Bridging the mental health treatment gap in India: A Policy-oriented framework using the care cascade approach

Abstract

India carries one of the world’s highest mental health treatment gaps. Despite the Mental Healthcare Act 2017 and national programme expansions, large proportions of people with common and severe mental disorders remain undiagnosed or untreated. The care cascade framework, originally applied in HIV and tuberculosis, provides a structured approach to identify points of attrition across seven stages: awareness, help-seeking, access, diagnosis, initiation of treatment, continuity of care, and recovery. Evidence from programme evaluations highlights major drop-offs at recognition, initiation, and long-term adherence. Task-sharing with non-specialist providers, digital platforms such as Tele-MANAS, strengthened District Mental Health Programme services, and integration through Health and Wellness Centres have improved reach but remain fragmented and uneven. Cascade-based indicators allow health systems to monitor performance at each stage and to prioritise interventions where the loss is greatest. Embedding this framework within national policy can enable more efficient resource allocation, reduce inequities, and promote recovery-oriented mental health services in India.

INTRODUCTION

India carries one of the largest burdens of mental disorders globally, yet it also faces one of the highest treatment gaps. The National Mental Health Survey (2015–16) estimated that between 70 and 92 percent of people living with mental illness in India receive no formal treatment. And similar trend was also followed in individual researches in India.[1,2,3] This is a critical public health and human rights issue that calls for urgent system-level reforms. The challenge is not limited to the shortage of professionals or infrastructure; it is rooted in a failure to deliver coordinated, continuous, and inclusive care. The mental health care cascade framework offers a scientifically grounded, stage-wise model to identify attrition points across the mental health system and design targeted policy interventions.

The care cascade, initially conceptualized in HIV and TB care models, has been adapted to mental health systems to represent the sequential stages a person must pass through to achieve recovery. These include: (1) awareness and recognition, (2) help-seeking behavior, (3) access to services, (4) accurate diagnosis, (5) initiation of treatment, (6) adherence and continuity, and (7) recovery and reintegration. Each stage can be measured and optimized, making the cascade a powerful tool for surveillance, service planning, and policy evaluation [Figure 1].

Figure 1.

Mental health cascade

Stage 1 and 2: Awareness and help-seeking

Mental health literacy in India remains low. Most individuals do not recognize common mental disorders such as depression or anxiety as medical conditions requiring professional care.[4,5] In the National Mental Health Survey, nearly 80% of respondents had never heard of schizophrenia or bipolar disorder.[6] Cultural beliefs and stigma further inhibit help-seeking behavior. People often attribute mental illness to supernatural causes, leading to reliance on faith healers or informal networks instead of medical services.[5] These findings indicate a major drop-off in the earliest stages of the cascade. Without recognition of symptoms and proactive help-seeking, individuals cannot access the formal care system.

Policy interventions must prioritize mental health awareness campaigns integrated into school curricula, workplaces, and community health outreach. Public messaging should use non-stigmatizing language and leverage community leaders, religious figures, and persons with lived experience to shift narratives around mental illness. Evidence from anti-stigma programs worldwide shows that such approaches are effective in reducing prejudicial attitudes and increasing willingness to seek care.[7]

Stage 3 and 4: Access and diagnosis

India’s mental health infrastructure is inadequate and unevenly distributed. The World Health Organization reports approximately 0.75 psychiatrists per 100,000 people, which is less than recommended minimum of 1 per 100,000. Most professionals are urban-based, leaving rural areas underserved.[8] Most specialists work in cities, and rural districts have little access to care. Many graduates in psychiatry move to urban centers in search of better professional opportunities and living standards. Undergraduate exposure to psychiatry is limited, and in many colleges, it is not a distinct, rigorously examined subject. Medical officers at primary health centers (PHCs) therefore lack confidence to diagnose and treat common mental disorders, even after short trainings. General practitioners often miss cases, which delays care and widens the treatment gap.

To address this, the District Mental Health Programmed (DMHP), operational in over 700 districts, must be strengthened with increased funding, dedicated staff, and reliable medicine supplies. Mandatory mental health training for primary care providers, combined with simple screening tools such as PHQ-9 or GHQ-12, can significantly improve detection rates. Integrating mental health into existing service platforms, like maternal health programs, non-communicable disease (NCD) clinics, and adolescent health services, can create multiple entry points for diagnosis.

Stage 5 and 6: Treatment initiation and adherence

Even when diagnosed, many individuals do not begin treatment. Reasons include fear of side effects, lack of access to preferred therapy options, and cost of care. Public facilities often experience drug stock-outs, while psychological services are limited or unavailable.[9] Studies show that nearly 40% of individuals fail to return after their first mental health consultation.

Effective treatment initiation requires a dual strategy: Ensure availability of essential psychotropic medications and scale-up delivery of brief psychological interventions. Lay counselors, when properly trained, can deliver evidence-based therapies such as behavioral activation or problem-solving therapy at the community level. Task-sharing models validated in India, including the Tele-MANAS and Healthy Activity Program trials, demonstrate feasibility and cost-effectiveness.[10]

Improving adherence necessitates systems for continuity of care. Tele-MANAS, India’s national tele-mental health helpline, has received over one million calls since its 2022 launch. While its primary function is crisis support, it can be expanded into a long-term engagement tool. Integration of SMS reminders, follow-up calls, and referrals to district-level services can convert one-time contacts into sustained care trajectories. Additionally, training ASHA workers to conduct monthly follow-ups for patients with known mental illnesses can reduce drop-outs.

Stage 7: Recovery and reintegration

Recovery in mental health encompasses more than symptom reduction; it includes restoration of function, social inclusion, and economic participation. India has limited infrastructure for psychosocial rehabilitation.[11] Only a small number of day-care centers, halfway homes, and supported employment schemes are available. Without these services, many individuals relapse or become dependent on caregivers.

Policy frameworks such as the Mental Healthcare Act (2017) and the Rights of Persons with Disabilities Act (2016) recognize mental illness as a disability and mandate access to rehabilitation and livelihood support. However, implementation is weak. Ministries of Health, Social Justice, and Labor must collaborate to operationalize recovery pathways through skill development programs, job reservations, and disability pensions.

POLICY RECOMMENDATIONS BASED ON CASCADE ANALYSIS

To transform the care cascade framework into an actionable policy instrument, the following strategic measures are recommended. It is important to recognize that India has already initiated several key programs aimed at improving mental health outcomes. These include the DMHP, the national tele-mental health platform Tele-MANAS, and the integration of services into Ayushman Bharat’s Health and Wellness Centers.

However, the implementation of these initiatives remains inconsistent and variable in depth across states and districts. This gap between policy design and real-world execution is a critical concern. As such, these recommendations do not merely call for new interventions, but also emphasize the need to strengthen, scale, and monitor existing frameworks to ensure they are functioning as intended.

To transform the cascade framework into a policy tool, we propose the following measures:

1. National Mental Health Surveillance System: Establish stage-specific indicators—for example, percentage of population with mental health literacy, diagnosis-to-treatment initiation ratio, 6-month treatment retention—to monitor cascade performance.

2. DMHP 2.0: It has been more than two decades since its launch, DMHP need major update regarding intervention delivery in the integrated manner at primary and secondary care level with robust monitoring mechanism, regular funding, and appropriate use of technology.

3. Cascade-Based Budgeting: Allocate resources based on observed drop-offs. For instance, if awareness is a major gap in a state, fund community campaigns; if adherence is weak, invest in follow-up infrastructure.

4. Decentralized Service Delivery: Integrate mental health care into the 1.5 lakh Health and Wellness Centers under Ayushman Bharat. Provide frontline workers with digital tools and telepsychiatry support.

5. Human Resource Expansion: Create mid-level mental health providers through diploma programs. Task-sharing should become standard practice in DMHP.

6. Inter-Ministerial Coordination: Establish a national task force involving health, education, labor, and social justice ministries to ensure recovery and rehabilitation services.

CONCLUSION

India’s mental health burden is projected to cost the economy over $1 trillion between 2012 and 2030 due to lost productivity and premature mortality. The treatment gap remains unacceptably high despite decades of policy attention. A cascade approach offers a structured, data-driven method to deconstruct the problem and guide investment. By addressing drop-offs at each stage—awareness, access, diagnosis, treatment, adherence, and recovery—India can make significant progress toward universal mental health care. The time to act is now. A scientifically rigorous, cascade-informed mental health system is not only feasible but essential to ensure health equity, economic growth, and social justice.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.