The Great Push for Mental Health: why it matters for India

Mental illness: the neglected global health priority

Much has been written in recent years about the large global burden of mental illness and the neglect by all sectors in the global, national and local health systems to respond appropriately to the needs and rights of people affected by mental illness1. Put bluntly, mental illnesses affect countless millions of people around the world, creating untold misery through the personal suffering to individuals and their loved ones, leading to adverse impacts on social and economic well-being. Despite the fact that most persons can be helped with affordable and safe treatments, the vast majority do not receive these treatments. The lack of access to evidence based care experienced by people affected by mental illness is in itself a contravention of their basic human rights; much worse, though, is the discrimination that many individuals face in their daily lives. Not surprisingly, the failure to respond to these needs and rights has been referred to as a ‘failure of humanity’2. Yet, there are signs that the tide is turning. A number of landmark publications over the past 15 years1,3, culminating in a series of articles in the Lancet in 2007 has spurred a global interest in this neglected health priority, in particular to promote improved access to effective interventions through affordable delivery systems4. Three key events since then signify the growing momentum for change: the publication by the WHO of its first evidence based guidelines for the treatment of mental, neurological and substance use disorders by non-specialist providers in routine care settings5; the Grand Challenges in Global Mental Health, backed by some of the world's leading health research funders, which has identified a set of challenges which need to be overcome to reduce the global burden of these disorders6; and the launch of the Movement for Global Mental Health, a coalition of institutions and individuals from diverse backgrounds, sharing a common platform to mobilize global opinion and resources to make a change7. Still, there remains a long way to go; the continuing neglect of mental health in resource allocations in national health budgets, the lack of access to mental health care in primary care, and the absence of mental health from this year's UN General Assembly meeting on Non-Communicable Diseases indicate that much work still needs to be done. Thus, the Great Push for Mental Health.

The Great Push for Mental Health

The Great Push for Mental Health is a programme of the World Federation for Mental Health (WFMH)8 in alliance with the Movement for Global Mental Health. WFMH is an international membership organization founded in 1948 to advance the prevention and care of mental illnesses and the promotion of mental health. The Federation, through its members and contacts in more than 100 countries on six continents, is the key worldwide grassroots advocacy and public education organization in the mental health field. Its organizational and individual membership includes mental health workers of all disciplines, consumers of mental health services, family members, and concerned citizens. World Mental Health (WMH) day, celebrated in countries around the world, was conceived by the WFMH. This year, the theme for WMH Day is the “Great Push for Mental Health”. This initiative aims to identify and address the problems which retard the promotion of mental health and prevention and treatment of mental illness. Four elements have emerged: unity, the perception of disunity in the mental health community weakens its voice; visibility, mental illness is not generally visible and therefore neglected; rights, the lack of public understanding about mental illness, compared to physical illness, leads to stigma and deprivation of human rights; and recovery, there is a resulting failure to provide for the treatment and rehabilitation which should lead to recovery. Each of these elements needs specific consideration.

There are some disagreements between various groups of mental health care providers and between mental health care providers and consumers of mental health services. For example, some psychologists may disagree with psychiatrists on the need for medical diagnosis, while some consumers/users argue against compulsory hospital admission and treatment, others against the use of electroconvulsive therapy. While such differences of opinion can be found in all fields of medicine, these usually form the basis for further research and an improved evidence base. In the case of mental health, however, the views of vociferous minorities are sometimes used to excuse inactivity by civil society, health services and charities. As part of the unity component, WFMH surveyed the views of its members and contacts. The 530 replies showed 97 per cent agreement on the 10 principles of WFMH8. There was widespread agreement on what should be done, while leaving science to sort out the disagreements. As a part of unity, the Great Push is addressing the issue of integrating mental health with the agenda on Non-communicable Diseases (NCD). However, it's campaign to ensure a greater recognition of mental health in the recent UN Special Session on NCDs met with limited success: although mental health was not explicitly addressed in the special session, several governments acknowledged that this was a crucial ‘missing’ NCD. The Great Push will now advocate for a special session devoted to mental health at the UN. Mental illnesses must be recognised as of equal importance alongside other NCDs.

Mental illness occurs in the brain and is neither generally “visible” nor understood. The Great Push aims to make it possible through WFMH's World Mental Health Day to increase visibility through a range of events, celebrations of good mental health by rallies and marches where consumers/users, family carers participate with providers of services, scientists and volunteers demonstrate together, supporting one another, dispelling fear and stigma and drawing attention to the importance of mental health. Serious abuses of human rights which occur in all countries against the mentally ill, arise from prejudice, ignorance, neglect or wilful bullying. The Great Push intends to convene a virtual multidisciplinary centre for collecting evidence, improving practice, making governments aware and holding them responsible. Finally, recovery. What can be done for the millions who go untreated because of lack of resources? We know that several interventions, both pharmacological and psychosocial, can promote recovery from a range of a mental illnesses5. When combined with actions to promote empowerment of people with mental illness, such interventions are not only a vital goal for persons affected by mental illness and their families, but can also serve to challenge the pervasive stigma associated with mental illness.

Making it happen in India

India was one of the first developing countries to recognize the need to address mental health with its National Mental Health Programme (NMHP) being launched in 1982, although the actual implementation at the level of service development took another 14 years to be initiated. Several commentators have charted the history of the programme since its founding and chronicled not only the increasing resource allocation by government but also how the essence of the programme's core vision of integrating mental health in primary care (the District Mental Health Programme, DMHP) has largely not been attained9. On the other hand, there have been considerable improvements in the conditions of care in mental hospitals in India after actions were initiated by the National Human Rights Commission10. Ironically, even as political will and financial resources for mental health care have become more forthcoming, a variety of other barriers have stood in the way to implementation of India's mental health care programme. These include the lack of clearly identified and accountable leaders for the programme in each state; the top-down highly prescriptive model of the district mental health programme which makes adaptation to local contexts difficult, even impossible; the fragmentation of the mental health sector between different government departments, in particular the separation of health professional education from health care delivery and of disability from health; the lack of a meaningful engagement of primary health care system reducing the DMHP to essentially a psychiatrist led out-patient clinic in district hospitals; and a complete absence of any linkages between health care facilities (for example, district hospitals, mental hospitals and primary care facilities) and between health care facilities and the communities in which they function.

The timing of the Great Push is salutary for country has embarked on a radical revision and re-haul of the dysfunctional NMHP. Under the leadership of the Central Ministry of Health and Family Welfare, a new Mental Health Act has been written following extensive consultations around the country with diverse stakeholders. Earlier this year, the Ministry began the task of writing India's first mental health policy and of rewriting the DMHP for the 12^th Five year plan (2012-2017) by constituting a Mental Health Policy group comprising diverse stakeholders, holding consultations around the country and inviting submissions of recommendations11. This is a unique moment in our history when there appears to be both political will and financial resources to support a range of actions to improve access to mental health care and promote human rights of persons affected by mental illness. Such an opportunity for a radical transformation comes once in a generation, if at all. This is a moment for all concerned stakeholders to set aside their differences. A coalition involving both professionals in the mental health sector and people affected by mental illness, and extending to policy makers and general health care providers and concerned members of the community, is needed to spur collective action for change. Such a coalition should vociferously, and with a united voice, demand for greater visibility of mental illness in the national policy and programmes, so that the rights of people with mental illness to access care and live a life with dignity are respected, creating the necessary circumstances which can facilitate recovery. These are the pillars of the Great Push for Mental Health and we will need to stand on these to ensure that the new National Mental Health Programme achieves its visionary goals at last.