We examined summary trends in prevalence of mental health conditions from 2002 to 2018 reported in nationally representative surveys and the latest status of mental health service delivery infrastructure and human resources coverage in the state of Kerala. Overall, we found that burden was greater in Kerala as compared to national averages and has been steadily growing. We also found that the availability of infrastructure and health workers falls short of globally recommended thresholds.
A third of patients seeking care in community based or psychiatric hospital setting have been reported to experience internalised stigma [36]. Even accounting for under-reporting in surveys assessing mental disability, prevalence is increasing. Indeed, actual burden may be higher in Kerala, but is the level of health literacy and health seeking in the state, in a larger context where emphasis is being placed on reporting on this issue. This is a clear area for further study. Studies have attributed the rise of depression in Kerala to a shift in family patterns from joint to nuclear families and the associated rise in loneliness and abandonment of the elderly, rising divorce rates, unemployment, gender inequalities, economic migration to countries in the Middle East/Gulf region (with wives staying behind in Kerala), overconsumption, pressure on students, alcoholism, and tensions associated with modern living [17, 37]. National Crime Records Bureau (NCRB) data from 2016 report that family problems, illness, alcohol/ drug abuse and bankruptcy are also major drivers of suicide in India [38]. Clearly, more study is needed in this domain.
Having been the first Indian state to formulate a mental health policy (in 2003), Kerala has been expanding services in order to offer screening and management of common mental health conditions at the primary health care level [39]. In 1999 the District Mental Health Programme (DMHP), and Direct Intervention System for Health Awareness (DISHA) released in 2013 were designed to strategize around and implement mental health initiatives by expanding the district mental health program and integrating it with the private sector [40]. Alongside this, strong referral pathways have to be established to provide more specialised care for mental health [41]. These programmatic aspects need to be assessed and evaluated.
Studies have indicated a lack of mental health service provision in primary health centres in the state [40, 42]. This is now expected to change given the reforms brought about under the aegis of Kerala’s Aardram flagship initiative, which established depression screening clinics named Ashwas (which roughly translates into “assurance”) (initially) in nearly 170 Family Health Centres (FHCs) across the state. Ashwas doctors and staff nurses are trained in psycho-social counselling and clinical guidelines, and are directed to manage screening for depression and treatment at FHCs, while trained field health workers are to identify cases in defined vulnerable and high risk groups for referral to FHCs [43]. The degree to which this program can improve diagnosis, treatment and care of those with mental health conditions is a critical area for further monitoring and research. The DHMP and Ashwas clinics are joined by the private sector in providing services in the face of continued calls for improved accessibility, availability, and quality of mental health services and family-support services for this target population [40, 44, 45]. This is another area of further study.
Delivery of services for mental health depends on the availability of human resources for providing such services. India has a long way to go in this area: a 2011 WHO report found that for every million people in India, there are just three psychiatrists, and even fewer psychologists, 18 times fewer than the Commonwealth norm of 5.6 psychiatrists per 100,000 people [46]. In Kerala, the number of psychiatrists available per thousand population was higher than the Indian average, however there were relatively fewer clinical psychologist, psychiatric social workers and no psychiatric nurses available in the state. The shortage of mental health professionals is especially acute in the public sector [42]. An assessment conducted in 2013 found that district level shortages abound; 75% of psychiatrist positions were found to be vacant in Malappuram and Palakkad districts [47]. This has been tied to medical education; Roy and Rasheed found a deficiency in the number of psychiatry post graduate seats, attributing this to the inadequate number of psychiatrists in the country [25]. These shortages can be addressed with appropriate training for health care professionals at the primary level [48] as well as non-specialist health-care providers [12].
The toll of COVID-19 on mental health is well established [49]: globally, around three fourths of COVID- affected persons have been diagnosed with posttraumatic stress disorders (PTSD) along with depressive and anxiety disorders [50]. Studies have found that health providers are facing stress, anxiety, depressive symptoms, insomnia, denial, anger and fear due to social isolation [51, 52]. People in quarantine have reportedly experienced boredom, loneliness, anger, anxiety and guilt about the effect of contagion and stigma on family and friends [52, 53]. A recent study found that during the COVID-19 pandemic in Kerala, depression was a major problem faced by people under home quarantine (75.2%) followed by stigma (69.5%) and anxiety (69.4%) [54]. In response, the state adopted inter and intra-departmental coordination to ensure continuity of services and access to additional support like medications and rations – in part to mitigate these challenges [52]. Clearly more is needed: COVID has starkly revealed that both Kerala and India are indicative of the phenomenon common in Low and Middle Income Countries (LMICs), where despite substantial and growing burdens, support for mental health and psychological care is vitiated by scarcity of resources and lack of adequate information in the population [41]. Research and programmatic support are required to strengthen these responses.
Limitations
Despite the similarity of domains analysed, the scale of measurement differed for most of the surveys. Some reported in percentages, others in proportions and some in absolute numbers, which raised issues of comparability across the years. The focus of mental health surveys has also varied over the years and now perception of mental illness has changed resulting in change of operational definitions, again limiting comparability over the years. Ideally, secondary data would be triangulated across multiple data sources to improve quality and ensure reliability [55]. This is of course difficult to do with survey data, which is of long periodicity typically, and tends not to afford such comparison or triangulation. Often, routine health data can be used for this purpose. In our case, however, routinely collected departmental data on mental health illness in the state was not available in the public domain. A report by NITI Aayog, a premier think tank of the Indian government, has also raised concern that routinely collected data in our public health system has quality issues (like incompleteness and lack of validation) [56]. Another limitation in our analysis was our inability to look at population subgroups facing greater burdens of mental illness. Future research should draw from across sources to carry out more precise and triangulated analyses, adjusting for age, sex, as well as other dimensions of inequality, such as socio-economic status, occupation, and more.
