness are evidence of the power of awareness and reducing stigma, respectively.

   2. Education in schools and colleges: Integrate mental health education into school curricula to promote understanding and empathy from a young age. Conduct workshops and seminars in colleges to address stigma and promote mental health literacy. School-based awareness programs have been shown to reduce suicide attempts and suicidal ideation. The universal school program affects both the recognition of mental disorders, prejudice, and knowledge about where to seek help and, consequently on the mental health literacy of adolescents. One such program that needs to be mentioned is the Young Mental Health First Aid Program, conducted in Australia, to help young adults learn the skills required to recognize early signs of mental illness in adolescents and provide help as and when required.

   3. Promote positive portrayals in media: Media has the most powerful effect on changing attitudes and images. The portrayal on the screen is almost the truth for the public at large. Thus, it is recommended to collaborate with media outlets to portray mental health issues sensitively and accurately. There should be strict laws against the incorrect or deceptive portrayal of mental health issues in the media. Highlight stories of recovery and resilience to inspire hope and reduce fear.

   The Schizophrenia Research Foundation (SCARF) in Chennai, India, has been sponsoring a film festival called “Frame of Mind,” which includes various films depicting mental illness and an international competition for short films on mental health and stigma. This approach has been a big success, with three editions published so far. Similar celebrations have subsequently taken place in places such as Kolkata. Many nongovernmental organizations (NGOs) employ short videos to raise awareness about their work or cause, although the effectiveness of such initiatives has not been studied.

   1. Celebrities and influencers: The psychology of advertisements teaches us that the source of information to the public influences how well that information is accepted. Engage celebrities and influencers to share their own experiences with mental health challenges, thereby normalizing the conversation. Encourage influential figures to use their platforms to spread awareness and advocate for mental health.

   2. Support groups and peer networks: Create safe spaces where individuals can share their experiences and find support from others who have faced similar challenges. Peer support networks can play critical roles in reducing isolation and combating stigma.

   3. Training for healthcare professionals: Provide training for healthcare professionals to deliver culturally sensitive and stigma-free care to individuals with mental health issues. Equip healthcare providers with communication skills to address mental health concerns without judgment.

   4. Engage religious and community leaders: Collaborate with religious leaders and community figures to promote understanding of mental health and challenge harmful beliefs. Religious institutions can be influential in spreading positive messages about mental well-being.

   5. Legal and policy measures: MHCA 2017 has been beneficial to people with mental health disorders and is right-based. However, for people who are suffering from mental stress and are not diagnosed with any mental disorder, another set of policies and advocates might be required. This includes a smooth path for obtaining help when required without being marginalized due to the prevailing stigma.

   6. Mental health days and events: Organize events like World Mental Health Day to draw attention to mental health issues and foster open discussions. Use these occasions to launch awareness campaigns and educational initiatives. These can also be used by the government to launch schemes to facilitate help for mental stress.

   7. Corporate initiatives: Encourage workplaces to prioritize employee well-being and promote mental health awareness. Provide resources for employees to seek help and create a supportive environment.

   8. Open conversations: Encourage individuals to openly share their experiences with mental health, which helps break down walls of stigma. Engage in conversations with family, friends, and colleagues to normalize discussions about mental well-being.

   9. Empowerment and advocacy: Empower individuals with lived experience to become mental health advocates, sharing their stories to inspire change. Support advocacy organizations that work to reduce stigma and improve mental health services.

      It has to be remembered that changing deeply ingrained societal attitudes takes time and consistent effort. By implementing these steps and fostering a culture of understanding and empathy, India can make significant progress in reducing the stigma against mental health and creating a more supportive environment for individuals facing mental health challenges.

4. Integration of mental health services

   It is crucial to integrate mental health services seamlessly into the broader healthcare system in India to ensure that individuals receive well-rounded care encompassing both their physical and mental well-being. The integration of mental health services into primary care settings facilitates early detection, timely intervention, and an all-encompassing approach to healthcare. Achieving this goal necessitates collaborative efforts among mental health professionals, general physicians, and community health workers, fostering a coordinated response to address mental health needs.

   1. Policy and legislative support: Develop policies and guidelines that mandate the integration of mental health services into primary care. Ensure that existing mental health legislation, such as the Mental Healthcare Act, supports integration efforts.

   2. Health workforce training: As stated above.

   3. Screening and assessment: Integrate mental health screening tools into routine primary care assessments to identify individuals at risk of mental health problems. Further research is required to develop culturally sensitive assessment protocols considering local beliefs and practices. This will ensure a valid and reliable assessment and increase its sensitivity.

   4. Referral pathways: Establish clear referral pathways between primary care and specialized mental health services for complex cases. This ensures a continued level of care, starting from the primary level, and instills confidence in the staff at the primary level and trust in the clientele. Develop mechanisms for prompt and seamless communication between different levels of care.

   5. Collaborative care model: Implement a collaborative care model where mental health specialists work closely with primary care providers to deliver integrated care. Facilitate regular case discussions and joint treatment planning.

   6. Telemedicine and technology: Utilize telemedicine platforms to connect primary care providers with mental health specialists for consultation and guidance. Develop mobile applications for mental health education, self-assessment, and support.

   7. Community-based initiatives: Establish mental health clinics or centers within CHCs to provide accessible mental health services. Train community health workers to deliver basic mental health support and education.

   8. Health information systems: Develop electronic health records that include mental health assessments and treatment plans, this will ensure continuity of care, and this could be further elaborated to implement data-sharing mechanisms between primary care and mental health services.

   9. Establish cross-sectoral partnerships (Legislative, Executive branches of Government, Medical infrastructure, NGOs, etc.) to address social determinants of mental health. This will collectively focus their expertise and resources on this issue. This will help the various parties bridge the gaps existing in their solo operations.

   Integration of mental health services in India requires a concerted effort involving policymakers, healthcare providers, mental health professionals, and communities. By building a strong foundation of policies, training, and support mechanisms, India can enhance access to mental healthcare and improve the overall well-being of its population.

   1. Telemedicine and technology: Expand telemedicine initiatives to increase access to mental health services, especially in remote and underserved areas. Develop mental health apps and digital platforms for psycho-education, self-help, and remote counseling. The technology will be discussed in detail in the next section.

5. Culturally-adapted interventions

   It is important to develop evidence-based interventions that are culturally sensitive and contextually relevant to the diverse population in India. Involve community leaders and local organizations in designing and implementing mental health programs. The adaptation of policies and programs to the local culture of the target population will go a long way in terms of acceptance, implementation, and benefits. India is a culture-driven nation, and congruency with culture should be the foremost criterion of any policy. Similarly, campaign programs that include Nukkad Natak, puppet shows, and talks by local teachers or leaders are far more acceptable than a lecture behind the dais. Similarly, art therapies, such as dance, theater, and folklore, apart from providing entertainment, have been in India for decades and are one of the means of imparting health education in rural India.

   Many screening schedules are not culture-sensitive and thus do not give correct information to the health workers. More research into these areas is required to formulate scales sensitive to our diverse culture.

6. Strengthening policies

   Revise mental health policies to align with international standards and emphasize prevention, early intervention, and community-based care. This is dealt in detail in the next section.

7. Support for families and caregivers:

   Offer counseling and support services for families and caregivers of individuals with mental health conditions to empower them to provide effective care and reduce stigma.

8. Research and data collection

   Invest in research to generate local evidence on effective interventions, prevalence rates, and factors affecting mental health. Establish a comprehensive mental health database to track trends, evaluate interventions, and inform policy decisions. Research to assess the effectiveness of integrated mental health services and identify areas for improvement.

9. NGO collaboration

   This will assist in the reach of mental health services and community-based support programs. Foster partnerships between the government, NGOs, and private sector to leverage resources and expertise for mental health initiatives

10. Front-line workers to support the individuals affected by mental stress

    The recommendations stated above require consistent efforts, which are expected to take time. Although the above is essential for quality care, as a stop-gap measure, a short training course in mental health needs to be initiated for all health workers at PHC and CHC levels. Workshops for sensitizing these first-line health workers can be easily done at tertiary care centers by psychiatrists and psychologists, which will enable them for early detection of mental stress or mental health issues. This will further increase the level of mental healthcare in the area and in turn, increase mental health awareness. The extent of services that can be provided and the population that can be handled by such centers depend on the available manpower and will act as a learning benchmark as this process comes into effect.

11. Monitoring and evaluation

    To improve anything, the best way is to measure it continuously. So, regular monitoring and evaluation of the implemented programs, policies, and procedures needs to be done. This should be followed by informed adjustments and improvements. This continuous effort will ensure that the procedures in place are functional, improving, and being updated to meet the required needs. The reports and returns need to be stringent in concept and format and should be evaluated strictly.

Huge treatment gap for all mental disorders

There is a huge treatment gap for all mental disorders due to various reasons such as a deficit in the number of trained human resources, the need for standardized delivery of care, need to address the specific needs of special populations like women, pediatric, and geriatric population; and as well as due to lack of awareness related to mental illness among general public.

Less availability of mental health professionals

According to the Indian Psychiatric Society, there are around 9,000 psychiatrists currently practicing in India. Every year, about 700 more psychiatrists graduate from various medical institutions across the country. However, the number of psychiatrists available in India is quite low, with only 0.75 psychiatrists per 100,000 people, which is much less than the recommended minimum of three psychiatrists for every 100,000 inhabitants. Clinical psychologists are also very less in number.¹⁰³ There is a significant deficit in the availability of human resources trained in mental health who can cater to mental stress. Hence, there is a need for training in the mental health field at different tiers as discussed below.

Need for training at different tiers of healthcare services

Mental Health Awareness Training (MHAT) is important to cater to community-level interventions and prepare individuals to identify early signs of distress before the breakdown occurs. Identification of stressors and skills to handle these stressors can be achieved through training. Training can be imparted to provide support at the community level by primary-level care providers and equip them to cope with levels of stressors involving adjustments and coping during stressful periods. This can be achieved by a three-tier level approach as given below in Figure 6. Further trained human resources can be generated by introducing these skills at education levels, both graduate level of Psychiatry and Clinical Psychology.

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Figure 6:

Training at different tiers of healthcare services.

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The current mental health budget has been mentioned in Table 2.

Mental health awareness strategic approach

Enhancing mental health awareness in the country will lead to its promulgation, creating its demand. Additionally, as awareness expands in a democratic society, there will be an emergence of advocacy efforts, the utilization of political will, increased funding, and the development of cross-synergies. Srivastava et al.,¹⁰⁶ (2016) envisaged that a significant portion of the contributions to awareness shall flow from the various platforms shown in Figure 7.

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Figure 7:

Platforms for creating mental health awareness.

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Adapted from: (Srivastava et al., 2016).¹⁰⁶

Need to incorporate technological advances to increase reach

There is a need to incorporate Government initiatives of the Digital India Mission as an add-on arm to mental health initiatives.

Very low budget allocation and lack of adequate infrastructure

There is a pressing need to rationalize the budget allocation for mental health programs, as it is less than 1% of the current total budget, which hinders the expansion of services for mental health promotion as well as the development of services that can cater to the huge prevalence of mental stress among the general population. Also, there is a need to allocate adequate budget for research in the field of mental health.

These are five important components essentially required to mitigate stress as depicted in Figure 8.

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Figure 8:

Strategies to mitigate mental stress.

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Infrastructure development

Suggested policy activities and advocacy for policymakers

• Sensitive public healthcare approach, which is person-centered, culturally sensitive, collaborative, and transdisciplinary. It should be able to adequately address bio-psycho-social determinants, especially for vulnerable groups, and promote community engagement.

• Policy convergence to align all government departments, NGOs, integration of stress mitigation and public mental health policies with primary care, establishing implementation units at national, state, and district levels, and mobilizing existing community resources.

• Implementation strategy for program development, building human resources, setting up service delivery standards, and aligning those to the needs of the community.

• Sensitizing important stakeholders such as community leaders, teachers, employers, and parents for early identification of stress and its manifestations.

• Formulation of telepsychiatry and telepsychotherapy guidelines.

• Implement a collaborative care paradigm with primary care professionals and mental health professionals.

Recommendations for health/medical professionals

• Develop effective pathways to care by training lay counselors, ASHA workers, community leaders, and so on, screening vulnerable populations, and developing systems for triaging, referrals, service contracts, and delivery of services.

• Have a basic understanding of stress, its manifestations, and identification of common mental disorders.

• Greater utilization of basic counseling skills to deal with issues at the primary care level and knowing when and where to make a referral.

• Undertaking offline or online courses imparted by government agencies such as Project Extension for Community Healthcare Outcomes (ECHO) for the training of medical professionals and lay counselors.

• Integrate psychosocial rehabilitation along with treatment of mental health issues.

• Launch public awareness initiatives around the country to dispel myths and factual information.

• Bring mental health education into the classroom and run awareness campaigns at schools, colleges, and universities

Suggestions to create awareness among the public, NGOs, and community stakeholders

• Community awareness and engagement through IEC activities to de-stigmatize impact of stress, build capacity for information dissemination, sensitization, experiential learning, and peer support.

• Provide support for vulnerable groups - prioritize children, adolescent, and youth development. Empowerment of women, elderly care, and outreach to vulnerable groups.

• Initiate workplace interventions to tackle stress at the workplace.

• Sensitizing teachers in educational institutes to carry out stress prevention activities, engage in life-skill training, identify early signs of stress in students, and understand where to make referrals.

Any other

• Inputs would include:

  • Increased number and dispersion of mental health personnel

  • Training of all medical and nursing personnel and community health workers in assessing and addressing stress

  • Streamlining of access to care and referral processes

  • Coordination of stress mitigation policies across all departments or arms of government

  • Increased use of force multipliers through technology, for example, websites, apps, and so on.

• Workforce Development in dealing with stress management:

  • Psychiatric nurses, psychologists, counselors, and psychiatrists should all receive more training in this area.

  • Improve graduate-level psychiatry education for family practitioners and other medical specialists.

  • Provide rewards, scholarships, and financial aid to draw people to jobs in mental health.

  • Create telehealth training for reaching remote places.

  • Create peer networks and support systems.

  • Teach medical staff or other concerned trainers to deliver treatment without judgment.

• Outcomes would be assessed by:

  • Screening for stress in the community to track trends in schools or colleges; PHCs, workplace (formal/ informal sector), and community through surveys.

  • Measures of change of awareness in the community

  • Tracking of NGO and community support group activities

• Impact would be measured by:

  • Improved or increased identification of stress and consequences

  • Shortened pathway to care

  • Reductions in delay of treatment, cost of treatment, and outcome.

  • Reduction in mental health gap

  • Increased care-seeking in the community or population

  • Reductions in surrogate markers of stress like substance use, suicide, depression, anxiety, and physical illness

  • Reduction in stigma

  • Increased integration of those with stress-related illnesses

The implementation plan requires comprehensive discussions involving both medical professionals and a diverse array of stakeholders. This multi-stakeholder approach should encompass individuals with mental health issues, those with programmatic and administrative expertise, financial specialists, and others. The selection of prioritized strategies should be informed by both empirical evidence and a nuanced understanding of the country’s distinctive cultural, social, economic, and political context.

These chosen strategies must be closely tied to quantifiable outcomes assessed within appropriate timeframes. Defining objectives that are specific, measurable, achievable, reliable, and time-bound (SMART objectives) is essential to gauge the effectiveness of these strategies. Such a framework will be instrumental in directing resources effectively and optimizing inputs for the intended outcomes.