Closing the treatment gap

Abstract

Byline: M. Thirunavukarasu The importance of mental health in the global health scenario has been amply demonstrated. Worldwide, community-based epidemiological studies have estimated that lifetime prevalence rates of mental disorders in adults are 12.2-48.6%, and the 12-month prevalence rates are 8.4-29.1%. [sup][1] In India, the prevalence of mental illness has been estimated to be around 7.3%. [sup][2] Neuropsychiatric disorders account for about 10.8% of the global burden of disorders in the country. [sup][3] As per the Government of India's National Commission on Economics and Health Report of 2005, the prevalence of serious mental illness in the Indian population is at least 6.5%, which, by a rough estimate, would be 71 million people. [sup][4] Despite these unnerving statistics, the treatment gap, as measured by the absolute difference between the true prevalence of a disorder and the treated proportion of individuals affected by the disorder, has been found to be very high. A large multicountry survey supported by the WHO showed that 35-50% of the serious cases in developed countries and 76-85% in the less-developed countries had received no treatment in the previous 12 months. [sup][5] One of the major reasons attributed to such a wide treatment gap is the problem of inadequate resources, which is more apparent in developing countries like India. In India, inadequacy exists for infrastructure as well as for human resources. This has been made apparent by the statistics provided by the WHO Mental Health Atlas, [sup][6] as summarized in [Table 1]. For example, India has 0.20 psychiatrists per 10,000 population. This can be compared with the ideal of 1 per 10,000 population. [sup][7]{Table 1} The inadequacy has been reported not only in the form of quantity but also in the quality of mental health services. Human rights violations in mental health institutions have been widely criticized as well. The National Human Rights Commission Report [sup][8] (1999) highlights these issues. The report mentions that many institutions still retained a prison-like structure and ambience and prison-like practices such as roll-call and lining up for handover still existed. Exclusively closed wards existed in 59% of the hospitals examined. The building maintenance was unsatisfactory in many hospitals with leaking roofs, eroded floors, overflowing toilets and broken doors. The overall ratio of beds to patients was 1:1.4, indicating that many patients slept on the floor. Some hospitals had no toilets and patients urinated and defecated in the cell, and archaic practices like shaving heads (for both male and female patients) and wearing uniforms were still prevalent. [sup][9] Bridging the GAP These deficits in the quantity and quality of mental health services have not been ignored and steps have been taken to bridge the treatment gap, especially to decrease the deficits in human resources. This has been attempted through the National Mental Health Program (NMHP), which envisages integration of mental health care with general health services, especially at the primary care level. Although the District Mental Health Program (DMHP), the basic unit of the NMHP, was launched with huge fanfare, the program failed to gain the desired momentum, and progress has been very slow. Stagnation in sectors like Departments of Psychiatry in medical colleges and mental hospitals has not only robbed the DMHPs of vital managerial support but had also led to an attitude of indifference and apathy among mental health professionals. [sup][10] Even if properly implemented, this program would have the disadvantage that it may have a long latency time before having the desired effect. Other innovative strategies have also been proposed to improve the gap, like starting short-duration courses for post-graduate training in psychiatry through distance learning. These may improve the quantity of mental health resources at the cost of quality. …