National mental health survey of India 2015–2016

Abstract

During the past few months, mental health has received public and media attention in an unprecedented manner. This was related to the release of the report of the National Mental Health Survey (NMHS).[1] Media referred to the findings of the report as follows: “India needs to talk about mental illness;”[2] “Every sixth Indian needs mental health help;”[3] “8% of people in Karnataka have mental illness;”[4] “Mental problems more in 30–49 age group or over 60; low income linked to occurrence of mental disorders;”[5] and “urban areas to be most affected”[2] were some of the headlines in the mass media. The NMHS[1] will be a milestone in understanding the epidemiology of mental disorders in the country. It is against this importance of the survey, the current commentary places the survey in the historical context, describes the methodology of the survey, salient findings and discusses the implications of the survey. Psychiatric epidemiology has been an area of great interest among all the leading psychiatrists. The other similar area of interest is the psychiatric classifications. In both these fields, there are more “failures” than successes in the past 60 years. There have been great times and not so great times in the Indian psychiatric epidemiology. It has been well reviewed.[67] One of the first studies, a massive plan by Govindaswamy as quoted by[67] in the 1st year of the All India Institute of Mental Health, Bengaluru, was so ambitious in identifying the causative factors that it did not get off the planning stage. The next major, a milestone, was the Agra study.[8] This study is significant for the size of the studied population (nearly 30,000 in one study center, as compared to 30,000 + in the National Mental Health survey (NMHS), which is in the focus of the current review) and the identification of factors contributing to mental disorders (rural–urban differences, migrancy, etc.). There were a number of small size studies in the 1960s and 1970s. The most important of these was the “The Great Universe of Kota”[9] considered later. There was a recognition for the need for a large-scale multicentered epidemiological study in 1976 and the Indian Council of Medical Research Department of Science and Technology (DST) project came up.[7] This was a four-centered epidemiological project in Bengaluru, Baroda, Calcutta, and Patiala. Initially, the study aimed to “estimate the prevalence of psychiatric morbidity at different selected centers and investigate the sociodemographic correlates.” However, midway in the project, the objective was shifted to an interventional study, “develop and evaluate methods designed to reach, and offer services to the sick population.”[7] There was a lull in general population, psychiatric epidemiological studies till the early 2000. The next major multicentered study using the World Mental Health Survey (WMHS) occurred in the beginning of the current century. It has had challenges is clear from the fact that it is being published only after 12 years of completion of the study (published in the current issue).[10] The background is important to understand as the NMHS is the most expensive (around Rs. 5 crores), and most ambitious general population epidemiological study undertaken in the country to date. For this reason, it is important to understand the findings in detail and draw lessons for the future. As a scientific discipline, epidemiology has an important place in health sciences. It was Morris who described the seven purposes of epidemiology. These are: (i) understanding the magnitude of the mental disorders; (ii) the causative factors; (iii) calculating the morbid risk; (iv) monitoring the historical trends; (v) completion of clinical picture; (vi) identification of new syndromes; and (vii) treatment utilization in the community.[11] NATIONAL MENTAL HEALTH SURVEY METHODOLOGY The NMHS was undertaken in 12 states across six regions of India (North [Punjab and Uttar Pradesh]; South [Tamil Nadu and Kerala]; East [Jharkhand and West Bengal]; West [Rajasthan and Gujarat]; Central [Madhya Pradesh and Chhattisgarh]; and North-East [Assam and Manipur]). In each state, the dedicated team of investigators included mental health and public health professionals. A uniform and standardized methodology was adopted for the NMHS. A pilot study was undertaken in the district of Kolar, the Public Health Observatory of National Institute of Mental Health and Neuro Sciences (NIMHANS). The Master Protocol for the study was drafted based on the results from the pilot study and finalized after deliberations with the National Technical Advisory Group and the National Expert Panel and discussions with the state teams. A detailed operational guidelines document was developed to conduct the survey. The report provides detailed account of the methodology adopted for the study (pages 7–83) and results (pages 84–132) and presents recommendations (pages 138–144). The methodology adopted was multistage,