India and the world have committed to Universal Health Coverage (UHC) as part of achieving the Sustainable Development Goals by 2030. UHC is realised when all people have access to the health services they need, when and where they need them, without financial hardship. This includes services linked with mental health and well-being, which is an often overlooked public health concern in India. 

In 2019, Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, asserted: “Mental health must be an integral part of Universal Health Coverage (UHC). Nobody should be denied access to mental health care because she or he is poor or lives in a remote place.” Such declarations, especially from influential figures and organisations are important since mental health is often invisible, is perceived as weakness, and is therefore neglected. Globally, people who suffer from mental health issues often face discrimination, stigma, and human rights violations. India is no exception.

Therefore, the question that we should ask is: What does mental health mean, what is its impact as a public health concern, and does this impact necessitate government intervention?

What is mental health?

Mental health is a state of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn well and work well, and contribute to their community. Mental health includes our emotional, psychological, and social well-being. Our mental health strongly affects our own lives, and the ways in which we shape the world around us. Mental health, therefore, has intrinsic and instrumental value, helping us to connect, function, cope, and thrive.

So then, what characterises mental illnesses? Three terms are crucial here. 

‣ First, mental disorders, which are characterised by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour. These include anxiety disorders, depression, bipolar disorder, Post-Traumatic Stress Disorder, Schizophrenia, disruptive behaviour, dissocial disorders, and neurodevelopmental disorders.

‣ Second, psychosocial disability that arises when someone with a long-term mental impairment interacts with various barriers that may hinder their full and effective participation in society on an equal basis with others. Examples of such barriers are discrimination, stigma, and exclusion. 

‣ Third, the broad term mental health condition covers mental disorders and psychosocial disabilities. It also covers other mental states associated with significant distress, impairment in functioning, or risk of self-harm.

Therefore, mental health is more than simply the absence of mental disorders. It should be understood as a varied and comprehensive part of life, and is experienced differently by each person.

What causes mental health conditions?

There are four broad sets of factors that contribute to mental health conditions.

First are individual psychological and biological factors. Psychological factors relate to individuals’ intrinsic and learned abilities and habits for dealing with emotions and engaging in relationships, activities, and responsibilities. These include severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse; critical early loss, such as the loss of a parent; and neglect. Biological factors include genetics, but also, for example, high potency cannabis use, substance use by the mother, and oxygen deprivation at birth, among others.

Second, a person’s mental health is strongly shaped by their family and community. Parenting is extremely influential. Harsh and authoritarian parenting, neglect, emotional abuse, and corporal punishment significantly contribute to mental health issues. Bullying is a leading risk factor as well. Community level factors include neighbourhood trust and safety, community-based participation, and violence or crime. Furthermore, in India, vulnerable communities and groups including marginalised caste and religious groups and LGBTQIA+ individuals are also at higher risk.

Third, structural factors affect mental wellness. These factors exist outside of individuals and families, and operate at a social level. This includes access to basic services such as access to quality education, health services, sanitation, housing, and social support, food insecurity, unemployment and uncertainty in employment determine the opportunities available to people and their capabilities. This subsequently affects their ability to shape their lives, which is linked to mental wellness. One way in which this was sharply brought to the fore was the COVID-19 pandemic, and related job loss and financial hardship, future especially due to lockdowns. The pandemic caused stress, anxiety, or depression due to social isolation, and uncertainty about the future. Additionally, social stability is critical. Wars, conflict, terrorism, and displacement cause significant mental stress.

Lastly, prevailing beliefs, norms, and values are also crucial. Placing the responsibility of mental health on individuals rather than structural issues causing them and broader notions of productivity culture also adds to mental health conditions. 

These factors often overlap and interact with each other in complex and dynamic ways. For instance, a child may face neglect at home due to parents working long hours to support the family, which in turn could be due to precarity in employment, which again may be due to broader public policy.

Given this complexity, should the government intervene?

In India, mental disorders are among the leading causes of non-fatal disease burden. One in seven Indians were affected by mental disorders of varying severity in 2017. And worryingly, the proportional contribution of mental disorders to the total disease burden in India has almost doubled since 1990. As per the WHO, the estimated economic loss due to mental health between 2012 and 2030 amounts to a staggering ₹85.25 lakh crore. Furthermore, mental healthcare is often unaffordable.

One argument for the government to intervene is to provide support to those who need it. Governments, especially in countries like India aim to protect vulnerable groups and provide social services. Since the determinants of mental health are diverse and varied and merit a response across many sectors, the government is best placed to form policy and programmes to intervene. 

Additionally, reshaping the determinants of mental health often requires action beyond the health sector and so promotion and prevention programme involve the education, labour, justice, transport, environment, housing, and welfare sectors. The government can facilitate multisectoral collaboration and coordination, enabling a broad-based response.

However, government intervention would be a costly endeavour. As per one study, implementing the Mental Healthcare Act (2017), would cost more than ₹90,000 crore, or more than the entire allocation for the Ministry of Health and Family Welfare in Financial Year 2022-23. This is a major stumbling block to government intervention, especially in a resource constrained environment like India. 

This blog is part of a series on mental health as a public health matter and public policy in India. The next blog in this series will explore the Government of India’s response.

Ritwik Shukla is a Senior Research Associate at Accountability Initiative.

Also Read: Big Questions India Needs to Focus on About Implementing a Right to Health