Mental disorders are highly prevalent. According to the Global Burden of Disease study, mental disorders have risen to become the 6th leading cause of health loss worldwide, up from 9th place in 1990 [1]. In 2021, 13.9% of the global population experienced mental disorders. Depressive and anxiety disorders are among the top causes of Disability-Adjusted Life Years (DALYs), ranking 12th and 23rd, respectively. These conditions also show the most significant increase in DALY rates from 2010 to 2021. The global age-standardized suicide rate was 9.0 per 100,000 population in 20191. In India, the suicide rate is 12.4 per 100,000 population2.

The prevalence of depressive disorders in BRICS nations is 4.09%, exceeding the global average of 3.91%. In terms of absolute numbers, India, China, Brazil, and Russia rank 1st, 2nd, 4th, and 6th respectively for the highest number of individuals affected by depression. Collectively, BRICS nations account for approximately 44% of the global burden of depression [2].

According to the National Mental Health Survey [3], 2016, the estimated prevalence of mental disorders among individuals over the age of 18 in India, excluding tobacco use disorders, was 10.6%. The lifetime prevalence of these disorders in the surveyed population was 13.7%.

Between 76% and 85% of individuals with mental, neurological, and substance use conditions do not receive adequate care, with the treatment gap exceeding 90% in many low- and middle- income countries3. In India, the National Mental Health Survey [3] revealed a treatment gap of 28% to 83% for mental disorders and 86% for alcohol use disorders.

Globally, there are 1.7 psychiatrists and 1.4 psychologists per 100,000 population4. In India, however, the median number of psychiatrists is just 0.2 per 100,000 population, significantly below the required levels. The number of psychologists is even lower, at only 0.03 per 100,000 [4].

The 2030 Agenda for Sustainable Development, adopted by all United Nations Member States in 2015, provides a shared blueprint for peace and prosperity for people and the planet, now and into the future. At its heart are the 17 Sustainable Development Goals (SDGs), which are an urgent call for action by all countries – developed and developing – in a global partnership. Goal 3 is related to health – Ensure healthy lives and promote well-being for all at all ages5. Within the health-related sustainable development goals, two targets are directly related to mental health and substance abuse:

Target 3.4 “By 2030, reduce by one third premature mortality from Non communicable diseases through prevention and treatment and promote mental health and well-being”5.

Target 3.5: “Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol”6.

From the discussion above, it is evident that mental health should be a major concern for BRICS nations. Various service delivery models exist for managing mental disorders, with the Public Health Delivery model being particularly significant. In this article, the authors outline the Public Mental Health system in India, which could serve as a model for other countries.

India was one of the first nations in the world to have a National Mental Health Programme (NMHP) which was launched in 1982 with the following objectives:

The model of service delivery in NMHP was through Primary Health Centres and Community Health Centres. However, this was not successful. It was later felt that District will be a better unit to provide mental health serves. The District Mental Health Program (DMHP) was launched under NMHP in the year 19968. The main goal of DMHP was to provide Community Mental Health Services and integration of mental health with General health services through decentralization of treatment from Specialized Mental Hospital based care to primary health care services. The DMHP has objectives and components presented in Table 1.

As per DMHP Guidelines8, one psychiatrist, one clinical psychologist, one psychiatric social worker, one psychiatric nurse, one community nurse, one monitoring and evaluation officer and case registry assistant and one ward assistant are the staff of the District Mental Health Programme Team. The DMHP has currently been approved for 767 districts across the country. Under DMHP, the service provision at various levels is as described in Table 2.

There is also a public private partnership model in DMHP. It is being utilized for following activities:

The NMHP was re-strategized in 20039 to include two schemes as tertiary care component, modernization of state mental hospitals and up-gradation of psychiatric wings of medical colleges/general hospitals. 25 Centres of excellence have been sanctioned to increase the intake of students in Post graduate departments in mental health specialties as well as to provide tertiary level treatment facilities. Further, the government has also supported 19 government medical colleges/institutions to strengthen 47 Post graduate departments in mental health specialties.

Telangana. The state has adopted integration of perinatal mental health as part of comprehensive Ante Natal Care (ANC). Screening tools by Auxiliary Nurse Midwife (ANM) are introduced in the mother and child protection card and the MCH portal has included the indicators of the same for reporting. ANC counselling cards integrated with elements on mental health.

Tamil Nadu. "Mental Health Thursdays," known as "Mana Nala Viyazhan." Dedicated to raising awareness about mental health among the health care workers on a regular (weekly) basis through messages shared on WhatsApp.

Odisha. Mobile Mental Health Units (MMHU) for providing doorstep mental health care services to the Persons with Mental Illness (PwMI). Fixed day visits to CHC, PHC, HWC for providing mental health care services.

Karnataka. Various initiatives undertaken by the state are as follows:

India also has a separate National Mental Health Policy10 which was released in October 2014 with the following goals:

The policy calls for universal access to quality services, equitable distribution, community participation, rights-based approach, intersectoral coordination, use of appropriate technology and a holistic approach to mental health.

It is fully implemented, and its principles have been incorporated in the National and District Mental Health Programmes and Mental, Neurological and Substance Use Package of services at Ayushman Bharat Health & Wellness Centres.

In 2022, the National Tele Mental Health Programme (Tele MANAS) was also launched with the following aim and objectives11.

Aim: to provide universal access to equitable, accessible, affordable and quality mental health care through 24x7 tele-mental health counselling services as a digital component of the NMHP across all Indian States and Union Territories with assured linkages.

Objectives:

As of July 23, 2024, 36 States/ UTs have set up 53 Tele MANAS Cells and have started telemental health services12. The service is available in 20 different languages. More than 1 million calls have been handled on the helpline number since inception with an average of 3500 calls per day13.

The Government of India also rolled out Comprehensive Primary Health Care14 under the Ayushman Arogya Mandir approach. The approach covers Mental, Neurological and Substance use disorders. As per the guidelines15 of the same, a five-pronged approach is being used to enable the integration of mental health care in primary health care:

In addition to the above programmes, India also has a National Suicide Prevention Strategy16 which has the following objectives:

India has a strong legislative mechanism with regards to mental health. The Mental Health Care Act of India, 2017 is a progressive act and follows a rights-based approach in line with the United Nations Convention on the Rights of Persons with Disabilities17. The Rights of Persons with Disabilities Act, 2016 also covers mental illness as a disability18.

Mental health service delivery in India faces numerous challenges, many of which are also encountered by other nations. These challenges are listed below.

These are important times for mental health in India. The Ministry of Health and Family Welfare has steadily increased its focus on mental health. Various societal groups, including NGOs, celebrities, professional organizations, and human rights associations, have been advocating for advances in mental health service delivery. The dialogue on mental health has gained momentum across different sections of society.

India has embraced technology wholeheartedly. The widespread availability of internet connectivity, smartphones, and affordable mobile connections has led to innovative approaches in service delivery and training. The country had the world’s second-largest internet population at over 1.2 billion users in 2023. Of these, 1.05 billion users accessed the internet via their mobile phones. Estimates suggest that this figure would reach over 1.2 billion by 205020. Artificial Intelligence is also being explored as a tool for enhancing mental healthcare. Chatbot based tools are being developed. Various mental health smartphone apps have been developed providing mental health screening and diagnostic tools, counseling services, health promotion and consultation services [5].

There has been a steady shift from hospital-based mental healthcare to community-based care, with efforts towards 'de-institutionalization.' Many mental hospitals have moved beyond the colonial mindset and approach. The rights of persons with mental illness are being given due importance, and rehabilitation services, such as halfway homes, skill development, and employment opportunities, are being expanded.

The focus has also shifted to a lifespan approach. The mental health of children and adolescents is being specifically addressed, with the School Mental Health Programme being strengthened [6]. The geriatric population is included in various mental health care approaches. Women's mental health, especially perinatal mental health, has become a focus area [7]. Various corporate organizations are also addressing the mental health of their employees. Additionally, the mental health aspects of climate change and disasters are being prioritized.

The authors would also like to emphasize the restoration of family as a support system as an important strategy to promote mental health as well enhance care for persons with mental illness. The family provides buffer, guidance and support to its members going through stress. The sharing of resources and emotional availability plays a huge preventive role. Further, if one develops a mental disorder, the family provides support, ensures adequate treatment and helps the person recover from their problems.

Further, efforts should be made to create community based self-help groups. These groups provide a supportive network where individuals can share experiences, offer mutual support, and work collectively towards better mental health. Such groups can be instrumental in reducing stigma, normalize the mental health issues, promote empowerment and self-efficacy, build social connections, provide an emotional outlet and complement the professional help, all this in a very accessible cost-effective manner.

India still has a long way to go to achieve the goals envisioned in various programs, but efforts are increasing every year. It is believed that India's Public Mental Health Model can serve as a guide for other nations.

1. Suicide worldwide in 2019: global health estimates. Geneva: World Health Organization; 16 June 2021. Accessed August 5, 2024. https://www.who.int/publications/i/item/9789240026643 2. Accidental Deaths & Suicides in India 2022. New Delhi; National Crime Records Bureau; 2022. Accessed July 4, 2024. https://data.opencity.in/dataset/6af5e9d7-9de5-4689-9fe3-3418790bb0d5/resource/493c904b-d83b-48bc-bf55-678594ffffff/download/1701611156012adsi2022publication2022.pdf 3. mhGAP operations manual: mental health Gap Action Programme (mhGAP). Geneva: World Health Organization; 8 January 2018. Accessed August 5, 2024. https://www.who.int/publications/i/item/mhgap-operations-manual 4. Mental health ATLAS 2020. Geneva: World Health Organization; 8 October 2021. Accessed August 5, 2024. https://www.who.int/publications/i/item/9789240036703 5. Sustainable Development Goals. The United Nations: Department of Economic and Social Affairs. Accessed August 5, 2024. https://sdgs.un.org/goals 6. Sustainable Development Goals. The United Nations: Department of Economic and Social Affairs. Accessed August 5, 2024. https://sdgs.un.org/goals 7. National Mental Health Programme (NMHP). Ministry of Health and Family Welfare, Government of India. Accessed August 6, 2024. https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=1043&lid=359 8. District Mental Health Programme. Accessed September 1, 2024. https://mohfw.gov.in/sites/default/files/56464578341436263710_0_0.pdf 9. National Mental Health Programme. Ministry of Health and Family Welfare, Government of India. Accessed August 6, 2024. https://dghs.gov.in/content/1350_3_NationalMentalHealthProgramme.aspx 10. National Mental Health Policy of India. Ministry of Health and Family Welfare, Government of India. October 2014. Accessed August 6, 2024. https://nhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf 11. National Tele Mental Health Programme of India. Ministry of Health and Family Welfare, Government of India. Accessed August 6, 2024. https://telemanas.mohfw.gov.in/aimobjectives 12. Mental health programmes. Press Information Bureau. Ministry of Home Affairs. Accessed August 6, 2024. https://pib.gov.in/PressReleaseIframePage.aspx?PRID=2039067#:~:text=As%20on%2023.07.,handled%20on%20the%20helpline%20number 13. In a significant milestone achieved under the National Tele Mental Health Programme of India, the Tele-MANAS Helpline receives over 10 lakh calls since its launch in October 2022. Press Information Bureau. Ministry of Health and Family Welfare. Accessed August 6, 2024. https://pib.gov.in/PressReleasePage.aspx?PRID=2022057 14. Comprehensive Primary Health Care. National Health Systems Resource Centre. Accessed August 6, 2024. https://nhsrcindia.org/practice-areas/cpc-phc/comprehensive-primary-health-care 15. Operational Guidelines Mental, Neurological and Substance Use (MNS) Disorders Care at Health and Wellness Centres. Accessed September 1, 2024. https://aam.mohfw.gov.in/download/document/Final_MNS_Operational_Guidelines_-_Web_Optimized_PDF_Version_-_19_11_20.pdf 16. National Suicide Prevention Strategy. Ministry of Health and Family Welfare, Government of India; 2022. Accessed September 1, 2024. 17. The Mental Healthcare Act, 2017. Accessed September 1, 2024. https://mohfw.gov.in/sites/default/files/Mental%20Healthcare%20Act%2C%202017_0.pdf 18. The Rights of Persons with Disabilities Act, 2016. Accessed August 6, 2024. https://depwd.gov.in/acts/ 19. Comprehensive Primary Health Care. National Health Systems Resource Centre. Accessed August 6, 2024. https://nhsrcindia.org/practice-areas/cpc-phc/comprehensive-primary-health-care 20. Basuroy T. Mobile internet users in India 2010-2050. Statista, Jul 18, 2023. Accessed August 6, 2024. https://www.statista.com/statistics/558610/number-of-mobile-internet-user-in-india/