How primary health care can bridge the mental health gap

India faces a significant burden of mental health conditions, contributing nearly 15 percent of the global mental health disorder burden. Between 1990 and 2017, the country witnessed a doubling of the disease burden from mental health issues.

In 2017, prior to the pandemic, approximately 200 million people in India were estimated to need mental health care, with the treatment gap exceeding 80 percent. This underscores the pressing need to scale up mental health services across the country.

The Mental Health Care Act of 2017 accorded mental health care as a right. However, the present status of mental health services in the country is inadequate to realize this right. PATH, through a systems approach, is capacitating the health workforce and supporting the public health systems in the intervention geographies to bridge the gaps for comprehensive mental health care services.

Unlike other noncommunicable diseases, mental health issues are not widely discussed within communities and are highly stigmatized, which hinders their normalization and care-seeking.

Many people still believe that mental health conditions are attributed to a person’s weaknesses, bad deeds, or supernatural causes. There is a considerable lack of awareness and understanding of mental health conditions, which further makes it difficult for people to identify the symptoms and take treatment.

The provision of mental health services in India has predominantly been specialist-driven, concentrated in highly specialized tertiary care institutions. The country faces a critical shortage of mental health professionals, with only 0.3 psychiatrists, fewer than 0.01 child psychiatrists, 0.07 psychologists, and 0.8 mental health nurses per 100,000 people—well below the recommended density.

Moreover, there are significant regional disparities in access to care, with northern states and rural areas, where the majority of the population lives, having far fewer resources and services available.

Mental health services in the private sector are expensive and primarily concentrated in urban areas. Additionally, mental health professionals, including psychiatrists, psychologists, and other health care providers, often work in isolation, leading to confusion and fragmentation for individuals and families seeking care. Moreover, there remains a predominant focus on the biomedical approach to treating mental health conditions, which frequently overshadows the critical role of psychosocial interventions.

There has been a limited focus on providing reliable and easy-to-use self-care tools for mental health (not including the plethora of mental health apps, which have their own challenges in terms of coverage and quality). The country has also not prioritized the systematic development of skills of non-specialists to provide basic mental health services or setting up systems to support such care provision at scale.

Integrating mental health services into primary care is a viable way of closing the treatment gap and ensuring that people get the mental health care they need. Mental health care within primary care settings is cost-effective, promoting early interventions and efficiently addressing comorbid conditions. This approach enables patients to stay active within their communities and maintain household productivity while receiving care.

Integration also enhances treatment adherence, simplifies access to medications, and improves overall patient outcomes. Because primary care services are not tied to specific conditions, they reduce the stigma, making care more acceptable and accessible.

The importance of integrating mental health into primary care and adopting community-based approaches has been well-recognized in India and endorsed through national health and mental health policies and programs. This effort gained further momentum with the Government of India’s flagship initiative, Ayushman Bharat. Under this program, existing sub-centers and primary health centers have been transformed into Health and Wellness Centres (Ayushman Aarogya Mandirs, AAMs).

Mental health services have been included as one of the twelve essential service packages offered at these centers. To improve accessibility to quality mental health care at AAMs, a comprehensive model has been developed, ensuring a seamless care continuum through backward and forward linkages.

PATH began its work in the mental health space in India in 2021, focusing on advancing mental health literacy and services, particularly for youth. Through the Stakeholder-Led Advancement of Mental Health of Young People (SAMYP) project (Jan 2021–Jan 2023), funded by Fondation Botnar, PATH conducted a comprehensive analysis of multisectoral policies and programs, addressing the mental health needs of young Indians aged 15-24.

Using methods like desk reviews, stakeholder consultations, and youth engagement, SAMYP created resources to enhance mental health literacy and encourage self-care and help-seeking behaviors among young people.

In 2023, PATH began working toward reimagining comprehensive primary health care for young people and adolescents. Our efforts focused on building resilient urban health ecosystems in three cities in Manipur by integrating services at urban primary health care facilities and creating adolescent-friendly hubs to provide responsive, affordable, and quality care.

During this period, PATH also provided technical assistance to the Asian Development Bank on technologies for the management of noncommunicable diseases (NCDs) and mental health in primary care settings. After conducting a landscape assessment and tech-innovation challenge, PATH developed an open-source digital directory of cost-efficient, patient-centered technologies to enhance NCD and mental health management. PATH also completed a multicounty landscaping exercise, which helped in learning more about science and practice globally towards scaling up mental health services.

Early in 2024, in collaboration with the Government of Karnataka and supported by the Indira Foundation, we launched a three-year project (2024-2027) titled ASPIRE. This initiative aims to build a scalable public health model for youth mental health in Chikkaballapura district, aiming to empower young people aged 15-24 years with mental health literacy and self-care in collaboration with the education department and programs run by the youth affairs and sports department and empower Community Health Officers at AAMs to provide screening and first level of counseling and referral services.

Currently, PATH is providing technical assistance to The Ministry of Health and Family Welfare, Government of India, and governments in ten states to build the capacity of primary health care providers for expanding mental health services at AAMs.

The path forward is for concerted action across the sector, focusing on the following:

1. Empowering primary health care providers with literacy and skills for early identification, screening, and first-line care—counseling, diagnosis, treatment, and follow-up—that is based on clearly defined roles, decisions, and referral pathways.
2. Health systems strengthening to ensure regular supply of essential drugs and commodities at the primary health care level, regular recording and reporting of data through a mental health information system.
3. Identifying factors and addressing inadequate help-seeking for mental health problems in the intervention areas.
4. Integrating care of comorbid mental health conditions alongside physical health conditions across the platforms of care needs to be prioritized, as mental health conditions affect individuals across the lifespan and often co-occur with chronic physical health conditions.
   
   For India, it is imminent that we strive toward bridging the gap, and work toward building a system that recognizes “there is no health without mental health." At the helm should be a commitment to empowering service providers and addressing the community's needs and priorities for equitable access to mental health resources and care.