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Published in final edited form as: SSM Ment Health. 2023 Dec 2;4:100277. doi: 10.1016/j.ssmmh.2023.100277

Mental health in India: Sociocultural dimensions, policies and programs – An introduction to the India Series

Venkatesan Chakrapani a, Shalini Bharat b,*
PMCID: PMC7616029  EMSID: EMS196009  PMID: 38807921

In 2015, a famous Bollywood actor – Deepika Padukone – opened up in the media about her struggle with depression (Indian Express, 2021). It was her mother who recognized the symptoms and ensured she got treated for it. Padukone admitted that the stigma around mental health initially posed a dilemma for her and her family in seeking immediate professional help. A celebrity openly sharing her mental health problem was until then unheard of in India. It opened up a country-wide discussion on the hidden and ignored burden of mental health in the country, its prevalence and impact, the associated stigma and lack of awareness about its symptoms and pathways to prevention and treatment. The COVID-19 pandemic has further highlighted the importance of focusing on mental health when people struggled to cope with social isolation, loneliness, and sudden loss of lives and livelihoods amid a huge scarcity of accessible and affordable mental health services.

Mental health awareness and attributions to mental illness

With a 17.7% share of the global population, India contributes significantly to the global mental health burden and treatment gap. For example, the treatment gap for common mental disorders is estimated at 85% (Murthy, 2017). The 2016 National Mental Health Survey reported that the weighted prevalence of common mental disorders (CMDs) such as depressive and anxiety disorders was 5·1% (95% CI: 5.06-5.13), with the prevalence highest among females and those aged 40-59 years and living in metros; 60% of those with CMDs reported having varying degrees of disabilities; and the treatment gap was 80.4% (Jayasankar et al., 2022). Fast-paced lifestyle, urbanization, rising divorce rates and relationship conflicts, pressure to excel at education or in the workplace, and gaming and other addictions are cited as factors contributing to stress, isolation and psychological suffering (Gonsalves et al., 2019; Radhakrishnan, 2012; Varma, 2015). The reported rising trends of depression and anxiety in several states of India in recent decades have been attributed to larger sociocultural transformations and a craze for material wealth, with accompanying narratives of a decline in cultural and moral values (Gururaj, 2016; Lang, 2019; Nayar, 2012).

There is a general lack of adequate knowledge among the lay Indian public about mental health problems (Srivastava, Chatterjee, & Bhat, 2016; Tesfaye et al., 2021) and available options for their diagnosis, treatment and care, although it is higher among the educated and urban populations. However, even educated persons would seek professional help only if they develop severe symptoms or if their symptoms are severe enough to catch the attention of their family members (Kudi, Khakha, Ajesh Kumar, & Sinha Deb, 2022). Educational status, beliefs about causes of mental health illness, severity and nature of illness and affordability all have been shown to influence decisions regarding the timing of seeking any kind of mental healthcare services and the type of provider (Dutta, Spoorthy, Patel, & Agarwala, 2019; Roberts et al., 2018). The other influencing factors are: the setting (urban or rural), the gender of the ill person, and the type and qualifications of mental health service providers (Goyal, Sudhir, & Sharma, 2022; Sahu, Patil, Purkayastha, Pattanayak, & Sagar, 2019). For example, a study from a North Indian tertiary care center in Delhi reported that patients with bipolar disorder first approached psychiatrists (43.8%), followed by traditional faith healers (32.8%) and general physicians or neurologists (17.2%) (Sahu et al., 2019). However, studies from two tertiary care centers in Delhi and Jaipur reported that faith healers were the most preferred (Jain et al., 2012; Kudi et al., 2022) and significantly often the ones who refer the patients to psychiatric care when they believe they can no longer handle their patients’ condition. The range of providers approached for mental healthcare, not in any particular order, includes: psychiatrists, non-psychiatric physicians, psychologists, psycho-social counsellors, faith or spiritual leaders, traditional healers, ritual healers, and persons who are believed to engage in black magic (Goyal et al., 2022; Jain et al., 2012; Khemani et al., 2020; Kudi et al., 2022; Sahu et al., 2019). Visiting temples and dargahs (shrines or tombs of religious leaders) for seeking “cure” and/or drawing comfort and solace also has immense cultural significance in the country (Raguram, Venkateswaran, Ramakrishna, & Weiss, 2002).

People’s belief systems and family members and relatives seem to play a significant part in treatment-seeking decisions (Khemani et al., 2020). Allopathic providers are chosen if family members believe in the bio-medical and psychological causation of mental illness, while a belief in black magic, spirit possession, evil curses and sins committed in past lives as causes seem to make people approach faith or ritual healers, especially for severe mental health disorders. For example, in Tamil Nadu state, families who believe that “Billi, Sooniyam, Yeval and Saivinai” (terms that refer to evil curses or the use of black magic to destroy a person or family) are responsible for mental health problems commonly approach black magic practitioners or faith healers believed to have powers to tackle such causes (Jani et al., 2021; Saravanan et al., 2007). But, some evidence from South India suggests consideration is also given to psychiatric explanations (Halliburton, 2004) and families are known to combine both types of treatments in the hope that one or both may work (Schoonover et al., 2014). Some faith-based healing institutions also provide residential care for people with mental illness at the request of family members. Belief in and use of spiritual and religious healing is reported to help in coping with the stress of having a mental health illness and the burden of care and give psychological comfort (Raguram et al., 2002). It is also reported to treat some moderate conditions, although in the more severe mental health conditions, it may cause treatment delay and neglect, abuse, and harm to the ill person (Schoonover et al., 2014). It was a gruesome fire accident in a faith-based setting (‘Erwadi tragedy’ in a South Indian city) that claimed the lives of 28 chained people with mental illness in 2001 (Trivedi, 2001). That tragedy contributed partly to raising awareness about the ill-treatment of people with mental illness and formulating a rights-based Mental Healthcare Act, 2017, and protecting the rights of people with mental illness under the ‘Rights of People with Disabilities Act, 2016 (MoSJE, 2017). Post the Erwadi tragedy, any institute providing residential mental health care is now mandated to be registered with the government (Murthy, 2001; Trivedi, 2001).

Some patients and their families prefer counselling and other non-allopathic approaches (religious discourses, spiritual lectures) rather than medication. And those opting for medication often do so secretly to avoid stigma, labelling and discrimination. In some cases, medicines prescribed by mental health professionals are avoided because it is an admission of a personal mental health problem (Gaiha, Taylor Salisbury, Koschorke, Raman, & Petticrew, 2020). Given that a significant proportion of those with mental illness seek faith-, traditional-, or ritual-healers, some psychiatrists and non-governmental organizations (NGOs) advocate for both allopathic and non-allopathic approaches. For example, in parts of South India, some approve the use of ‘theertam (holy water from the temple) along with marunthu ([allopathic] medicine)’ (Saglio-Yatzimirsky & Sébastia, 2015), and in the north and western parts ‘dawa ([allopathic] medicine) and duwa (prayer)’ are commonly advocated (Saha et al., 2021). Although many psychiatrists are wary of this approach that seems to implicitly accept the legitimacy of the non-allopathic faith-based or traditional ways of healing, not in line with the biomedical model, there is growing evidence for these approaches to be the middle ground (Patel & Agrawal, 2023), that may encourage people to continue with allopathic treatment, especially for severe mental health disorders that require regular medication (Saglio-Yatzimirsky & Sébastia, 2015).

Social stigma and mental health

Given the lack of complete knowledge about the symptoms and treatment possibilities and the importance of mental health as well as the stigma associated with having a mental health problem, people with a mental illness (and their families) often hide and delay seeking mental healthcare and may not even reveal their symptoms to significant others (Jani et al., 2021; Saravanan et al., 2007). Consequently, people with mental illness often suffer in silence, with minimal or no social or medical support, although support from Indian families for people with mental illness has been reported to be better than in other developed countries (Luhrmann & Marrow, 2016). Thus, suffering from mental illness, given its invisibility, does not capture the attention of society or policymakers as a public health priority, and many times escapes the eyes of family members until it is too late.

Pervasive stigma towards people with mental illness in India is partly attributable to the conceptions of what leads to mental illness (Kaur et al., 2021). Mental illness could be attributed to a simple lack of discipline or willpower, or mental ‘weakness’ (explanation for depressive symptoms such as fatigue or sadness) to possession by evil spirits or suffering under the spell of black magic unleashed by one’s enemies (Nambi et al., 2002). Further, people with mental illness have often been portrayed as dangerous to others, thus adding a fear element (Thornicroft, 2020). Often, these conceptions lead to neglect and abuse of people with severe mental illnesses like Schizophrenia by family members, although families often care for their members with mental illness.

Traditionally, in India, caregiving within families, even for mentally ill members, is an acceptable and expected role and socially valued. Despite the financial and emotional burden of caregiving, even poor and urban slum dwellers are reportedly taking responsibility for reintegrating people with mental illness into their families (Frontline, 2016). However, family members and caregivers of people with mental illness are often stigmatized (stigma by association) (Jani et al., 2021; Saravanan et al., 2007) and are at high risk of psychological distress and burnout (Dijkxhoorn, Padmakar, Bunders, & Regeer, 2022).

Some families thus reject and neglect their family members with mental illness in anticipation of negative consequences for the family (e.g., loss of family prestige, difficulty in finding marriage alliances for siblings of people with mental illness). Financial and emotional burdens caused due to prolonged mental illness of a member and feelings of shame and embarrassment are often reasons for discrimination or abandonment of the sick member (Mahomed, Stein, Chauhan, & Pathare, 2019).

Studies have well documented that stress, stigma and discrimination faced by people with marginalized identities contribute to the production and co-occurrence of mental health problems (Operario et al., 2022; Singer, Bulled, Ostrach, & Mendenhall, 2017). In India, that association between stigma related to marginalized identities and mental health problems has been demonstrated among sexual and gender minorities (Chakrapani, Newman, Shunmugam, Logie, & Samuel, 2017), sex workers (Biradavolu, Blankenship, Jena, & Dhungana, 2012) and people who inject drugs (Mizuno et al., 2015). Despite the understanding that mental health stigma affects access to and use of mental health services, very few interventions have focused on reducing mental health-related stigma. A 2021 systematic review identified only nine intervention studies that focused on reducing stigma related to mental health in India (Kaur et al., 2021). Most of those interventions were multilevel – using a combination of individual, interpersonal and community-level strategies to reduce stigma and improve access to care; none focused on healthcare providers and none were at the structural or policy level, possibly because designing interventions at structural and policy levels require greater resources as well as support from multiple stakeholders, including government. These findings highlight the need for large-scale multilevel stigma reduction interventions to support improved access to mental health services.

Acts, policies and delivery of mental health services in India

Following the WHO Mental Health Advisory Group’s resolution in 1979, India was one of the first countries to launch its National Mental Health Program (NMHP) in 1982 (Wig & Murthy, 2015). The NMHP restrategized to modernize state mental hospitals in 2003, and under the human resources development scheme, upgraded the psychiatric units in general hospitals in 2009 (Ahmed, Dumka, Hannah, Chauhan, & Kotwal, 2022). NMHP’s objectives included the treatment and rehabilitation of mental disorders, and the promotion of positive mental health (“National Mental Health Programme,” 2018) through the integration of mental health services with primary health care, creation or strengthening of tertiary care institutions for treatment of mental disorders, and protection of rights of people with mental illness through regulatory institutions such as the Central and State Mental Health Authorities. In 1996, District Mental Health Program was added to the NMHP, with districts as its implementation and administrative units (GoI, 2014). In 2014, the National Mental Health Policy was released (GoI, 2014). It used a rights-based framework to promote mental health, ensure treatment and recovery, reduce stigma and ensure the socio-economic inclusion of people with mental illness.

In 1987, India enacted the ‘Mental Health Act, 1987’ to replace archaic British India’s laws related to mental health (e.g., the Indian Lunacy Act). That Act was critiqued to have several drawbacks: applicable only to mental hospitals, admissions of patients can be involuntary with an order from a magistrate, lack of a procedure to appeal to an independent judicial review against compulsory treatment or admission, no safeguards for legal minors who require admission, and lack of protection of rights of people with mental illness (Namboodiri, George, & Singh, 2019). Thus, the ‘Mental Health Act, 1987’ was repealed and replaced by the ‘Mental Healthcare Act, 2017’, which came into effect in mid-2018. Stakeholders differed in their views on the advantages of the 2017 Act. The 2017 Act applies to all settings where people with mental illness reside for mental healthcare, including traditional care. Under this Act, the admissions of people with mental illness can be ‘independent’ (for persons who have decision-making capacity) or ‘supported’ (for persons who lack decision-making capacity) and all supported admissions need to be reviewed by a quasi-judicial body called ‘Mental Health Review Board’ and overseen by State and Central Mental Health Authorities. These structures are beginning to be placed and are in various levels of functioning, especially given the delay in implementation during the COVID-19 pandemic. Some commentators opined that the 2017 Act is ambitious and aspirational but possibly too early because adequate mental healthcare delivery systems are yet to be in place (Math et al., 2019; Namboodiri et al., 2019). In fact, after visiting 43 state government-run and three union government-run mental healthcare institutions in 2022, the National Human Rights Commission reported that many institutions are “illegally” keeping patients long after their recovery infringing their human rights and noted that the governments are not fulfilling the obligations under the Mental Healthcare Act of 2017 (NHRC, 2023).

In the government healthcare system, tertiary mental health care is available through mental health institutions in selected cities; secondary care is available in district-level government hospitals, which usually have a psychiatric unit; and the first point-of-care is supposedly available in primary health centres, where mental health care specialists or trained mental health professionals are largely absent. Services in government hospitals are free; yet, even people from lower socio-economic status may not be willing to bring their family members with mental illness, possibly due to mistrust in the quality of care as well as due to hidden costs (e.g., travel costs, accommodation and food costs of ‘attendants’ of people with mental illness who need to stay outside the hospital) associated with in-patient admissions. The Mental Healthcare Act of 2017 has mandated that private health insurers cover the costs for treating mental disorders, given that the right to mental healthcare is explicitly stated in the Act. The health insurance schemes of the Union government (Ayushman Bharat) and most state governments cover mental healthcare costs. Most persons do not have private health insurance and cannot use government health insurance if their preferred provider is not empanelled in the providers approved by those insurance schemes. The government has recognized the “AYUSH” group of alternative systems of medicine (AYUSH being an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa Rigpa and Homeopathy; AUS is sometimes called ‘Indian Systems of Medicine’) (Chandra & Patwardhan, 2018) and services through government-run hospitals are free. However, a 2018 national survey reported that only 6.5% of middle-aged and older adults, especially those who are older (>60 years) and from lower socio-economic status and those who lack insurance, were more likely to use AYUSH (Pengpid & Peltzer, 2021). A 2014 cross-sectional national survey on social consumption reported that only 3% were treated for “psychiatric and neurological” illnesses by non-allopathic systems of medicine in the past 15 days (Rudra, Kalra, Kumar, & Joe, 2017), indicating that a vast majority apparently used allopathic medicine for mental healthcare.

With only 0.75 psychiatrists available for 100,000 people in India (Sandhu, 2020), only 898 clinical psychologists in the country (MoH&FW, 2017), poor visibility of community care services and lack of support made available for family caregivers, the care and treatment gap is significant. The government has now introduced trainings on mental health for general physicians in government hospitals or clinics, so that a greater number of people can be benefited. It is also recognising NGOs providing community-based mental health services or developing and testing public-private partnerships to ensure a continuum of mental healthcare – from hospitals to ‘mid-way’ homes to families. Sangath, an NGO with its main office in Goa, focuses on closing the treatment gap by training lay counsellors and conducts studies to convert evidence into action. A study from Sangath reported that a lay health counsellor-led collaborative stepped-care intervention for common mental health disorders was effective in public sector primary care clinics (Pereira, Andrew, Pednekar, Kirkwood, & Patel, 2011). It also reported that private sector general practitioners did as well with or without the lay counsellor. Similarly, Banyan, a reputed NGO in Chennai, is known for its flagship project ‘Emergency Care and Recovery Centers’ that offers multidisciplinary, person-centered hospital-based care for homeless people with mental health issues. Banyan helps them to have stable housing and community living arrangements, given the nexus between poverty, homelessness and mental illness (Narasimhan, Gopikumar, Jayakumar, Bunders, & Regeer, 2019). Other two innovative and successful de-institutionalization programs of Banyan are its ‘Cluster Group Homes’, which houses a group of recovered women who only need maintenance therapy and ‘Home Again’ for those who need long-term daily care, supported by live-in trained caregivers (Seshadri, 2021). Tarasha, a field action project of Tata Institute of Social Sciences links psychosocial care, with shelter and livelihood needs, to facilitate reintegration of women with mental illness who are abandoned by their families (Maitra, 2021). Karuna Trust, another NGO, is known for its contribution to training primary care providers on mental health in the government’s primary health centers (Prashanth et al., 2017). Such initiatives from NGOs are contributing to ‘task-shifting’, community-based care, and models for integrating persons with current mental illness or who have recovered, with their families and communities. However, innovative programs like these by a small group of NGOs alone are not sufficient to address the vast care and treatment gap, given the small and patchy scale of such initiatives, with restricted geographical coverage and funding, and differences in the focus areas of care (Malhotra & Chakrabarti, 2015).

India series

SSM-MH’s India series aims to provide a cohesive narrative on history, epidemiology, culture, policies, programs and services, and politics around mental health. We have two papers when writing this opening piece in the India Series.

In the first paper (“Mental health law, policy & program in India – A fragmented narrative of change, contradictions and possibilities”), Ranade et al. (Ranade, Kapoor, & Fernandes, 2022) present a critical review of the evolution of mental health laws, policies and programs in India. They demonstrate that although the mental health law in post-independence India originated from colonial laws, international developments such as the UN Convention on Rights of Persons with Disabilities have considerably shaped the framing of progressive legislation in India. They also highlight the influence of international developments, such as the deinstitutionalization of mental health care, the growth of community psychiatry in the late 1970s, and the later movement for global mental health in the early 2000s, on current legislation. Although India’s Mental Health Care Act of 2017 has been seen as progressive by some commentators, employing evidence from literature and extracts from the policies and laws, Ranade et al. argue that there is a disconnection between the progressive frames of this law and the policy framework, and the national and district mental health programs. Regarding the post-COVID-19 pandemic’s focus on technology-assisted solutions for mental health care, they raise questions on its effectiveness and contribution to decreasing the mental health ‘care gap’ in India. A common theme across Ranade et al.’s paper is their critical view on the dominance of Western biomedical psychiatry as the guiding framework for India’s mental health policies and resource allocation.

In the second paper (“Will increasing access to mental health treatment close India’s mental health gap?”), Weaver et al. (2023) critically examine the assumptions in India’s National Mental Health Survey report that the mental health treatment gap results from a lack of access to and awareness about psychiatric services. Based on research conducted in the context of increasing attention towards task-shifting in the provision of mental health care, their paper analyzes qualitative in-depth interview data from a community-based sample of 66 adult women in Mysuru, a medium-sized South Indian city. They report that these urban women, across caste and socio-economic groups, displayed awareness of mental healthcare and its purpose, and had knowledge about mental health services in their city. They also found that just over half of the participants had any level of depression, and 27% had moderate or severe depression. The authors report that most participants attributed their distress to social and structural forces (e.g., family conflicts, poverty, illness), not medical causes, and reported fears of stigma and doubts about the usefulness of psychiatric referrals. The authors argue that these beliefs prevented those who screened positive for moderate or severe depression from going to a mental health professional, even though the research project offered support for expenses towards navigation and consultation fees. However, for hypothetical others (women in case vignettes), participants recommended referrals to psychiatrists or psychologists. These findings, the authors contend, challenge the notion that increased awareness and availability of mental health services and scaling up task-shifting could decrease the treatment gap. The authors conclude that cultural mismatch could be responsible for at least a part of the participants’ lack of use of psychiatric services. The authors provide several recommendations on how task-sharing approaches could be modified to incorporate culturally-relevant conceptions of distress and its appropriate management in future research and interventions.

Conclusion

We expect the India Series to highlight the similarities and diversity of Indian experiences and contrast them with the experiences of other LMICs or high-income countries. The papers in this Series may serve as study cases for learning about and expanding our understanding of global mental health. The critical and diverse perspectives offered by the authors in this Series, we hope, will initiate new dialogues on the influences of diverse contexts on the national mental health policies and programs and critically review and refine the strategies and implementation framework of national mental health programmes, moving beyond the biomedical framework and solutions. The present collection is expected to provide ideas for advancing mental health of all, both in India and other LMICs, especially in a post-pandemic context.

Acknowledgments

The authors thank Dr. Jayakumar Velayudham and Dr. Anindya Ray for their rich discussions and valuable critical feedback. Dr. Chakrapani was supported, in part, by the DBT/Wellcome Trust India Alliance Grant (IA/CRC/22/1/600436).

Funding

Not applicable.

Footnotes

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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