Bipolar affective disorder in India: A multi-site population-based cross-sectional study

Abstract

Introduction:

Bipolar Affective Disorder (BPAD) merits careful consideration within the medical and healthcare communities, researchers, and policymakers. This is due to its substantial disability burden, elevated prevalence of co-morbidities, heightened lifetime risk of suicidality, and a significant treatment gap. This article focuses on the lifetime and current prevalence, correlates, co-morbidities, associated disabilities, socio-economic impact, and treatment gap for BPAD in the adult population of the National Mental Health Survey (NMHS) 2016.

Materials and Methods:

The NMHS 2016 was a nationally representative study conducted across 12 Indian states between 2014 and 2016. A multi-stage, stratified, random cluster sampling technique based on probability proportionate to size at each stage was used. The diagnosis of BPAD was based on Mini-International Neuropsychiatric Interview 6.0.0. Sheehan's Disability Scale was used to assess the disability.

Results:

A total of 34,802 adults were interviewed. The overall weighted prevalence of BPAD was 0.3% [95% confidence interval (CI): 0.29–0.31] for current and 0.5% (95% CI: 0.49–0.51) for lifetime diagnosis. Male gender [odds ratio (OR) 1.56] and residence in urban metropolitans (OR 2.43) had a significantly higher risk of a lifetime diagnosis of BPAD. Substantial cross-sectional co-morbidities were noted as per MINI 6.0.0 with the diagnosis of current BPAD such as tobacco use disorder (33.3%), other substance use disorders (14.6%), and anxiety disorders (10.4%). Two-thirds of persons with current BPAD reported disability of varying severity at work (63%), social (59.3%), and family life (63%). The treatment gap for current BPAD was 70.4%.

Conclusion:

Most individuals with current BPAD reported moderate–severe disability. There were substantial co-morbidities and a large treatment gap. These warrant concentrated efforts from policymakers in devising effective strategies.

INTRODUCTION

Bipolar affective disorder (BPAD) is a chronic and severe mental disorder.[1] The unique characteristic of BPAD, lying on a spectrum of extremes of mood with varying degrees of severity, makes it a challenging disorder to diagnose and treat. One of the largest series of international studies that provide the prevalence rates of BPAD has been the World Mental Health (WMH) Survey by the World Health Organization (WHO), which estimated the prevalence of BPAD as 0.8% globally (0.4% in low-income, 0.6% in medium-income, and 1.1% in high-income countries).[2] The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) has reported a substantially greater lifetime prevalence of Bipolar I disorder of 3.3% and Bipolar II of 1.1%.[3] The Global Burden of Disease Study (GBDS) estimated the prevalence of BPAD to be 0.7% overall, 0.6% among males, and 0.8% among females worldwide.[4] The prevalence of BPAD as per GBDS in India is 0.6% (for both males and females).[5] Globally, the male-to-female prevalence ratio was 0.8 (0.5–1.1).[4]

Although the prevalence of BPAD is relatively low compared to common mental disorders, it is one of the leading causes of premature mortality owing to high suicidality and other co-morbid psychiatric and medical conditions.[6,7] Psychiatric with BPAD co-morbidities are considered a rule rather than an exception, and these are anxiety disorders, personality disorders, substance use disorders, obsessive-compulsive disorders, attention deficit hyperactivity disorders, oppositional defiance, conduct disorders, and post-traumatic stress disorders.[8]

BPAD is also one of the top 20 leading causes of disability worldwide. There is a high disability weight attached to a manic episode [years of healthy life lost due to disability (YLD): 138.3/100,000], which is comparable to severe medical illnesses like asthma and Alzheimer's disease. Unfortunately, despite the availability of effective treatment, BPAD continues to be an illness that is underdiagnosed, misdiagnosed, or diagnosed after a substantial delay.[9] The duration between the onset of symptoms and treatment is as high as 6–10 years.[10,11] The National Institute for Health and Care Excellence (NICE) 2015 report suggests that one in every four individuals with BPAD do not receive required treatment.[12]

Many well-conducted epidemiological studies have helped to identify the burden of the disease, facilitate the identification of treatment needs, and help in the planning of services, mental health policy, and equitable distribution of resources. India had no large-scale studies on BPAD, and the previous epidemiological studies differ substantially in their methodologies; hence, it is not easy to draw reliable national-level estimates of BPAD in India. India's National Mental Health Survey was undertaken to fulfil this objective.

We will discuss the estimates of the prevalence, correlates, co-morbidities, associated disabilities, socio-economic impact, and treatment gap for BPAD in the analysis of the representative Indian population in this paper.

MATERIALS AND METHODS

A detailed description of the methodology is available online (http://indianmhs.nimhans.ac.in/nmhs-reports.php) and elsewhere.[13] Briefly, NMHS 2016 was a large population-based study conducted across 12 states of India (2014–2016). A multi-stage, stratified, random cluster sampling technique based on probability proportionate to size at each stage was used. According to census of India, 2011, each inhabited village constituted the rural cluster, and each ward in the urban area included the metropolitan/non-metropolitan urban cluster.

All adults 18 years and older were included. All eligible adult respondents within the identified household were interviewed. A non-responder was defined as a person who could not be interviewed after three visits. Ethical clearance was obtained from the Institute Ethics Committee (IEC) of the National Institute of Mental Health and Neurosciences, Bengaluru, India, and corresponding IECs of partner institutions in each state. Informed consent was obtained from the respondents before conducting the interview.

The diagnoses were established using the Mini-International Neuropsychiatric Interview (MINI) version 6.0.0, a structured diagnostic tool designed for identifying mental disorders as per the International Classification of Diseases (ICD-10) criteria, available in various Indian languages. To assess disability, the Sheehan Disability Scale (SDS) was employed, which evaluates impairment in three key areas: work, social interactions, and family life. A specialized questionnaire was created specifically for the NMHS survey with the aim of examining treatment-seeking behaviors and healthcare utilization patterns, thereby evaluating both the treatment gap and the socio-economic consequences.

The weighted prevalence estimates were derived considering the unequal probability of selection and non-response rates. All estimates are presented with 95% confidence intervals (CIs). Firth penalized logistic regression was done considering BPAD diagnosis as the dependent variable and socio-demographic characteristics (i.e., gender, age, education, occupation, marital status, and place of residence) as independent variables. The rationale for using Firth penalized logistic regression has been explained elsewhere.[14] The odds ratio (OR) was calculated. In addition, an analysis of the co-occurrence of other diagnostic categories of MINI was undertaken in the sample with BPAD. SPSS V.27·0 was used for statistical analyses.

RESULTS

In the NMHS of India 2016, 10,610 households were contacted spread across 12 states of India, and among them, a total of 9666 households were surveyed. A total of 39,532 adults were contacted, and 34,802 adults were interviewed (an individual response rate of 88.0%). The socio-demographic profile revealed that females (52.3%), age category 18–29 years (34.0%), rural areas (68.8%), married status (74.7%), illiterate (24.3%), and occupation being “household duties” (30%) constituted a majority in the respective categories of the total sample.

Prevalence: BPAD had an overall weighted prevalence of 0.3% (95% CI: 0.29–0.31) for current (cross-sectional) time period and 0.5% (95% CI: 0.49–0.51) across the lifetime. A total of 96 adults (male = 52, female = 44) and 168 adults (male = 99, female = 69) had a current and lifetime experience of BPAD, respectively. Among various age groups and residence categories, those in the 40–49 (39%) and urban metropolitan residents (73%) had a higher prevalence for a current BPAD, respectively.

Socio-demographic correlates: Firth penalized logistic regression analysis for factors associated with lifetime and current BPAD is depicted in Table 1. Place of residence (Urban metropolitan/urban non-metropolitan/rural) was found to be significantly associated with current BPAD. Residents of cities with a population greater than 1 million (urban metropolitans) had close to 7 times higher odds, and those living in non-metropolitan urban areas had close to 3 times higher odds of having current BPAD in comparison with rural residents. Male gender (OR 1.56) and residence in urban metropolitans (OR 2.43) had a significantly higher risk of a lifetime diagnosis of BPAD, while the middle (OR 0.62) and highest income (OR 0.61) quintiles were associated with lower odds of a lifetime diagnosis of BPAD in comparison to the lowest quintile.

Table 1.

Firth penalized logistic regression analysis for factors associated with lifetime and current bipolar affective disorder among adults in India: NMHS 2016

Variables	BPAD-lifetime (n=168)			BPAD-current (n=96)
	OR	95% C.I	P	OR	95% C.I	P
1. Gender
Female (ref)	1			1
Male	1.56	1.07-2.30	0.02	1.42	0.56-3.61	0.46
2. Age
18-29 (ref)	1			1
30-39	1.22	0.74-2.02	0.43	0.99	0.29-3.25	0.99
40-49	1.50	0.91-2.51	0.12	1.35	0.41-4.46	0.62
50-59	1.28	0.72-2.25	0.40	0.86	0.19-3.42	0.83
60 and above	1.05	0.59-1.88	0.86	0.48	0.09-2.05	0.33
3. Marital Status
Never married (ref)	1			1
Married	0.99	0.60-1.70	0.98	0.61	0.20-1.93	0.39
Divorced/separated	1.22	0.51-2.75	0.65	0.97	0.13-5.66	0.97
4. Residence
Rural (ref)	1			1
Non-metro urban	0.87	0.54-1.34	0.54	2.97	1.10-7.62	0.03
Metro urban	2.43	1.64-3.53	<0.001	6.83	2.75-16.94	<0.001
5. Education
Not literate (ref)	1			1
Primary	1.15	0.72-1.83	0.54	1.08	0.37-3.17	0.89
Secondary	0.98	0.59-1.61	0.93	0.51	0.12-1.83	0.31
High school	0.81	0.48-1.35	0.43	0.76	0.23-2.42	0.64
Pre-university	0.90	0.47-1.63	0.72	0.22	0.02-1.18	0.08
Graduate	0.68	0.34-1.29	0.24	0.44	0.09-1.81	0.26
6. Employment status
Working (ref)	1			1
Not working	0.92	0.63-1.34	0.67	2.18	0.86-5.85	0.10
7. Household income in quintiles
Lowest (ref)	1			1
Second	0.70	0.44-1.11	0.13	0.71	0.22-2.13	0.54
Middle	0.62	0.38-0.99	0.04	0.55	0.15-1.73	0.30
Fourth	0.72	0.45-1.13	0.15	0.61	0.19-1.86	0.38
Highest	0.61	0.37-0.99	0.04	0.70	0.22-2.14	0.53

Current co-morbidities and suicidality: Of the total individuals with current BPAD, 10.4% had a current prevalence of co-morbid diagnosis of anxiety disorder, 14.6% had substance use disorder (dependence or harmful use pattern) excluding tobacco use, and 33.3% had tobacco use disorder. Concerningly, as high as 37.5% who had a diagnosis of current BPAD also had a current prevalence of suicidality. Table 2 depicts the current co-morbidities and suicidality in adults with lifetime and current BPAD.

Table 2.

Current co-morbidities and suicidality in adults with lifetime and current BPAD

Current co-morbidity	Lifetime-BPAD (n=168)	Current-BPAD (n=96)
1. Anxiety Disorder (Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, and Agoraphobia)	21 (12.5)	10 (10.4)
2. Obsessive Compulsive Disorder	7 (4.2)	5 (5.2)
3. Substance Use Disorders
Any Substance Use Disorder (without Tobacco)	24 (14.3)	14 (14.6)
Alcohol Use Disorder	19 (11.3)	11 (11.5)
Tobacco Use Disorder	62 (36.9)	32 (33.3)
4. Current prevalence of suicidality
Suicidality-high	22 (13.1)	16 (16.7)
Suicidality-moderate	7 (4.2)	6 (6.3)
Suicidality-low	28 (16.7)	14 (14.6)
Overall suicidality	57 (34)	36 (37.5)

These diagnoses were established as per MINI 6.0.0

Disability and socio-economic impact: Disability and socio-economic impact were assessed among subjects with an exclusive diagnosis of current BPAD. Around two-thirds of the persons with current BPAD reported disability of varying severity at work (63%) in social (59.3%) and in family life (63%), which is depicted in Table 3. Most individuals with current BPAD had a moderate-severe form of disability in various domains of life. Among the individuals with current BPAD, 40.7% reported some difficulty in the activities of daily life. Such difficulties in activities of daily living were present for a median of 24 days in the previous month of the survey period. The illness was also noted to impact the family members. When the impact on work was assessed, a median of 10 days was found to be the average number of days that the family members of patients with BPAD were unable to work in the last 3 months. On average, INR 2000 per month was reportedly spent by the family members to care for a person with current BPAD [Table 4].

Table 3.

Disability in various domains among adults with current bipolar affective disorder (n=27)

Domains of disability	No disability n (%)	Any disability n (%)#	Severity of the disability n (%)
			Mild	Moderate	Severe	Extreme
At work/school	10 (37)	17 (63)	3 (11.1)	7 (25.9)	5 (18.5)	2 (7.4)
In social life	11 (40.7)	16 (59.3)	4 (14.8)	4 (14.8)	6 (22.2)	2 (7.4)
In Family life	10 (37)	17 (63)	2 (7.4)	6 (22.2)	6 (22.2)	3 (11.1)

Analysis was restricted to only those with current BD without associated comorbidities

Table 4.

Respondents with BPAD experiencing difficulty with activities of daily life (%) and the socioeconomic impact on them and their family

Difficulties with activities of daily life (%)
(i) Could do as usual	59.3
(ii) Could do but not everything	11.1
(iii) Could do only something	14.8
(iv) Extreme or could do nothing	14.8
Socioeconomic impact (n)
1. Median number of days with difficulty to carry out usual activities in the past 30 days	24
2. Median number of days family members were not able to go to work in the past 3 months for care of patients	10
3. Median number of days family, leisure, or social activities were missed	20
4. Median monthly expenditure (Indian rupees)	2000

Analysis was restricted to only those with current BD without associated co-morbidities

Treatment gap: The treatment gap for current BPAD (defined as the proportion of individuals diagnosed with current BPAD and not on any treatment with a formal/trained healthcare provider) in the study population was 70.4% and varied by gender (more in females, 80%, in comparison with males, 58.3%) and place of residence (more in urban metro, 80%, in contrast with rural, 60%). Though the reported median duration of illness was 43 months, the period of being on treatment was 36 months, and the average interval between the onset of the disorder and consultation was 11.5 months. Though the reported median duration of illness was 43 months; for individuals undergoing treatment, the average duration of their treatment received spanned 36 months; and the average interval between the onset of the disorder and consultation was 11.5 months [Table 5].

Table 5.

Treatment gap and care characteristics of adults with current bipolar affective disorder (n=27)

	Overall	Male	Female
Treatment gap (%)	70.4	58.3	80
Median duration of illness (in months)	43	41	44
Median interval between onset of illness and consultation (in months)	11.5	12	11
Median duration of being on treatment	36	36	36

Analysis was restricted to only those with current BD without associated co-morbidities

DISCUSSION

NMHS is one of the most extensive population-based surveys that have been conducted in India with a robust methodology in terms of sampling technique, use of standardized instruments, trained field data collectors, and rigorous supervision. This survey provides estimates of the burden of BPAD in a nationally representative sample.

The present study reports a weighted prevalence of 0.3% for current and 0.5% for lifetime BPAD, which is lower than the global prevalence reported by the WMH survey (0.8%) and the GBDS (0.7%).[2] WMH surveys reported a lower prevalence in low-income countries (0.4%) in comparison with the high-income countries (1.1%), and the findings of this study reiterate the same.[15] The prevalence of BPAD in India as per the GBDS is 0.6% and hence slightly greater than the prevalence reported by our study.[5] The lower prevalence of BPAD in our study could be due to the use of stricter criteria for the diagnosis of BPAD, the difference in the study methodology and instruments, and a limited account of the BPAD spectrum of illnesses compared to the other studies. Earlier large studies[16] have reported a higher prevalence of BPAD in females; however, in this study, males had 1.5 times higher odds of having a lifetime diagnosis of BPAD.[4]

Earlier studies have indicated that urban environments are associated with a higher prevalence of BPAD; however, it is still unclear if it is a causal factor for the same.[17] Our study also highlights a significant association between urbanicity and the prevalence of both current and lifetime diagnoses of BPAD. Social determinants of health play a crucial role in the causal pathway of mood disorders.[18] However, recent epidemiological studies have found either no association or a weak association of BPAD with persons from a lower socio-economic background.[19] In our study, while the middle- and highest-income groups have significant associations with the diagnoses of current BPAD, the high- or low-income group does not.

Notably, this study's results indicate that the diagnosis of BPAD is associated with several co-morbidities, most commonly anxiety and substance use disorders. An earlier study from Southeast Asia reported lifetime co-morbidity of BPAD with a psychiatric and physical illness to be 45% and 51%, respectively.[20] The study also reported that OCD was the most common psychiatric co-morbidity, and chronic pain was the most common physical condition co-morbid with BPAD. Other medical conditions such as hypertension, asthma, migraine, and hypothyroidism are highly co-morbid with BPAD.[21] However, medical co-morbidities were not assessed in our study. An earlier study of 396 consecutive in-patients with BPAD from India has reported a prevalence of 7.6% for co-morbid OCD.[22] A recent review reported that close to half of the patients with BPAD are likely to develop an anxiety disorder in their lifetime, and nearly a third of them will manifest it at any point in time.[23] Our study reports that close to one-tenth of the patients with current BPAD had a co-morbid anxiety disorder, which is lower than previous estimates.

One of the most concerning aspects of BPAD is its association with suicidality. A systematic review and meta-analysis of studies found that the standardized mortality ratio for suicide in individuals with BPAD is approximately 20, indicating a 20-fold increased risk of suicide compared to the general population.[24] Similarly, studies have consistently demonstrated that individuals with BPAD are at a significantly higher risk of suicidal ideations and suicide attempts, compared to the general population.[25] In our study, the current prevalence of suicidality was as high as 37.5% in individuals with a current diagnosis of BPAD and 34% in those with a lifetime diagnosis of BPAD. In other studies, the lifetime prevalence of suicidal ideation and attempts in individuals with BPAD has been reported to range from approximately 25% to 50%.[26,27]

A recent systematic review and meta-analysis reported that the co-morbid substance use with BPAD rates was lower in Asia (alcohol use disorder nearly 18% and substance use disorder almost 22%) compared to the studies in the United States (alcohol use disorder nearly 42% and substance use disorder almost 57%) and other non-Asian countries.[28] We also found that the co-morbid substance use disorders except tobacco use disorders is considerably low (almost 15%) compared to the United States and other non-Asian countries. A recent review reported that around one-third to half of the patients with BPAD attempt self-harm at least once in their lifetime, and we found similar results for patients with both current and lifetime diagnoses of BPAD.[29]

In the GBD study 2013, BPAD was the 16^th leading case of global YLDs. Among the mental and substance use disorders, it was the fifth leading cause of disability-adjusted life years (DALYs) (after major depressive disorder, anxiety disorder, schizophrenia, and alcohol use disorder, respectively).[4] Despite having a lower prevalence compared to other mental illnesses, it accounted for 5.7% of the burden.[5] This can be explained due to the high disability weight carried by BPAD, which is as high as that of other conditions like asthma and Alzheimer's disease. In our study, around two-thirds of the persons with current BPAD reported disability of varying severity at work (63%), in social life (59.3%), and in family life (63%). In most of the cases, there was a moderate-severe form of disability. Also, as per the NMHS, among those reporting disability, extreme disability was the highest among persons with schizophrenia and other psychotic disorders (20.5–28.2%), followed by those with BPAD (11.8–17.6%), indicating that disability correlates with severity of mental disorders.[13] Various studies have reported that even BPAD patients in remission have significant disability and poor quality of life.[30] However, as Sheehan's scale was used in our research, which accounts for current disability, we have calculated disability only in patients diagnosed with current BPAD who did not have any other co-morbidity to highlight the disability exclusively due to BPAD.

Various studies across the globe and India have shown that BPAD is associated with a significant caregiver burden.[31] Factors such as longer duration of illness, a higher number of episodes, and poor compliance to treatment are all associated with greater caregiver burden. Our study also emphasizes the socio-economic impact of the illness on caregivers/family members. Therefore, it is not only the patients with BPAD who experience the impact of the illness; the burden extends to include their caregivers as well. Our study estimates a cost of 2000 Indian Rupee (INR) per month (translates to 24,000 INR per year), which is similar to the cost estimated by a previous Indian study that accounted for both direct and indirect costs of BPAD.[32] However, it is essential to note that the average national income of the bottom 50% of the Indian population is 53,610 INR as of 2021.[33] This study also elucidated that the number of visits to the hospital significantly correlated with the total cost, indirect cost, and provider's cost.[32] Therefore, providing community based treatment at the doorsteps can potentially reduce the costs of illness and the treatment gap. Studies from India and other developing countries have found that providing community based doorstep services to patients with BPAD was highly successful and had multiple benefits such as task-sharing, reducing the cost of illness borne by the patient, and improved social and clinical outcomes.[34,35]

Another glaring concern is the large treatment gap and the delay in initiating timely treatment. Earlier studies across the globe have reported a similar treatment gap for bipolar disorder, except for a few highly developed regions.[36,37] One possible way to overcome this hurdle in a developing country is by strengthening the National and District Mental Health programs.

Gender may also possibly influence treatment-seeking behavior in BPAD. In our study, the treatment gap was as high as 80% in men, while it was 58% in women. In some societies, traditional expectations of male emotional stoicism and help-seeking as a sign of weakness often lead men to delay seeking help, sometimes until their symptoms worsen.[38] Conversely, women with BPAD tend to be more proactive in seeking treatment, including participation in psychotherapy and adherence to medication regimens.[39] Men with BPAD may also exhibit a higher propensity for co-morbid substance use disorders, which can complicate their help-seeking behavior. Additionally, both men and women with BPAD often grapple with self-stigma tied to their mental health condition. Recognizing and addressing these gender-related disparities is essential for early diagnosis and effective treatment, emphasizing the importance of de-stigmatization and personalized interventions tailored to individual preferences and needs.

The survey comes with a few limitations. First, it does not account for the entire spectrum of bipolar illnesses. Future epidemiological studies from India may consider the entire spectrum and types of bipolar illnesses, including bipolar I, bipolar II, and cyclothymia. Also, several clinically important pieces of information about bipolar illness are not available, such as the number of episodes, index episodes, number of hospitalizations, and medical co-morbidities. Future studies could consider investigating the same as it would provide important insights into the severity and burden of the illness. It would additionally be meaningful to account for the degree of inter-episodic recovery as several studies highlight that recovery may not be complete in bipolar illnesses and significant disability may persist even during this period. Therefore, there is also a need to assess the disability associated with bipolar illnesses even while the patients are in “remission” clinically. Unfortunately, the structured survey tool MINI does not capture the entire range of psychiatric co-morbidities. Furthermore, this survey does not account for the individuals living in cities with a greater than 10 million population. Future studies may consider examining the cohorts from these “metropolises” as well. Last, future studies may consider the assessment of the prevalence and correlates of BPAD in individuals dwelling in urban slums (and those urban areas which are concentrated by individuals belonging to a lower socio-economic status) to understand further the higher prevalence of BPAD in these populations.

Looking ahead, there is an increased need to extend the reach of effective treatments to remote areas and to strategically utilize technology for the delivery of mental healthcare services. This imperative must be coupled with the reinforcement of primary mental health care and the seamless integration of technology to address the substantial treatment gap that currently exists for mental disorders. The Ayushman Bharath Health and Wellness Centres would improve care at the grassroots level. These centers have great potential to bridge the gap, provided that they function seamlessly. This would require a regular supply of medications, the availability of human resources, and other essentials to run the services. Tele-mental health is the need of the hour to facilitate service provision, capacity building, and research in a resource-constrained setting like India. It has been provided with the much-required impetus from the Centre through a dedicated budget allocated to a National Tele-Mental Health Programme for the first time in the history of India.[40]

CONCLUSIONS

To conclude, the overall weighted prevalence of BPAD was 0.3% (95% CI: 0.29–0.31) for current and 0.5% (95% CI: 0.49–0.51) for lifetime BPAD. Male gender (OR 1.56) and residence in urban metropolitans (OR 2.43) had a significantly higher risk. Substantial co-morbidities were noted, and lifetime suicidality was found in 37.5%.

Most individuals with current BPAD had a moderate-severe form of disability in various domains of life. The treatment gap of BPAD is large and would require concentrated efforts to narrow it. Although the prevalence of BPAD is relatively lower compared to other psychiatric disorders, the disability weight of the illness is concerning. Strengthening community services, penetrating to the grass-root level through various programs like the DMHP and the Ayushman Bharath Health and Wellness Centres, task sharing, using technology to provide services, and capacity building are some of the ways forward to overcoming the large treatment gap and reducing the burden and cost of the illness.

Financial support and sponsorship

The National Mental Health Survey (NMHS) was funded by the Ministry of Health and Family Welfare, Government of India and was implemented and co-ordinated by National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, INDIA in collaboration with state partners. NMHS phase 1 (2015-16) was undertaken in 12 states of India across the 6 regions and interviewed 39,532 individuals (http://indianmhs.nimhans.ac.in). Funder had no role in implementation, data acquisition, data analysis and interpretation and write up of the paper.

Conflicts of interest

There are no conflicts of interest.