National Tele-Mental Health Program in India: A step towards mental health care for all?

India has a huge burden due to mental health problems, with one in every seventh person estimated to be suffering from a clinically diagnosable mental disorder.[1] This is likely to further increase significantly if we also consider subthreshold symptoms of psychological distress in the population, which also contributes to the poor mental health of the population. However, the latest National Mental Health Survey noted that despite this huge demand for mental health care services, the available mental health resources in terms of infrastructure and trained mental health professionals are severely deficient even as per the conservative international norms (e.g., at least one psychiatrist per lakh of population).[2] This grave problem is also reflected in the wide mental health treatment gap of approximately 83% for any mental disorder in India even prior to the onset of the COVID-19 pandemic. Apart from the usual ethical and public health arguments in favor of the need to invest more for improving the mental health of people, it has been well-established now that poor mental health is a significant contributor toward loss of productivity and a country’s economy. Poor mental health globally was associated with an estimated total financial loss amounting to approximately $2·5 trillion per year in 2010. It has been projected to rise to $6 trillion by 2030 if the current pattern continues. At the same time, spending on measures to scale-up treatment for depression and anxiety alone yields four-fold return on investment.[3] Further, the COVID-19 pandemic has significant direct and indirect negative effects on the mental health of the entire population. For example, the percentage increase in the prevalence of clinically significant depression and anxiety disorders due to the COVID-19 pandemic for the year 2020 was estimated to be approximately 35% in India.[4] Similarly, there has been a 10% rise in the number of suicide deaths reported for the year 2020 in India as compared to 2019.[5] This has brought back the focus of everyone over the importance of ensuring good mental health of the population. There has been a significant disruption in the existing traditional modes of delivering mental health services due to the COVID-19 pandemic (diversion/repurposing of resources, restrictions on non-emergency out-patient visits, etc.), and subsequent shifting toward alternative models of service delivery such as tele-mental health services to meet this huge unmet demand for mental health care.

In line with this, the central government of India in its recent union budget (2022–23) announced the launch of the National Tele-Mental Health Program (NTMHP). The Finance minister in her budget speech acknowledged the negative mental health consequences of the COVID-19 pandemic and announced that a network of 23 tele-mental health centers of excellence will be established under the NTMHP to provide people with better access to quality mental health counseling and care services.[6] These centers will function with NIMHANS as the nodal center for its successful implantation and the International Institute of Information Technology-Bangalore providing the requisite technological support. Subsequently, the Tele-Mental Health Assistance and Nationally Actionable Plan through States (T-MANAS) initiative was announced by the NIMHANS under the NTMHP to provide free round-the-clock tele-mental health services in all parts of the country, particularly to people living in remote or under-served areas.[7] The stated vision of T-MANAS involves linking these new tele-mental health centers with the existing network of locally available mental health resources at nearby centers of excellence, medical colleges, district hospitals, and other mental health services run by the central and/or state government. This will help in providing immediate mental health care to a person in acute psychological distress and facilitate continuity of care by making appropriate referrals to nearby specialized mental health services depending upon the person’s convenience and severity of the mental health problem. The NTMHP also envisions linking tele-mental health services with other health-related schemes and services provided by the government under the Ayushman Bharat Digital Mission (National digitalization of health records and services) and the e-Sanjeevani platform (National tele-consultation service). In addition, the Principal Scientific Advisor’s Office to the government launched a mobile app called “MANAS Mitra” aimed at promoting mental well-being among people in April 2021.[8] The feasibility and utility of this app are currently under field testing. However, there is lack of clarity regarding the operationalization of this welcome initiative announced by the government to bridge the huge mental health treatment gap in India. Here, we will briefly discuss the potential of tele-mental health services in addressing several of the shortcomings of the existing mental health program and provide a few suggestions to be considered while designing the T-MANAS services under the NTMHP for ensuring its successful implementation in India.

The existing National Mental Health Program (NMHP) and the District Mental Health Program (DMHP) have faced significant challenges in their successful implantation in India due to non-uniform delivery of services due to local administrative issues or inability to utilize allocated funds (e.g., some states doing better than others and some districts in a state doing better than others), lack of availability of adequately trained mental health professionals at the primary health care level, and absence of effective central monitoring and evaluation of the program activities to provide corrective feedback in a timely manner.[9] The term “tele-mental health” encompasses a wide range of mental health services that are delivered through the use of telecommunication or internet-based digital devices. This includes a broad spectrum of services involving varying levels of digital technology use such as telephonic calls, text messages, e-mails, and interactive audio-visual conferencing [Table 1]. The available literature suggests that tele-mental health services provide a viable solution to many of the problems hampering the successful implementation of NMHP and DMHP in India.[10] Tele-mental health can provide quality care in an easily accessible (accessible from home or nearby place with no need to visit medical center/hospital), affordable (free consultation, no travel cost, and no loss of daily wages), convenient (24 × 7 availability), and private manner (reduce stigma attached to mental health treatment-seeking behavior) to people experiencing mental health problems. Further, mental health professionals located in cities or distant centers can provide services to people living in remote or rural areas where trained mental health professionals are not available currently. This can also be used for capacity building and training of non-specialist health workers in identifying mental health problems and initiating initial treatment or specialist consultation through tele-mentoring and tele-monitoring initiatives.[11]

Table 1

Range of tele-mental health services

Tele-mental health service	Examples
Tele-mental health helpline (audio mode; telecommunication supported)	Distress helplines (suicide prevention), Telephonic psychosocial counseling
Text lines (text mode; telecommunication or internet supported)	Mental health support via mobile messaging/text messages or e-mail
Tele-psychiatry (audio-video mode; telecommunication or internet-supported)	Online consultation with mental health professionals (synchronous or asynchronous)
Online psychotherapy (audio, video, and text mode; internet supported)	Providing diagnostic or therapeutic services by clinical psychologists using audio-visual consultation, Counseling through artificial-intelligence-based chatbots
mHealth interventions (smartphone-based)	Mobile mental health apps have been developed to provide a range of mental health services such as psychoeducation, self-monitoring of symptoms, self-management of symptoms, or seeking professional help.

However, there are certain important challenges that need to be effectively tackled for the successful implementation of the recently announced NTMHP in India. There is a lack of clarity regarding the structure (e.g., first point of contact with psychiatrist, psychologist, trained health worker, or layperson; triaging; and referral process) and range of services (counseling, structured psychotherapy over multiple scheduled sessions, teleconsultation, prescription of medications if indicated, etc.) provided by tele-mental centers set up under the NTMHP. We will have to see if and how this will be distinct from the existing toll-free national mental health rehabilitation helpline being run by the Ministry of Social Justice and Empowerment in India for people to seek quality mental health counseling.[12] India is a country with great socioeconomic, cultural, and linguistic diversity. Thus, while planning tele-mental health services implantation at the national level, care must be taken to adapt these services to the local cultural context of different regions (e.g., operation capabilities in the local language and delivering interventions in a culturally sensitive way). There is a need to incorporate helpful indigenous treatment modalities such as yoga or mediation along with the delivery of psychoeducation about the bio-psycho-social model of mental health in a culturally sensitive manner. Moreover, it is not clear if and how the provision to provide appropriate psychotropic medications would be made available to people seeking care through tele-mental helplines under the NTMHP. Further, a significant proportion of the population in India has poor digital literacy and lack access to smartphones or quality internet connection, and are also often at greater risk of experiencing poor mental health and mental disorders. Thus, a range of tele-mental health services needs to be planned to promote equitable access to these services; for example, having a text messaging line to seek immediate intervention or schedule a call-back/appointment from the tele-mental health center based on initial basic information provided in the text message. There is significant stigma attached to mental health, and people often do not seek or are hesitant in seeking treatment due to the fear of this. Thus, assuring the patient of privacy and health-related data security is of critical importance in ensuring successful adoption of tele-mental health services by people. There is a need to have training programs to sensitize mental health professionals about the technological, legal, ethical, and clinical aspects related to the tele-mental health practice. In addition, there is a need to develop quality control mechanisms and systems for regular monitoring and evaluation of tele-mental health service delivery as well as assessment of mental health-related outcomes among its beneficiaries.[13] This will in turn help to create manpower that meets certain minimum quality standards and provide standardized mental health services. Lastly, there will be a significant group of patients with severe mental illness (e.g., schizophrenia, bipolar disorder), cognitive impairment (e.g., dementia, intellectual development disorder), sensory deficits (e.g., visual or auditory impairments), or some other problems (personal preference, paranoia, etc.) who will not be able to use any of the available tele-mental health services adequately and would need in-person care. Thus, tele-mental health services should supplement the existing traditional mental health care system (NMHP/DMHP) with digital technology-delivered interventions complementing the in-person care received by the person experiencing mental health problems.

The NTMHP is a welcome step toward achieving the goal of mental health care for all, but care should be taken to design and deliver standardized, evidence-based, and culturally appropriate tele-mental health services under the T-MANAS initiative. Further, there is a need to develop standard operating protocols and quality assurance mechanisms for these tele-mental health services. This shall be critical in ensuring the success of this program aimed at providing accessible and acceptable quality mental health services to the masses.