Rethinking and reclaiming psychiatry

The term psychiatry was coined by German physician Johann Christian Reil in 1808, derived from the ancient Greek words ’psyche’ (mind or soul) and ‘iatreia’ (healing). The word psychiatry literally means ‘medical treatment of the soul’. Prior to the 17^th century, there was no concept of diseased mind. Mental illness was in the realm of supernatural afflictions, animalism, and religion. In the 17–18^th century, the brain was thought to be the seat of mind. That is how psychiatry came in the fold of medicine. But descriptions of the mental phenomenon and psychopathology were derived from concepts of philosophy. Philosophy provided the vocabulary to psychopathology and psychiatry remained at crossroads between medicine and philosophy. During most of the 19–20^th century, there have been parallel developments in brain-based sciences like genetics or neurobiological theories and mind-based theories like psychoanalytic theory, learning theories, or psychosocial theories of mental illness. Methods of treatments based on brain-based theories and mind-based theories have been developed in parallel. Despite some tensions and schism, these two parallel streams have flourished separately and continue to remain complimentary to one another till date. In the 21^st century, with advancements in psychoneuroimmunology and cellular and molecular biology, psychiatry has moved much closer to somatic medicine.

Mental health and mental disorders generally have been poorly understood and often mishandled in society. There is lack of clarity on the boundary between mental illness and mental health, who can treat mental illness, what treatment methods are required, and for how long. A large variety of professionals such as psychologists, counselors, social workers, life coaches, skills trainers, even religious leaders, and physicians are delving into management of “mental health” and/or “mental disorders”, without knowing the distinction between them or the limits of their expertise. The problem is further compounded by the use of overlapping or similar sounding terms like mental (ill) health, mental illness, or mental wellness. It is important to understand what is mental wellness, where wellness ends and illness begins, and what is meant by mental health or ill health.

MENTAL ILLNESS VERSUS MENTAL HEALTH?

Although no definition of mental disorders can do full justice to the entire spectrum of conditions covered under the rubric of mental disorders, the following definition is officially approved by the international community and is used in clinical practice and research worldwide.

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable and culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above” (DSM5,[1] ICD 11[2]).

Mental illness as described above is ubiquitous and universal and occurs across all ages, genders, geographical locations, social classes, and religions in the world. According to WHO (2019), one in eight persons in the world suffers from mental illness at a given time. So, with 8 billion population of the world, there are 1 billion persons with mental illness. In India, 10.6% of the population has mental illness requiring treatment immediately and about 13.7% will need it in life time (National Mental Health Survey 2015–16).[3] Mental disorders arise from dysfunctions of the brain caused by complex interaction of a multitude of factors.

Mental health, on the other hand, reflects our emotional, psychological, and social wellbeing; how we think, feel, and act; and the way we interact with others, handle problems, and make decisions. There are no known limits to mental health, and it is a highly subjective state. Moreover, mental health is unique to each individual. What looks like good mental health for one person will not be the same for someone else. For example, parameters for good mental health will differ for a farmer from those for a teacher or a house wife or a top ranking business executive or a scientist. Although mental health and mental illness are two different constructs, like physical health and physical illness, these are not mutually exclusive [Figure 1]. Individuals diagnosed with mental illness can have periods or elements of physical, mental, and social wellbeing and vice-versa.

Figure 1.

Spectrum of Mental Wellness and Illness

One can have good mental health while living with a mental disorder, and many people live well with mental illnesses that are in remission or stabilized with medication, therapy, and so on or may harbor elements of minor aberration or deviance. It is important to realize that mental illness does not always lead to poor mental health and that poor mental health is not always due to mental illness. Blurring of boundaries between health and disease can cause people to misjudge, dismiss, or misperceive the condition. On the other hand, mental illnesses are medical disorders, arising out of genetic, biological, physical, and psychosocial factors, and are treatable. Psychiatry does not focus on the science of wellness.

Promotion of mental health/wellness is a big business industry these days. There are several professionals or even quasiprofessionals involved in managing mental health, so much so that the public is often at loss or confused as to whom to approach and what to choose from. Mental wellness taps into life style, spirituality, exercise, meditation, yoga, diet, and so on. All these are important for preventive as well as supportive interventions for mental disorders. However, none of these will treat mental disorder per se. There is urgent need to shed light on this confusion so that the public can make informed decisions and approach the right professional for the right purpose in the right time.

MENTAL HEALTH CARE WORKFORCE

Psychiatrists are primarily medical doctors with expertise in the field of psychiatry, which is a branch of medicine focused on diagnosis, treatment, and prevention of mental disorders. Their expertise lies in understanding the complex interplay between biological, psychological, and social factors that contribute to mental illness. Psychiatrists can assess and treat accordingly both the physical and psychological aspects of mental ill health that often coexist and influence one another reciprocally.

However, ‘psychologists’ are arts graduates with master’s degree in psychology. A few of them may have advanced training in clinical psychology and get registered with the Rehabilitation Council of India. They can do psychological testing to assist in diagnosis; can do psychotherapies as a component of treatment addressing certain specific mental symptoms such as obsessions, phobias, dissociation, cognitive symptoms, or problems such as marital issues, family issues, educational issues, vocational issues, or behavioral issues; and do research. They cannot prescribe medicines.

A ‘therapist’ or a ‘counsellor’ is also an arts graduate and may have a master’s degree or diploma in some mental health-related fields like guidance and counseling, family therapy, and transactional analysis. They can do counseling for a narrow and limited purpose.

Psychiatrists collaborate with mental health allied professionals or other ancillary service providers (such as psychologists, social workers, counselors, occupational therapists) and physicians to ensure comprehensive care. But these ancillary service providers cannot replace a psychiatrist. There is acute scarcity of psychiatrists in India (0.3/1 lac, as against recommended 3/lac) as well as that of mental health para/allied professionals and a very high mental health gap (70–90%).[4] There are about 9000 psychiatrists working in India (IPS Website 2023), and about 3800 (42%) are in the public sector (Government of India data 2015), and the remaining are in the private sector.

Scarcity of psychiatrists in the country, which constitutes the major impediment in planning and delivering mental health care, has led to thinking of alternative models such as shifting this task to other available manpower resources like GPs, general health care workers, or mental health allied or para professionals.

NATURE OF MENTAL DISORDERS

Psychiatry is a very large subject that can encompass all aspects of human experience and existence. Mental disorders can also possibly occur in a large variety of variations and manifestations.

The latest ICD 11,[2] under the category of “Mental, Behavioural and Neurodevelopmental disorders”, includes an exhaustive list of psychiatric disorders. These are categorized into 21 broad domains, 161 four character categories, and 17,000 individual diagnoses. This reflects the expansion of knowledge in the field of psychiatry in recent years. There has been tremendous advancement of knowledge in the domains of neurobiology, genetics, developmental neuroscience, and therapeutics.

Psychiatry is an independent branch of medicine, separate from neurology or pediatrics. Psychiatrists are the only experts who are trained in the art and science of mental or brain disorders, who can provide comprehensive assessment, diagnosis, and treatment of mental disorders. They have the expertise and training in identifying the nuances to make the diagnostic distinctions and to understand its implications in management.

Ideally, a psychiatrist should be the first point of contact for any mental, emotional, cognitive, or behavioral disturbance for a comprehensive assessment and treatment. But most patients do not directly go to a psychiatrist. They go to general physicians or other specialists like neurologists, pediatricians, or many other specialists, many of whom, instead of referring patients to psychiatrists, start treating core psychiatric disorders themselves. Using a simplistic approach of prescribing benzodiazepines or antidepressants across the board as a remedy for most mental disorders, as is commonly seen, is detrimental to a patient’s health and rights.

Dangers of other professionals treating mental disorders on their own are very many:

1. They are not qualified in the science of higher brain functions and its myriad vicissitudes.

2. There is irrational use of psychotropics, with wrong doses and wrong medications, leading to nonresponse, refractoriness, complications, and delay in treatment.

3. Excessive use and overuse of benzodiazepines have caused an iatrogenic epidemic of benzodiazepine dependence to the detriment of patients.

4. Pediatricians are treating neurodevelopmental disorders such as autism, SLD, ADHD, and psychosis and also emotional disorders like depression, anxiety, or mental health issues in adolescence without any training or knowledge of the science of higher brain/mental/emotional/cognitive functions.

5. It is unethical and also illegal as per law (MHCA 17) to practice in the specialty in which one is not trained.

PARADIGM SHIFT

Historically, there have been major changes in the practice of modern psychiatry through the centuries. It started with asylum psychiatry in the 13^th century, followed by proliferation of mental hospitals through the 18^th century, humane reforms, and deinstitutionalization in the 18–19^th century; care in the general hospital psychiatry units and community psychiatry movement in the 20^th century; and now personalized care in the 21^st century. The 20^th century also led to what can be called ‘a mental health movement’ when mental wellbeing got included in the definition of health (WHO Constitution 1948) and mental health was declared a universal right (World Federation of Mental Health 2023). WHO Mental Health Action Plan (2013–20) was adopted at WHO World Health Assembly in 2013 and has been extended to 2030.[5] It recognizes the role of Mental Health in Health-for-All (Alma Ata Declaration 1978)[6], shifted the focus from mental illness to mental health, sought Universal Health Coverage, shifted focus from treatment to Prevention and Promotion, and proposed integration of mental health into main stream medicine. These became the mandates for countries to follow.

In accordance with the international treaties, the Government of India initiated several programs supporting the delivery of mental health care services to all across the country.

Considering the huge mental health gap and scarcity of psychiatrists, several strategies have been followed in India.

• a. Task Shifting to General Physicians (GPs) and General Health Care Workers (HCWs):

Scarcity of mental health professionals and services in India led the Government of India to launch a national level program called National Mental Health Program (NMHP) in 1982[7] for making available and accessible, minimum mental health care for all, especially for the underprivileged and most vulnerable. NMHP aimed at training of primary care health workers in remote areas to identify and diagnose a few serious and common mental disorders such as depression, psychosis, and mania with simple tools; also, they were trained to prescribe a few specific medications to treat. This model was developed and tested in the rural area of Raipur Rani in North India[8] as part of the WHO international collaborative project “Strategies for Extending Mental Health Care through General Health” (WHO 1975) done at PGIMER Chandigarh (1975–81).[9] This was a laudable model for minimal intervention for patients in remote inaccessible areas where there is no psychiatrist within reach. However, this program did not meet the needs. GPs and General Health Care workers could not deliver psychiatric services. NMHP was later restrategized into District Mental Health Program (DMHP)[10] since 1996, where provision was made for outpatient and 10 bed inpatient facilities at the district hospital level and outreach services in the form of life skills education and counseling in schools, college counseling services, work place stress management, and suicide prevention. Additionally, the DMHP includes community services, day care services, long-term care, and rehabilitation services under the public–private partnership (PPP) model. Mental health services are to be provided by government mental hospitals, medical colleges, and psychiatric departments. In fact, DMHP and NMHP have not been fully successful as anticipated due to several limitations (Gupta and Sagar 2018).[11] The model of training general physicians in diagnosis and treatment of a few identified mental disorders after 3 months of training by psychiatrists has been spearheaded by the team of psychiatrists from NIMHANS Bangalore at a place called Bellary in Karnataka state, known as “Bellary Model” (1985–1990). This model has been adopted by the Government of India and followed in more than 90% (655 out of 724) districts in India (Gangadhar et al. 2023).[12] But again, DMHP has not been successful as mental health care has remained largely psychiatrist centric and could not be transferred to or integrated with general health care (WHO 2001, 2005)[4,13] as planned. The lack of success of the DMHP and NMHP is primarily due to GP’s lack of time from their primary duty, which is the care of physical illnesses, lack of motivation, lack of confidence in using psychotropic drugs, lack of legal protection, lack of incentives, and lack of continued support.

This lack of success raises several basic questions: Can the post hoc short-term training of GPs be sufficient for taking on the burden of treating mental disorders effectively? Do GPs have time or the inclination or motivation? Is it legally defensible? The answer is ‘no’. Moreover, it violates the principles of equity and justice.

The Mental Health Care Act 2017[14] allows a general physician to treat mental disorders in an emergency situation only for 72 hours. Thereafter, the care of the patient with mental disorder must shift to a psychiatrist and there is no provision for treatment by a nonmental health professional during follow-up. MHCA 17 also mandates diagnosis of mental illness as per ICD system, which will be extremely hard for nonpsychiatrists to learn and follow. Furthermore, the MHCA 17 includes treatment of alcohol and substance use disorders, which is most complex and cannot be passed onto general physicians. It eventually boils down to making the psychiatrists available to treat every patient with mental illness. It has been stated that it is time for DMHP strategy to look beyond the “Bellary Model” (Singh OP 2018).[15] As per the National Mental Health Policy (2014)[16] and ethical principles of justice and equity, the government is duty-bound to provide the best care and service to all patients irrespective of socioeconomic status, geographical location, and gender.

• b. Task shifting to allied or para mental health professionals:

Interventions for mental illness involve a whole range of services from emergency care to acute care, short-term care, long-term care, rehabilitation, remedial care, and so on, required for different sets and severities of symptoms, carried out in different settings such as general hospitals, psychiatric hospitals, half-way homes, supervised living, and shelter homes, requiring professionals with different kinds of expertise and skills. Psychiatrists have overall responsibility to assess, treat, and monitor the patients in all these settings and also invoke the requisite care by respective allied professionals. Medication is required in almost all patients at some stage of mental illness, which is done by the psychiatrist. For rehabilitation, social workers and occupational therapists will have the main role as they work for social inclusion of persons with mental illness and disabilities; for family therapy and counseling, psychologists will have the main role. The mental health allied and para professionals have a huge role in promotion of mental health and wellness and in rehabilitation and remediation and an ancillary role in the treatment of mental disorders. Comprehensive care requires creation of systems at different levels and all mental health allied professionals working as teams. There is need for an increase in mental health manpower at all levels, be it psychiatrists, psychologists, social workers, nurses, and other allied professionals, to provide support and ancillary services for comprehensive mental health care.

Converting the various diagnostic and management principles into simple guidelines or tools for effective use by nonspecialists or mental health paraprofessionals is required before this task can be passed onto them. Although we have followed the principle of task shifting, we have not created the necessary tools, which has been the major reason for failure of these approaches. The quick fix or simplistic approaches adopted so far has not benefitted the patients, rather on the contrary has been misunderstood into thinking that psychiatry is as simple or as limited as this. Moreover, patients seek as well as deserve quality care by a specialist and not a compromised care.

• c. Shifting focus from treatment to counseling and referral:

Ministry of Health and Family Welfare, Government of India, has started its flagship program “Tele Mental Health Assistance and Networking Across States” (Tele-MANAS)[17] during October 2022. This is a 24 × 7 toll-free helpline that aims to provide free tele-mental health services all over the country through 1600 trained counselors, particularly for people in remote or underserved areas. Tele-MANAS has a network of 38 telemental health centers of excellence in 27 states and UTs. Mental health services are provided in 20 languages. NIMHANS Bengaluru is the nodal center.

The calls are attended by a trained counselor at the first level. Depending upon the nature of the problem and the level of care required, the counselor can handle the problem if it lies within their capabilities or will refer the caller for specialist consultation. In case the caller requires specialized care, the call will be handled by a mental health specialist (a clinical psychologist, psychiatric social worker, psychiatric nurse, or psychiatrist). There are both audio- and video-based options. In case the caller requires urgent in-person intervention/complex evaluations and management, they will be referred to the nearest in-person service for physical consultation. An audio-visual consultation with a specialist will be arranged through eSanjeevani,[18] a national telemedicine service to facilitate easy and quick access to doctors and medical specialists and also health services through Ayushman Bharat Health and Wellness centers, run by the Ministry of Health and Family Welfare, Government of India.[19] These centers will range from Health and Wellness Centre (HWCs) to tertiary care centres as part of the DMHP. On the ground, “eSanjeevani has faced issues related to overworked healthcare personnel and glitches in technology, leading to uncertainty about whether eSanjeevani can keep up with the Tele MANAS referrals after integration” (Keshav Desi Raju 2023).[20]

Tele-Manas program relies on access to counseling services and mental health care through nonpsychiatrists in a stepwise approach and is measuring its success by counting the number of calls made. However, in reality, this approach is not and will not tackle the burning problem of treatment of core mental disorders such as schizophrenias, bipolar affective disorders, depression, anxiety disorders, psychosis, neurodevelopmental and neurodegenerative disorders, and so on, which cause maximum suffering and distress to patients and families.

First contact call to a counselor can only possibly provide triage service or deal with general distress states and refer the patient to the next level which is again a psychologist or a social worker or a psychiatric nurse. No mental health problems can be solved at this level either. Moreover, determining when to refer a patient to a psychiatrist is often difficult and requires a holistic assessment of symptoms and day-to-day experiences of the patients, which a counselor may not be skilled to do. By going through this stepwise system, the treatment will be delayed. Delay in reaching the psychiatrist is detrimental for the patient as the chances of recovery are linked to early treatment. This approach can only take care of minor and situational mental health issues like stress, but real patients are not going to be benefitted by this approach and are not tapping into Tele-Manas network. Tele-MANAS model is again supporting the misplaced notion that counseling services are a solution to treatment of mental disorders. This is akin to trivializing the seriousness of mental disorders and dilution of services. Moreover, it is difficult to assess the efficacy and effectiveness of Tele-Manas, and there are huge concerns about data privacy.

Furthermore, in this approach, a psychiatrist is equated and clubbed with a clinical psychologist, psychiatric social worker, and psychiatric nurse, indicating that these nonmedical allied professionals are at par with a psychiatrist in their ability to provide treatment for mental disorders. This is untrue and a wrong assumption. As mentioned earlier, mental health para/allied professionals can only provide supportive or specific psychotherapeutic interventions. To my mind, the entire premise of Tele-Manas is ill conceived. It has been mentioned that Tele-Manas cannot be the panacea to improve mental health care in the long run. It is imperative to establish and strengthen community-based mental health care services and District Mental Health Program (DMHP), which provides mental health care at the primary and community level, and is mandated in the Mental Health Care Act 2017.

Efforts to shift this task to GPs and general health care workers have not succeeded despite the government’s best efforts and funding support. Other mental health allied and para professionals have limited roles as supportive or adjunct therapists working as members of the multidisciplinary mental health teams. Moreover, they are even fewer in numbers as compared to psychiatrists.

Misperceptions about treatment of psychiatric disorders is leading to adoption of misdirected approaches by the government. This is causing a huge confusion as well as damage and dis-service to patients with mental illness and their families.

The Government of India has dedicated a huge resource on Tele-Manas. The total budget allocation for Mental Health of MoHFW in FY 24-25 was 1314 Cr.[20] Only 200 Cr (15%) of total mental health budget is given to mental health for the whole the country [Figure 2].

Figure 2.

Mental Health Budget

There are obvious budgetary disparities and policy pitfalls as shown in Figures 2 and 3.

Figure 3.

Policy Pitfalls in Mental Health Care

It is important that psychiatrists safeguard against dilution or drift in mental health care services and specialty and should remain steadfast in supporting and advocating for the right to treatment for persons with mental disorders, which has been compromised due to shift in focus.

Psychiatrists must put in their efforts and energies in reclaiming and restoring their domain of expertise and practice, advise the government, and inform the public to make a distinction between treatment and prevention of mental disorders; treatment and promotion of mental health; rehabilitation and remedial services for mental disorders; and so on. Resources must be equitably distributed for all stages and conditions, and certainly, the persons with mental disorders must get their due share from national resources. A major amount of resource is getting shifted to the advocates of wellness who are trying to create a narrative that their methods can treat or reduce mental illness. It is misplaced and a wrong argument. There is a report that prevalence of anxiety and depression in US, Canada, Australia, and UK has not decreased through 1990–2015, despite a substantial increase in provision of treatments.[21] Planners and policy makers must make this distinction and prioritize resource allocation where these are needed the most, that is, the persons with mental illness. The state of psychiatric institutions and mental hospitals where the majority of chronically sick persons with severe mental illness are treated continues to remain unacceptably bad and poor, and according to National Mental Health Survey (2015–16)[3] estimate, we have about 15 crore (150 million) persons with mental illness in India. These individuals are silent sufferers, invisible to society, media, and policy makers.

People with mental, neurological, and substance use conditions require access to affordable high-quality and evidence-based treatment and care that is consistent with human rights approaches.

At present, the challenges facing India about mental health care are huge and have led to a very confusing state of affairs. Dilution of psychiatric services by providing limited treatment for limited conditions through allied/para/general health care professionals is also not a desirable strategy. Delivery of mental health care cannot be equated with some other public health programs like immunization or malaria eradication, where interventions are simple and tangible, and health care workers have been used successfully. With such substantial workforce shortages, calls for greater investment in psychiatric training programs; equipping primary care providers with skills to deliver basic mental health care; developing community-based programmes; and task shifting services to lay providers, nonprofessionals, and caregivers (Kakuma et al. 2011)[22] will probably not be enough to close the mental health gap.

Road Map ahead/Solutions:

• There is need to reclaim psychiatry.

• Bring focus back on mental illness and medical treatment.

• Restore the psychiatrist’s domain of expertise and practice.

• Prioritize resource allocation where it is needed the most, that is, Persons with mental illness (PMI)

• Equity in distribution of resources for care of all PMI for all stages of illness, that is, emergency care, acute care, long-term care, rehab, community care, and so on.

In view of the pressing and urgent need for developing a robust mental health care system, within the limitations of specialist manpower and infrastructure resource in India, the following approaches, deployed together, can provide a viable solution.

1. Augmentation of mental health care work force; standardization of their education, competencies, and regulation: At present, there is no standardization of education for mental health para or allied professionals and no regulation of or control on their competencies or performance. There are umpteen examples of harm to patients where patients have become worse or have committed suicide, or families have broken due to misguided counseling. This unregulated field in current times is the biggest bane of mental health care scenario in the country. Dealing with patients with mental illness is a serious and sensitive matter and involves huge moral and ethical responsibility. It is necessary to have clear guidelines about the relative roles and scope of practice of all the allied/para professionals who are currently delving into the treatment of mental disorders.

   Niti Ayog has constituted the National Commission for Allied Health Care Professions (NCAHCP), which includes psychologists, behavioral health counselors, social workers, analysts, educators, and support workers, under the category of ‘Behavioural Health Sciences Professionals’ and clearly prescribed their qualifications, roles, and functions (Niti Ayog 2023).[23] There is recommendation of BSc (Hons) in Clinical Psychology and BA (Hons) in Psychiatric Social Work, 4 years course, and MA Clinical Psychology and MA Psychiatric Social Work, 2 years course after graduation. The role of BAs and MAs in general psychology needs to be defined and regulated if they are taken on board in mental health care. At present, this is a totally unregulated field.

   These recommendations once implemented will standardize the educational curriculum, streamline the career path, and specify the roles and scope of practice in these fields, which are hitherto totally unregulated and unstandardized. For delivering mental health care through general or allied mental health paraprofessionals, they will have to be appropriately trained and empowered with IT tools and the duly supported, supervised, and regulated.

   Public is ill informed about the nature of mental disorders and is unable to reach the psychiatrists at the first instance. Our physician colleagues need to advise patients to see the psychiatrist and also dispel any apprehensions or stigma that the patients may have in seeing a psychiatrist. This is in the best interest of the patients and society. Patients have a right to receive best treatment from the concerned specialist. There is a moral and ethical duty of all professionals to practice within the domain of their training, which should also be enforced by the respective professional societies and the regulatory bodies.

2. Integration of mental health care and physical health care: Fragmentation between physical and mental health services has been a major impediment in health care and has led to a crisis situation. Mental health conditions affect and are affected by physical conditions, and mental illnesses are often comorbid with physical illness and vice versa. People living with severe mental health conditions are also more likely to be affected by physical health conditions and are more likely to die 10–20 years earlier and often go unrecognized and untreated. Integration of mental health care with physical health care would require strengthening the primary health care system by empowering the GP with sufficient exposure and training in diagnosis and treatment of common mental disorders in the formative years at the under graduate medical curriculum level. It has been amply seen that the benefits of post hoc training of qualified GPs in mental health care are short-lived and unsustainable and have not succeeded in NMHP and DMHP. Considering that the prevalence of mental disorders is about 10–15%, the life time prevalence is about 25%, 30–40% patients attending a primary health care facility have some mental disorder, and about 40–80% patients with primary physical illness have associated mental disorder, psychiatry should find a more important place in undergraduate medical curriculum. There should be a paradigm shift where a primary care physician provides a basic mental health care; it would destigmatize psychiatry and make practice of medicine holistic, more convenient, and effective. India has an established system of primary health care that can be put to effective use. The main change that will be required is bolstering the undergraduate medical curriculum to include a significant component of psychiatry proportionate to the prevalence of mental disorders and consequent disability it produces. This would bring about a systemic change in the attitude as well as competence of GPs in managing mental disorders. Superficial band-aid like solutions as used in NMHP and DMHP have not succeeded and cannot succeed.

3. Leveraging technology: Mental health care availability and accessibility can be greatly enhanced by deploying technology-enabled solutions. Use of telemedicine and information and communication technology (ICT) can fill in for shortage of manpower as well as services to a great extent. Growth in mobile telecommunications and Internet access in India and many low-middle income countries has been unprecedented in recent years. This presents new opportunities to reach, support, and treat individuals living with mental disorders (Jones et al. 2014).[24]

India had the world’s second-largest Internet using population (over 1.2 billion) in 2023, and 1.05 billion of these accessed the Internet via their mobile phones. There are now over 1 billion active SIM cards in the country for a population of nearly 1.4 billion. There are 82 mobile connections for every 100 people in India (Statista, last accessed November 17, 2024).[25] This number is fast increasing. Digital India program of Government of India is aimed at increasing the penetration of Internet connectivity up to rural areas with high-speed networks for provision of various services to its citizens electronically.

There are several other programs initiated by the Government of India in the field of Digital Mental Health Care. Before Tele-Manas, in 2020, a crisis helpline called KIRAN, working in 13 languages across the country, was set up by the Ministry of Social Justice and Empowerment.[26] The helpline intended to offer 24 × 7 crisis support with possible onward referrals to mental health professionals if needed. However, shortage of staff and funding has been responsible for helpline not being consistently functional. According to Keshav Desiraju (2023),[20] in an attempt to test the helpline, 37 out of 40 calls went unanswered. In 2021, the government launched a mental wellness app called MANAS (Mental Health and Normalcy Augmentation System). The app is designed to provide several features that relate to mental wellness, like guided meditation, mood tracking, sleep advice, and task planning and management. This app has several technical glitches that prevented users from using it, as was shown in recent Android app store reviews.

Many mobile apps like Happify (a US app) and Sanvello offer therapy for stress, negativity, anxiety, and depression. Similarly, MindDoc (from Germany and Europe) provides psychological assessment, tips, and exercise, and Monsenso (from Denmark) provides features like routine tracking, self-assessment, and online therapy. Other platforms like Talkspace, BetterHelp, and My Online Therapy match users with licensed therapists for virtual sessions. MoodGym is a pioneering online CBT program, Woebot is an AI-driven chatbot providing CBT. Mind provides comprehensive information about mental illness, treatments, and coping. In India, the most popular apps are Calm, Headspace, Moodfit, YourDOST, Evolve, Wysa, Amaha, and Manas. There is a serious need to develop frameworks and guidelines for the evaluation of mental health apps. While the potential of mental health apps is not much in doubt, the worrying fact is that of little clinically validated evidence of their efficacy (Malhotra 2023).[27]

All these tools are valuable, but these contain advice of the content creators and not of qualified professionals and hence do not replace professional help. There is lack of clear efficacy data (Goldberg et al. 2022)[28] and minimal clinical integration of these apps (Connolly et al. 2021).[29] Most digital approaches pose a barrier to access for those without access to consistent high-speed Internet or adequate hardware, such as smartphones or computers (Lyles 2021).[30] Moreover, these Apps are designed mostly for people with good amount of digital literacy. Only a small proportion of apps have been assessed and accredited by organizations such as the Organisation for the Review of Care and Health Apps (ORCHA)[30] or the M-Health Index and Navigation Database (MIND). ORCHA is a UK-based organization that assesses key aspects of health apps, including user experience, data privacy, and aspects related to the app’s clinical assurance. A report by ORCHA (2021)[31] declared that only 32% of available mental health apps pass a benchmark score of quality assurance. In a paper which examined 578 mental health apps indexed in MIND and rated across 105 dimensions, it was revealed that a few apps offered innovative features and many represented privacy risks to users (Camacho et al. 2022).[32]

Review of top ten mental health care pieces of software in the world shows that these mostly address issues like charting, management of insurance claims, document management, reminders, EHR/EMR, treatment planning, medical billing, initial assessment, primarily helping mental health professionals in their practice management, and record keeping (Capterra).[33] Others are specific intervention pieces of software, for example, for mindfulness, relaxation, meditation, sleep, or stress.

There are many other initiatives like AI-powered diagnostics, immersive virtual reality therapy, secure video conferencing platforms, integration with wearable technologies, exposure therapy and CBT using virtual reality, and various self-management apps, which are the leading health care innovations, continuously being developed, and refined and upscaled at a rapid pace, that are revolutionizing the mental health care scenario. These tools are transforming the landscape of mental healthcare, making it more approachable, personalized, and effective.

However, we will need to develop IT tools suitable for the Indian population and sociocultural system. We also need to identify the gaps in the mental health care system and develop suitable tools specifically for those hiatuses. The IT tools available at present are limited in scope, tackling only a few common problems like anxiety, depression, or stress, whereas the larger body of major or severe psychiatric illnesses are left out. Also, the treatment modalities are limited to counselling or psychotherapy or self-help. Thus, the current IT tools and platforms are insufficient for taking care of mental health care needs in India. A 2016 metanalysis of 452 studies of telepsychiatry found high patient satisfaction and quality equivalent to in-person care (Hubley et al. 2016).[34]

Nevertheless, creating technology-based systems of service delivery will be most useful, efficient, and cost-effective.

• 4. Public–Private Partnership (PPP): The PPP model has met with considerable success in India over the past decade specially during Covid pandemic with the CoWin Portal, a technology-backed public–private portal for the world’s largest COVID-19 vaccination drive in India. About 60% of mental health care in India is provided in the private sector (Malhotra et al. 2024),[35,36] almost all of which is urban centric. However, the Government of India has the last mile health care infrastructure in the form of primary health centers and rural dispensaries albeit devoid of mental health care. Psychiatrists are mostly available at the district level in both the private sector and public sector. Technology can be used to serve as a bridge between the rural population and the psychiatrist. There are about 9000 psychiatrists working in India (IPS Website 2023), and about 3800 (42%) are in the public sector (Government of India data 2015) and the remaining are in the private sector. Involving the private sector in delivery of mental health care, through tele-technology, without having to mobilize either the psychiatrist or the patient, will be a huge step forward in bridging the mental health gap. It requires realigning the policy and develop service delivery programs on PPP model, commensurate with the objectives given in the National Mental Health Policy 2014 and the National Mental Health Care Act 2017. The Government should not hesitate to harness this manpower and service infrastructure resource and can associate with the Indian Psychiatric Society, the largest national body of over 9000 psychiatrists, as service partners.

Challenges in Implementation of Digital Mental Health Care Programs in India: While the government initiatives of Digital Mental Health Programs are ambitious and commendable, implementation has consistently fallen short, primarily due to a shortage of professionals and volunteers, uneven access to technology, and technical glitches (Keshav Desiraju, 2023).[20] Technology tools cannot work in the absence of sufficiently trained mental healthcare professionals. Moreover, any digital approaches that attempt to redistribute existing resources lead to overburdening of existing healthcare professionals, who may have competing priorities with in-person consultations. Many individuals in India may not have individual phones and may be sharing it with family members, or they may not be literate enough to use and navigate the digital platform. It is suggested that they may be helped by an intermediary like a ‘Digital Navigator’, helping to navigate the digital world for the user and be a link between the patients and the service provider. Research has suggested that human intervention in the form of a Digital Navigator helped compliance with mental health App (Chatterjee 2023).[37]

RETHINKING APPROACHES TO PUBLIC MENTAL HEALTH

There is a serious need for a total rethinking in our approach to public mental health in India. Technology-based solutions will be our saviors. It is also clear that digital mental health care models will have to be tailor made for Indian situation and population.

To succeed we will need:

1. Infrastructure:

   1. Manpower trained in mental health care as well as in use of digital technology;

   2. We need efficient technology tools that can empower the patient as well as the service provider to access care and benefit;

   3. Have the needed infrastructure in the form of high-speed Internet connectivity and low-cost mobile phones and connectivity;

   4. And services of a digital navigator especially in remote and rural areas with low literacy populations.

2. Suitable IT Tools: Since we have to pitch our mental health services on the shoulders of general physicians or nonspecialists, they will have to be empowered with high-performance IT tools such as expert systems like “clinical decision support systems” to assess and diagnose core mental disorders at the first contact with the patient, with guidance for treatment in the same tool. Only then, the mental health care will be conveniently accessible and timely delivered. We cannot contend with minimalist intervention for patients in remote areas for the sake of equity and justice, it is important to provide high-quality service also to them. Patients in far flung and rural areas must have a right to same-quality service as those in urban metros.

3. There should be integration into the clinical health care system with provision for onsite training and upskilling while performing the job, along with clinical work flow and potential for online payment. In a most recent article, the authors (Lim et al. 2024)[38] have proposed a hypothetical model of integrating the primary care-based mental health services and digital mental health tools as a solution to address the mental health needs of the population.

“AUTOMATED SYSTEM AND METHOD FOR TELEPSYCHIATRY”: A MODEL FOR DIGITAL MENTAL HEALTH CARE FOR INDIA

This is a system recently patented in India by the author “Automated System and Method for Telepsychiatry” (Patent No 540368), which is based on research in India. It comprises an automated system of medical knowledge-based clinical decision support system for diagnosis and treatment of mental disorders that has been used in delivering mental health care in remote areas through nonspecialists in the states of Himachal Pradesh, Uttarakhand, and Jammu and Kashmir with success (Malhotra et al. 2019).[39] This is an innovative digital model of mental health care, enabling and empowering the nonspecialists to deliver high-quality mental health care in remote areas. The model is powered by an online, fully automated clinical decision support system (CDSS), with interlinked modules for diagnosis, management, and follow-up, usable by nonspecialists after brief training and minimal supervision by psychiatrists, to deliver mental health care at remote sites (Malhotra et al. 2012, 2014, 2015a).[40,41,42] The CDSS has been found to be highly reliable and feasible, with sufficient sensitivity and specificity (Malhotra et al. 2017).[43] The CDSS is reasonably comprehensive and covers 18 major psychiatric disorders commonly seen in adults. It has a separate version for children and adolescents again covering 18 childhood psychiatric disorders similarly tested for diagnostic accuracy and reliability (Malhotra et al. 2015).[44,45] Psychologists, social workers, and GPs were trained online to conduct patient and care-giver interview using CDSS, leading to an automated diagnosis. Thereafter, there is link to management modules, where the GP is guided to choose and prescribe the psychotropic medication and/or psychological intervention as appropriate for the given diagnosis in that patient. The GP is assisted in the choice of medication, prescribing information and guidelines about the medication and a printable prescription. The feasibility and accuracy of pharmacological treatment prescribed by the GP were found to be highly satisfactory (Malhotra et al. 2013).[46] The GP is also assisted to prescribe psychological intervention in the form of psychoeducation, counseling, guidance, and self-guided relaxation, which is carried out by the psychologist or the social worker as per the modules provided in the CDSS (Malhotra et al. 2013).[47] There is also rating of symptom severity, psychosocial functioning, and medical illness if any. The remote site teams are supervised by the psychiatrist remotely for assistance in difficult cases through store forward data consultation as well as real-time video conferencing with the patient or the team members as necessary. There is a follow-up module that captures the patient’s progress in terms of symptom change, side effects, severity ratings, and psychosocial functioning.

This digital model of mental health care is unique and one of its kind in the world. It can be easily deployed and integrated with the primary health care system in India utilizing the available infrastructure and workforce. The model has the potential to make mental health care accessible to most patients even in the remotest of places. In a busy psychiatry clinic, this model will allow the psychiatrists to expand his/her area of operation for patients living at a distance and to make more efficient use of time. This is the first such system and the only system in the world that comes closest to the practice of clinical psychiatry for patients seen in the primary or secondary healthcare setting, combining benefits of both digital technology and information communication technology. This system empowers nonspecialists such as GP, psychologists, social workers, or psychiatric nurses to provide high quality and minimum error mental health care at their level with minimal support or supervision of psychiatrists. Repeated use of the CDSS has the advantage of self-learning and continuous upgradation of the knowledge and skills of the user, making them more efficient over time. The automated system is currently bilingual (English and Hindi) and supports the multilingual format and is brief, feasible, and user-friendly, with high levels of patient satisfaction tested on actual patients in real time (Malhotra et al. 2019).[39] Deployment of this system at the primary care level can solve the problem of mental health care delivery in one go.

A new Digital Personal Data Protection Act has been enacted in India in 2023 “to provide for the processing of digital personal data in a manner that recognises both the right of individuals to protect their personal data and the need to process such personal data for lawful purposes and for matters connected therewith or incidental thereto” (DPDP Act 2023).[48] This would further make the use of telepsychiatry and digital models of care safer with legal protection of sensitive and personal data as well as patient rights. India is already in a more advanced state of digital readiness compared to many other countries of the world. India can be a leader in proposing a reformative and revolutionary solution for deficient mental health care services to especially the low-resource countries and the world.

CONCLUSION

In conclusion summarizing from above, it is evident that we must:

• Resist dilution, trivialization, and diversion in mental health care services.

• Reclaim the place of psychiatry in total mental health care service delivery system.

• Pitch for equity in allocation of financial resource to mental health, overall and specific.

• Seek specific allocation of budget for treatment of serious psychiatric illnesses.

• Push for total integration of mental health care with general health care

• Establish clarity and control in the roles and scope of practice of different mental health para and allied professionals and physician specialist’s vis a vis treatment of psychiatric disorders.

Psychiatrists in India should resist the drift and not become too elite or siloed to the extent of becoming irrelevant as in the West, where the clinical work is being done by psychologists, social workers, and nurse practitioners, and psychiatrists’ major clinical role is to write prescription and paper work. In the practice of community psychiatry, more and more psychiatrists have been drawn into the social field and fewer and fewer are left to look after psychiatric hospitals (where bulk of psychiatry patients are found); hence, the lament that “psychiatrists are least found where they are needed the most” (Neki 1975).[49] Psychiatry is too important to be left to populist sloganism of governments and bureaucrats. There is need to prioritize treatment of mental illnesses that are prevalent, serious, life-threatening, or potentially harmful to self or society or produce chronicity or disability (Harding 1975).[50] Psychiatrists are at risk of moving away from their medical roots and getting dragged into undefined roles, for undefined needs, of undefined patients, which will make them appear as poorly trained social scientists. Psychiatry should be driven by 21st century science and not by 19th century teachings and mindset.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.