Bridging the Mental Health Gap: The Role of Digital Solutions in India

Introduction

The mental illness burden is enormous in India. As per the Global Burden of Disease, approximately 200 million Indians suffered from mental illness in 2017 and approximately half of them have anxiety or depressive disorders (Sagar et al. 2020). Globally, India contributes to approximately one-fourth of all male suicides and over one-third of all female suicides (India State-Level Disease Burden Initiative Suicide Collaborators 2018). According to National Mental Health Survey 2015-2016, approximately 10% of adults have diagnostic criteria for a mental health condition (Murthy 2017; Patel and Balaji 2020). Suicide has been the most common cause of death among youth in India (Patel et al. 2012; Mascarenhas 2016). The effect of COVID-19 on mental health has been huge and it is reported that 66 children committed suicide in Kerala within 100 days of the COVID-19 lockdown. An online survey of 152 doctors revealed that over one-third of them suffered from anxiety and depression during the pandemic (Chatterjee et al. 2020). Because of additional domestic responsibilities and domestic violence, women also experienced depression and anxiety problems during COVID-19 lockdown (Patel and Balaji 2020).

Mental Health Burden

Some of the reasons for India's growing mental health burden are:

• Shortage of mental health professionals in rural regions

• Restricted provision and access to mental health treatment

• Restricted understanding and knowledge on mental health

• Stigma related with mental illnesses

• Logistical challenges including lack of sufficient funding

• Out-of- pocket spending and poverty

• Reduced literacy levels

• Absence of cost-effective and evidence-based treatment protocols

• Absence of follow-up care and community based networks for mental health care

  
  

Government initiatives

The Government of India has launched a number of policy level efforts to address the mental health condition of the country.

• In October 2014, the National Mental Health Policy was formulated with the vision "to promote mental health, prevent mental illness, enable recovery from mental illness, promote de-stigmatization and desegregation, and ensure socio-economic inclusion of persons affected by mental illness by providing accessible, affordable and quality health and social care to all persons through their life-span within a rights-based frame work"(Ministry of Health and Family Welfare, Government of India 2014).

• Government of India enacted Mental Healthcare Act in 2017 that overrides the Mental Health Act, 1987.

• National Mental Health Programme(NMHP) has already been operating in the nation since 1982, with the inclusion of District Mental Health Programme (DMHP) in the year 1996.

State governments also initiated multiple measures to tackle the mental health scenario. In 2014, Government of Karnataka implemented "Manochaitanya Programme" with the objective "to integrate mental health care in all public health-care institutions.

Digital Solutions to Mental Health

The telecommunication and internet boom offers a perfect chance for India to close the huge gap that currently exists in the availability of mental healthcare services. The digital technologies have the potential to offer a significant platform for large-scale upgradation of mental healthcare in India. Some of the digital technologies that are being researched to enhance mental health include tele-psychiatry, tele-consultation, mental health apps and games, digital assessment, digital therapeutic methods, virtual tranining and clinical support, personal health trackers, social media websites, online forums for peer support, meditation and mental wellness apps (Roland et al. 2020).   

Digital Platforms

MANAS

On 14th April, 2021, the Government of India initiated "Mental Health and Normalcy Augmentation System (MANAS)", a national platform to increase mental well-being of the citizens of India (Office of Principal Scientific Advisor, Government of India 2021). It was developed jointly by National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Centre for Development of Advanced Computing (C-DAC), Bengaluru and Armed Forces Medical College (AFMC), Pune. MANAS platform is an amalgamation of work by numerous government ministries, national institutions and research bodies. The first mobile application version rolled out by the Government of India is designed to promote healthy mental health among the age group 15-35 years. In the future, the platform will be multi-lingual and integrated with other public health schemes in India like the National Health Mission (NHM), National Nutrition Mission (Poshan Abhiyan) and e-Sanjeevani.   

e-Manas: Karnataka Mental Healthcare Management System

On 26th June 2020, Karnataka Government rolled out an online portal "e-Manas: Karnataka Mental Healthcare Management System" to facilitate delivering mental health services in the state (International Institute of Information Technology-Bangalore 2021).The e-Manas system enables medical information regarding the patient to be viewed by his or her physician, with permission, at any time and any hospital or clinic, thereby greatly enhancing the quality of possible healthcare (Suraksha P 2020).

Pilot Initiatives

Project ESSENCE

Sangath, a Goa based not-for-profit organization initiated a five year (2017-2022) project titled "Enabling translation of Science to Service to Enhance Depression Care' (ESSENCE)"(Sangath 2021a).The project is supported by the US National Institute of Mental Health and has following goals:

• To establish and assess the performance of electronic interventions (against face-to-face training) in areas of training ASHA workers/govt. accredited community health workers in delivering HAP (Healthy Activity Programme) for care of depression.

• To enhance capacity in South Asian nations to execute implementation research, dissemination of its results and adoption of this evidence in policy and programs.

  
  

Project Empower

Project Empower is a joint initiative of the Lakshmi Mittal and Family South Asia Institute, Harvard University and the Tata Trusts (The Lakshmi Mittal and Family South Asia Institute, Harvard University, 2021).  This project emerged from Project ESSENCE and seeks to create an electronic platform to remotely train and oversee community health workers for detection and treatment of prevalent mental illnesses.

Amma Manasu (Mother's mind)

During the year 2017, the Government of Kerala launched a new initiative named Amma Manasu (Mother's mind), a state-wide maternal mental health programme (Ganjekar, Thekkethayyil, and Chandra 2020; The News Minute 2021).  It focuses on psychiatric disorders among pregnant and post-partum women (The New Indian Express 2019). The project was initiated in collaboration with the National Mental Health Programme.

MINDS Community Mental Health Worker Program

To bridge the gap of mental health professionals in rural settings, MINDS foundation started a Community Mental Health Worker (CMHW) program (The Mental Health Innovation Network, 2015). Under this program, community lay persons were trained for carrying out community level screening of mental illness and basic mental health first aid (MHFA). Such trained lay persons are referred to as Community Mental Health Workers (CMHW).

The Karnataka Telemedicine Mentoring and Monitoring Program (KTM)

Karnataka Telemedicine Mentoring and Monitoring Program (KTM) is an inter-agency program between NIMHANS (National Institute of Mental Health & Neurosciences) and Government of Karnataka.  It was run from January, 2019 to October, 2020 and was a four tier hub and spoke model involving 'hub', 'micro hub', 'mini-hub', and 'spokes'.

• 'Hub' was made up of a KTM trained psychiatrist (who was based at NIMHANS).

• 'Micro-hub' was the psychiatrist in District Mental Health Programme (DMHP), who was based at the district headquarters.

• 'Mini hub' was made up of the Primary Health Care Doctors at Primary Health Centres (PHCs).

• 'Spokes' was represented by the patients.

A total of 33 DMHP psychiatrists were trained in the program initially, who, in turn, trained 436 Primary Health Care Doctors (PCDs) spread across the state through the utilization of tele-psychiatric on-consultation training (Tele-OCT) and Clear Voice Capture (CVC).

NIMHANS ECHO model

NIMHANS ECHO model is a spoke and hub tele-mentoring model that strives to bridge the urban-rural gap in mental health and addiction treatment in India. NIMHANS ECHO tele-mentoring model is capable of capacity building in addiction treatment and mental health in remote and rural communities. NIMHANS ECHO model is a component of larger Project extension for community healthcare outcomes (Project ECHO) aimed at knowledge exchange and capacity development to alleviate disparities present in the care of chronic diseases between urban and rural populations (Mehrotra et al. 2018).

Atmiyata

The condition of mental illness is worse in rural India because of insufficient skilled manpower to meet the burden of Common Mental Disorders (CMDs). In order to counter this, Atmiyata intervention has been introduced in one of the rural regions of Maharashtra, India (The Mental Health Innovation Network secretariat 2014). The intervention makes use of the digital media like low cost mobile phones and Atmiyata app, and is a two-tier community-based mental health model.

• First is "Atmiyata Mitras" who represent different caste and religion-based segments of the village and are trained to recognize individuals in mental distress.

• The second level consists of Atmiyata Champions, who are significant community members (e.g., community leaders, previous teachers etc.) and are recognized and easily accessible in the village. Atmiyata Champions are trained to recognize people in mental distress and offer structured counselling to them, including those referred by Atmiyata Mitras.

  
  

Clinical Decision Support System (CDSS)

The initiative was taken by the Department of Psychiatry of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. "The objective of the project was to create and deploy a digitally empowered model mental healthcare system through the creation of an application for comprehensive diagnosis and management (i.e., CDSS), to deliver high quality mental health care, through non-specialists, in the geographically challenging and unserved regions" (Malhotra, Chakrabarti, and Shah 2019).

Ummeed (hope)

The increasing rates of mental health problems, child abuse and neglect in India are a cause for concern. Lockdowns due to the COVID-19 pandemic had further amplified these problems. To address the increasing mental health load among children, on 19th January 2021 the Government of Rajasthan in partnership with Save the Children has introduced a dedicated helpline for children named "Ummeed (hope)”. The helpline is also referred to as Mental Health and Pyscho Social Support Plus (MHPSS +) which enabled children to talk to the counsellor and receive help for their mental health issues. Helpline also enabled parents to receive guidance on how to engage their children through different recreational activities. Furthermore, parents and children can report child abuse or any offence under the Protection of Children from Sexual Offences (POCSO) Act, and it will subsequently be referred to the State Child Rights Commission, Government of Rajasthan for further procedure.

Muskurayega India

Muskurayega India (India will smile) is a tele-counselling program by NSS, Uttar Pradesh in association with UNICEF, Uttar Pradesh and Public Health Foundation of India (PHFI).  Mental health counsellors under this program provide tele-counselling service to students and general public.

Chiri (smile)

Following the growing suicidal tendencies among children in the Kerala state, the Kerala Government initiated a telecounselling programme named "Chiri (smile)".  The programme was undertaken as part of "Our Responsibility to Children (ORC)" programme, a planned community intervention that reaches out to individuals in the age group 12-18 years.

DELHI CARES

In June 2020, Delhi Commission for Protection of Child Rights (DCPCR) initiated telecounselling service, DELHI CARES, for the students of schools who have suffered from mental tension as a consequence of COVID-19.

'BMC-Mpower 1on1' helpline

For solving problems concerning mental health, the Government of Maharashtra and the Brihanmumbai Municipal Corporation (BMC) introduced a 24*7 toll-free helpline named 'BMCMpower 1on1'. The tele-counselling facility by psychiatrists and clinical psychologists is being offered by Mpower, which is a mental healthcare institute.

Act Now

'Act Now' is a mental health campaign initiated by a broadcasting network viz. Times Network. It is a special campaign film that seeks to create awareness regarding the issue of mental health, make people sensitive to make conversation on the issue a norm and be receptive to the mental health requirements of the population.

Mann Mela

Mann Mela is India's first digital museum that focuses on mental health concerns of India's youth. It is a project by Sangath, a non-governmental organization that operates in multiple states of India. Mann Mela utilizes technology and art to display first person accounts of mental trauma, overcoming stigma and recovery. Personal experiences serve to be one of the effective means to connect with individuals experiencing similar type of mental health concerns and hence support their recovery.

POD Adventures

'POD Adventures' is a lay counsellor-facilitated problem solving intervention, administered via a smart phone application in Indian secondary schools. The application has been developed as part of project PRIDE, one of the world's largest adolescent mental health research projects at Sangath (a Goa-based mental health research organization in India).The application has been designed around three steps of problem-solving:

• Identification of the problem

• Generation of options

• Making a 'Do it' plan.

Digital Initiatives by Startups

Inner Hour

Inner Hour is a Mumbai startup co-founded by two psychiatrists, Dr Amit Mailk and Dr Shefali Batra in 2016. It is an app-based organization that takes steps to minimize the gap between the patients and mental health professionals through the online provision of counselling and therapy.

Trijog

Trijog is a Mumbai startup company established in 2014 which provides mental health well-being solutions such as online counselling services to individuals, organizations and corporates. It is in association with the Rehabilitation Council of India (RCI).

ePsyclinic

ePsyclinic is a Gurgaon startup founded in 2015 providing curated special digital counselling sessions involving 24*7 free online chat support to women, frontline health workers, senior citizens and working professionals.

YourDOST

YourDOST is Bengaluru headquartered web counseling platform instituted in the year 2014 connecting individuals with counsellors & psychologists to avail personal, professional and educational counseling. YourDOST enables individuals to manage relationship problems, job stress and develop self-perception.

Wysa

Wysa is a Bengaluru startup founded in the year 2015. It is basically an artificial intelligence powered chatbot to solve mental health related problems. It is a conversational agent that quantifies the user's emotions. It utilizes evidence-based cognitive and behavioural strategies and micro-actions to make the user feel better.

TalktoAngel

TalktoAngel is an online Delhi-based venture committed to mental health and overall well-being.  It offers a variety of services such as one-to-one counselling, couple counselling, corporate wellness program, tele-consultation for medication management etc.

Way Forward

It is recommended that:

• Indian Government should come up with MANAS app to be used by people of all ages including children and elderly.

• State governments should take a leaf from Kerala's Amma Manasu (Mother's mind) and implement the same in states to tackle mental disorders among women at pregnancy and post-partum.

• To solve the deficit of mental health professionals in rural settings, state governments must promote and enact programs that aim to utilize community health workers for screening mental health illness and offering simple mental health first aid.

• To cope with the shortage of mental health professionals, governments at state levels must help establish and set up programs focusing on training professionals who are non-experts such as General Medical Practitioner, psychiatric nurse, social workers etc. for rendering mental health care services, mainly in rural regions and remote territories.

• Tele-counselling facility to students and the population in general needs to be encouraged.

• Applications of technology oriented solutions to addressing mental illness problems must be encouraged.

• Public-private partnerships for facilitating mental health needs to be empowered.

  
  

References

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