World Mental Health Day 2023: Increasing awareness of mental health in India & exciting opportunities for the future

In light of the recently hosted International G20 Summit in India this year in September and with the World Mental Health Day in the following month of October, it is a great time to reflect on the state of mental health in this country, as well as the exciting future it holds as a leader for mental health promotion. This editorial discusses three main topics: (i) the growing awareness of mental health in India, (ii) the contribution of westernization/development to increasing certain mental health issues in India, and (iii) the contributions that India can share for the world’s future mental health. These include innovative public health work and traditional spiritual practices with the potential for preventing and treating mental health issues.

Increasing awareness regarding mental health issues in India

Awareness of mental health issues is increasing in India. In a survey by the Live Laugh Love Foundation, out of 3497 respondents in nine Indian metropolitan centres, 92 per cent of the respondents in 2021 would seek treatment for themselves or someone they know, up from 54 per cent in 20181. Similarly, the percentage of people who believe that individuals with mental illness could hold jobs and lead healthy lives rose from 32 to 65 per cent from 2018 to 20211. Nowadays, even mainstream newspapers report on mental health issues2. By 2030, depression alone will likely to be the second- and third-leading contributors to disease burden in low-income and middle-income countries, respectively3. The Global Burden of Disease (GBD) study4 reveals that in 2017, 197.3 million (14.6%) Indians were affected by mental disorders. This represents a doubling of the total disease burden particularly due to mental disorders in India between 1990 to 20174. In 2022, India had a suicide rate of 11.6/100,0005.

Despite this dire need, the Indian government spends only about 0.06 per cent of its total health expenditure on mental health, with only 0.75 psychiatrists per 100,000 people6 and even lesser on mental health nurses, social workers and psychologists7. Moreover, lack of mental health awareness continues to be a major issue in rural areas and disadvantaged strata of the society. For example, 64.2 per cent of suicides were amongst those earning an annual income of less than ₹ 1 Lakh5. Although close to 200 million Indians could benefit from mental health services, fewer than 30 million seek care due to limited access and stigma2.

Worth noting is that the reported rates of mental illness in India are similar to those in western countries8,9. This might suggest the following: that between 1970 and the present, Indians have increasing comfort in reporting mental health symptoms in national epidemiological surveys and/or that the westernization of India has been associated with an increase in mental health burden.

Westernization of India – How is this impacting mental health?

Westernization – the adoption of western practices, culture and development has brought some positives, including increased access to varied technologies, like cell phones, which enable internet use, facilitate transactions and connect friends and families in ways never possible before. Since colonialization, India has long emulated the west – through the consumption of goods in hyper-malls, fashion and other social conventions. In this context one may frequently witness coffee table talk such as ‘India will have the world’s top GDP by 2030’! In many ways, India’s optimism for economic prosperity and social change is reminiscent of that felt during the ‘Boom Times’ of North America in the early 1960s.

Although a certain level of material prosperity and security is helpful for life and mental health, do we want to replicate the west? As previously mentioned, there has been a doubling of the mental disease burden in India over the past three decades4, a part of which may be secondary to rapid westernization. There are also other indications that this may be the case. The larger metropolitan cities have been observing increased mental health burden, particularly in the middle-aged workers7. In the past three decades, relative to low-income States, the prevalence of depression and anxiety increased more in high- and mid-income Indian States4. Indian students who are frequently under extreme pressure to perform and compete often suffer from anxiety and depression, and, in some cases, commit suicide10. To illustrate this point, a 2023 survey of 787 north Indian medical students found that 37.2 per cent had suicidal ideation, 10.9 per cent had suicide plans and 3.3 per cent had suicide attempts11.

Westernized education is a two-edged sword, in that it can be the basis of an intellectually developed, scientifically minded, materially prosperous society. However, in the pursuit of intellect and material wealth, deeper aspects of the mind, heart and soul are left sorely neglected. What we have seen living in North America, particularly so in the past decade, are the rising trends of fast-paced, work-driven existence, instability in romantic relationships (casual dating, serial monogamy and polyamory), divorce, fragmentation of families, loss of community, isolation, overreliance on smartphones and social media, addictions (including an increase of illicit substance use following the legalization of marijuana) and not to mention accelerated environmental degradation. In short, a maelstrom that bodes poorly for individual and collective mental health.

India as a future world leader in mental health

India has exciting opportunities to deliver interventions for the prevention as well as treatment of mental health issues through its growing biomedical and psychosocial infrastructure. Compared to the western nations, it has considerably fewer psychiatrists and less existing infrastructures in place; hence, this may translate into less bureaucracy. This makes the ground ripe for creative and innovative public health interventions to prevent and treat mental health in cost-effective ways.

There are already a number of large assessment and intervention programmes in India. For example, there is the National Mental Health Programme (NMHP) which started in 1981 and delivered basic psychological healthcare services at the grassroots level, in an attempt to ensure availability and accessibility to even the most underprivileged and vulnerable people7. The National Mental Health Survey initiative spearheaded by National Institute of Mental Health and Neurosciences, has helped characterize the epidemiology of psychiatric conditions across India, inform policies, address emergent mental health issues and implement mechanisms to address mental health nationwide12,13. Dias et al14 conducted a large randomized controlled trial, in which volunteers from the community were trained to support elders with sub-syndromal depressive symptoms. These volunteers succeeded in preventing major depression relapse among the study participants despite limited resources. Taking cues from this article was an inspiration to our Canadian research team, implemented a volunteer-based friendly phone programme for isolated older adults with similar success during the pandemic15.

India is also blessed with rich and ancient spiritual traditions and healing arts of meditation, yoga, Ayurveda and many other practices with their potential as adjuncts and alternatives for treating and preventing mental health issues. There is now emerging research supporting their application for mental health disorders. However, a nuanced approach is required to suit the needs of different populations. For instance, in people with psychosis, bipolar disorder, dementia or suicidality/trauma, moving forms of meditation like yoga may be more appropriate than silent sitting meditation16. A similar consideration is taken when tailoring interventions based on people’s interests and religious or ethnocultural contexts to make them more relevant and accessible17.

Scientific rigour and external validation are also important to ensure safe, high-quality interventions. In this context, national regulatory agencies can play a role to help standardize practices, in a way that will help validate and further support safe practices. There is a need for research with more rigorous study designs, for example, randomized controlled trials with active control groups using well-validated mental health and quality-of-life outcome measures. To complement this, a line of investigation of legitimate experts of certain meditative and yogic practices18, including neurobiological quantitative assessment and qualitative phenomenological interviews, can help understand the deeper mechanisms underlying these practices and the deeper aspects of the mind.

India’s philosophers have long contemplated these deeper aspects of the mind and its relationship to healthy individuals and communities. Sri Aurobindo expounded a profound psychology of the mind, which recognizes spirit, mind and body as being interdependent. The different spiritual methods teach the human mind to submit to the Self or God18. In our opinion, today’s mental health disorders are in large part due to the body (materialism and self-gratification) not being controlled properly by the mind nor the spirit; but rather the mind being controlled by the whims of the body.

India is the home of many rich religious traditions, with acceptance and greater interreligious tolerance than seen in most places. Religions universally emphasize selflessness, morality, service and goodwill. However, modern medicine and society emphasize focus on the individual self. Even mental health treatments focus on alleviating symptoms instead of supporting a broader outlook that goes beyond oneself feeling good and serving one’s own needs. Ironically, serving others without desire is associated with better personal mental health19.

In summary, there is tremendous potential for India as a world leader in mental health. This includes continued innovation and implementation of scalable, low-cost, accessible, culturally appropriate interventions, especially in people who are financially disadvantaged and in rural areas. Certain interventions can be delivered through smartphone, online or by telephone to increase accessibility and overcome stigma.

An emphasis on prevention (as opposed to treatment) is recommended since prevention is where, even with low costs; a significant impact can be made. A big part of prevention in India will be continued reflection on how to guide and temper economic development and other aspects of westernization in a way that does not erode family life, community and the social fabric, ultimately endangering people’s mental health. Future behavioural interventions for mental health pioneered by India could borrow wisdom from religious traditions to (i) help people cultivate selflessness, (ii) inculcate universal moral values and (iii) change the target of interventions from individuals to families and communities. Continuing and deepening India’s support towards the spiritual and moral growth of its citizens will help citizens become strong and better able to serve their families and communities and prevent mental illness nationwide.

Financial support and sponsorship

None.

Conflicts of interest

The author SR received an operating grant from Mitacs to support a post-doctoral fellow, is on a steering committee for an Abbvie post-marketing observational study, and is a shareholder in Aifred Health.