Mental health is a critical yet often neglected component of public health in India. The World Health Organization (WHO) defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” For community health nursing professionals, understanding the framework of mental health services in India is essential for providing holistic care to individuals and communities.

India’s approach to mental health care has evolved significantly over the years, moving from institutional care to community-based approaches. The three pillars that govern mental healthcare in India are the National Mental Health Programme (NMHP), the National Mental Health Policy, and the Mental Healthcare Act. These frameworks collectively aim to address the mental health burden in the country through a comprehensive, rights-based approach.

Figure 1: Visual representation of India’s National Mental Health Programme and Policy components

2. Mental Health Burden in India

Understanding the burden of mental health disorders in India provides context for the development of the national mental health frameworks.

                    Key Statistics on Mental Health Burden:
                    Approximately 6-7% of India’s population suffers from mental disorders
The World Bank report (1993) revealed that the Disability Adjusted Life Year (DALY) loss due to neuropsychiatric disorders is higher than diarrhea, malaria, worm infestations, and tuberculosis individually
Mental disorders account for 12% of the global burden of disease (GBD)
Projections indicate this will increase to 15% by 2020 (World Health Report, 2001)
One in four families is likely to have at least one member with a behavioral or mental disorder (WHO 2001)
Over 90% of people with mental disorders remain untreated
According to the National Mental Health Survey (2015-16), the prevalence of mental disorders in India is 10.6%
The lifetime prevalence of mental disorders is 13.7%, meaning approximately 150 million Indians need intervention

                

Poor awareness about symptoms of mental illness, myths and stigma related to mental health, lack of knowledge about treatment availability, and potential benefits of seeking treatment are significant causes for the high treatment gap in India. The economic burden of mental health disorders is also substantial, affecting productivity and quality of life at individual and community levels.

Factors	Impact on Mental Health
Socioeconomic Status	Poverty, unemployment, and financial stress contribute to increased risk of mental disorders
Stigma and Discrimination	Prevent people from seeking help and accessing mental health services
Mental Health Literacy	Low awareness about symptoms, treatments, and available services
Healthcare Infrastructure	Limited mental health facilities and workforce, especially in rural areas
Policy and Legislation	Historical gaps in mental health policies and implementation challenges

3. National Mental Health Programme (NMHP)

The Government of India launched the National Mental Health Programme (NMHP) in 1982, making India one of the first countries in the developing world to initiate such a program. The NMHP was conceptualized to address the massive mental health burden in the country and to provide mental health care services to all, particularly to the most vulnerable and underserved populations.

3.1 Objectives of NMHP

The National Mental Health Programme was established with three primary objectives:

To ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population
To encourage the application of mental health knowledge in general healthcare and in social development
To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community

3.2 District Mental Health Programme (DMHP)

The District Mental Health Program (DMHP) was launched under NMHP in 1996 during the 9th Five Year Plan. The DMHP was based on the ‘Bellary Model,’ which was first implemented as a pilot project in Bellary district of Karnataka. It demonstrated the feasibility of providing mental health services through existing primary healthcare infrastructure.

DMHP Components: “EITM”

Early detection & treatment of mental disorders
Information, Education & Communication (IEC) for public awareness
Training of general physicians and health workers
Monitoring and record keeping for evaluation

The training component of DMHP focuses on imparting short-term training to general physicians for diagnosis and treatment of common mental illnesses with limited medications under specialist guidance. Health workers are trained in identifying persons with mental illness and referring them to appropriate facilities.

The DMHP was initially launched in 4 districts and has since expanded to 692 districts across all 36 states and union territories of India (as of recent updates). This expansion reflects the government’s commitment to addressing mental health needs across the country.

3.3 Evolution of NMHP

1982

Launch of National Mental Health Programme (NMHP) with the objective of ensuring availability and accessibility of minimum mental healthcare for all

1996

District Mental Health Programme (DMHP) launched during the 9th Five Year Plan based on the ‘Bellary Model’

2003

Re-strategized NMHP during 10th Five Year Plan with increased budget allocation

2007

India signed United Nations Convention on the Rights of Persons with Disabilities (UNCRPD)

2014

National Mental Health Policy launched to provide direction and framework for mental health services

2017

Mental Healthcare Act enacted, replacing the Mental Health Act of 1987, focusing on rights-based approach

2022

National Tele Mental Health Programme (Tele MANAS) launched to provide 24×7 tele-mental health services across the country

4. National Mental Health Policy

In October 2014, the Government of India launched the National Mental Health Policy titled “New Pathways, New Hope.” This policy was a significant milestone in India’s approach to mental health, providing a comprehensive framework for addressing mental health needs of the population. The policy was formulated in response to the high burden of mental disorders and the recognition of mental health as an integral component of overall health and wellbeing.

4.1 Vision and Values

Vision of the National Mental Health Policy

“To promote mental health, prevent mental illness, enable recovery from mental illness, promote destigmatization and desegregation, and ensure socio-economic inclusion of persons affected by mental illness by providing accessible, affordable, and quality health and social care to all persons within a rights-based framework.”

Core Values and Principles:

Value	Description
Equity	Equal access to mental healthcare services for all citizens
Justice	Fair treatment and protection of rights of persons with mental illness
Integrated Care	Holistic approach combining medical and psychosocial interventions
Evidence-Based Care	Treatment and interventions grounded in scientific evidence
Quality	High standards of care and treatment services
Participatory Approach	Involvement of persons with mental illness in decisions about their care
Rights-Based Framework	Recognition and protection of the rights of persons with mental illness
Governance	Effective administrative structures for implementation
Holistic Approach	Addressing biological, psychological, and social dimensions of mental health

4.2 Goals and Objectives

Primary Goals:

To reduce distress, disability, exclusion, morbidity, and premature mortality associated with mental health problems across the lifespan
To enhance understanding of mental health in the country
To strengthen leadership in the mental health sector at national, state, and district levels

ASPIRERS: Key Objectives of the National Mental Health Policy

Access: Provide universal access to mental health care
Services: Increase access to comprehensive mental health services
Protection: Ensure rights protection and harm prevention for persons with mental illness
Inclusion: Address needs of vulnerable populations
Reduction: Reduce risk factors, prevalence, and impact of mental disorders
Eliminate: Work to eliminate stigma associated with mental health problems
Resources: Enhance availability of skilled human resources
Support: Increase financial allocation and address psychosocial determinants

4.3 Strategic Areas

The National Mental Health Policy identifies several key strategic areas to achieve its goals and objectives:

Strategic Area	Key Components
Effective Governance	Establishing administrative mechanisms for implementation at national, state, and district levels
Mental Health Promotion	Programs at Anganwadi centers, schools, workplaces, and community settings
Prevention and Reduction	Initiatives to prevent mental illness and reduce suicides
Universal Access	Family-centric services, community-based rehabilitation, and assisted living services
Human Resources	Increasing trained mental health professionals in communities
Community Participation	Engaging communities in mental health service provision and development
Research	Promoting studies on mental health and allied disciplines

The policy was accompanied by the National Mental Health Plan-365 (2013), which outlined the roles and responsibilities of each stakeholder for implementing specific actions. The major stakeholders include the central government, state governments, local bodies, civil society organizations, persons with mental illness, healthcare providers, educational institutions, private sector, and media.

5. Mental Healthcare Act 2017

The Mental Healthcare Act, 2017, enacted on April 7, 2017, and implemented from May 29, 2018, replaced the previous Mental Health Act of 1987. This landmark legislation marks a paradigm shift in India’s approach to mental health, moving from a custodial model to a rights-based approach. The Act aligns with India’s obligations under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD).

5.1 Key Features

Definition of Mental Illness

The Act defines “mental illness” as “a substantial disorder of thinking, mood, perception, orientation, or memory that grossly impairs judgment or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.”

CARES: Core Features of Mental Healthcare Act 2017

Community living and rights protection
Advance directives for treatment preferences
Regulatory bodies (Mental Health Authorities and Review Boards)
ECT restrictions (prohibited for minors, must use anesthesia)
Suicide decriminalization

5.2 Rights of Persons with Mental Illness

The Act establishes several fundamental rights for persons with mental illness:

Right to access mental healthcare services that are affordable, accessible, of good quality, and available in sufficient quantity
Right to equality and non-discrimination in healthcare
Right to live in the community and not be segregated
Right to protection from cruel, inhuman, and degrading treatment
Right to information about treatment and participate in development of treatment plan
Right to confidentiality regarding mental health status, treatment, and records
Right to access medical records
Right to personal contacts, communication, and legal aid
Right to make complaints regarding deficiencies in services

The Act mandates the provision of free treatment for homeless persons with mental illness and those from below poverty line families, even without proof of BPL status.

5.3 Advance Directive

One of the most progressive features of the Act is the provision for advance directives. This allows individuals with mental illness to specify:

How they wish to be treated (or not treated) for their mental illness
Who should be their nominated representative to make decisions on their behalf when they are unable to do so

The advance directive must be in writing and witnessed by a medical practitioner. This provision respects patient autonomy and gives them greater control over their treatment process.

Institutional Structure under the Act

The Act establishes two key regulatory bodies:

Central and State Mental Health Authorities: Responsible for registering, supervising, and maintaining registers of mental health establishments and professionals, developing quality and service provision norms, and advising the government on mental health matters.
Mental Health Review Boards: Responsible for protecting the rights of persons with mental illness, addressing complaints regarding deficiencies in care, and reviewing advance directives.

Important Prohibitions

Electroconvulsive therapy (ECT) without anesthesia is prohibited
ECT is prohibited for minors
Sterilization of men or women with mental illness is prohibited when intended as treatment for mental illness
Chaining of persons with mental illness in any manner or form is prohibited
Solitary confinement and physical restraints are restricted

6. Role of Community Health Nursing in Mental Health

Community health nurses play a crucial role in implementing the National Mental Health Programme, Policy, and Act at the grassroots level. Their position at the front line of healthcare delivery makes them instrumental in early identification, intervention, and community-based management of mental disorders.

6.1 Assessment and Screening

Assessment Area	Nursing Actions
Mental Health Screening	Using standardized tools to screen for common mental disorders during routine health visits
Risk Assessment	Identifying individuals at risk of suicide, self-harm, or harm to others
Community Assessment	Identifying community-level risk factors for mental health problems
Family Assessment	Evaluating family support systems and caregiving burden
Treatment Adherence	Monitoring medication compliance and treatment follow-up

SCREEN: Mental Health Assessment Framework for Community Nurses

Symptoms assessment using standardized tools
Caregiver burden and support evaluation
Risk factors identification (suicide, violence)
Environmental assessment (home, community)
Education needs analysis
Network mapping of available resources and support systems

6.2 Community-Based Interventions

Community health nurses implement various interventions to promote mental health and manage mental disorders in community settings:

Intervention Area	Specific Activities
Mental Health Education	Conducting awareness campaigns about common mental disorders Dispelling myths and misconceptions about mental illness Educating about warning signs and when to seek help
Case Management	Follow-up of persons with mental illness in the community Medication management and monitoring side effects Linking patients with appropriate mental health services
Psychosocial Support	Providing basic counseling and supportive therapy Organizing support groups for patients and caregivers Teaching stress management and coping skills
Rehabilitation	Supporting community reintegration of persons with mental illness Facilitating vocational training and employment opportunities Promoting social inclusion and reducing stigma
Crisis Intervention	Identifying and responding to mental health emergencies Suicide prevention interventions De-escalation techniques for agitated patients
Advocacy	Advocating for the rights of persons with mental illness Facilitating access to social welfare schemes and benefits Promoting compliance with the Mental Healthcare Act

Community health nurses also collaborate with Accredited Social Health Activists (ASHAs), Anganwadi workers, school teachers, and community leaders to create a supportive environment for mental health promotion and care within communities.

7. Challenges in Implementation

Despite the progressive frameworks established by the National Mental Health Programme, Policy, and Act, several challenges hinder their effective implementation:

Challenge Area	Specific Issues	Implications for Nursing
Resource Constraints	Limited financial allocation (0.06% of health budget), inadequate infrastructure, shortage of mental health professionals	Increased workload, need for task-shifting, compromised quality of care
Implementation Gaps	Delay in establishing regulatory bodies, insufficient guidelines for operationalizing the Act, state-level variations in implementation	Uncertainty in practice protocols, ethical dilemmas in care delivery
Mental Health Literacy	Poor awareness, stigma, discrimination, cultural barriers to help-seeking	Need for intensive community education, anti-stigma interventions
Service Accessibility	Urban-rural divide in service availability, affordability issues, geographic barriers	Need for outreach services, telemedicine approaches
Training and Capacity	Inadequate training of primary care providers, limited mental health content in nursing curricula	Need for continuous professional development, specialized training
Coordination Issues	Poor intersectoral coordination, fragmented service delivery	Need for care coordination roles, liaison with multiple agencies

Critical Implementation Barriers

A major concern is the availability of mental health professionals. India has approximately:

0.3 psychiatrists per 100,000 population (compared to global average of 1.5)
0.07 psychologists per 100,000 population
0.12 psychiatric social workers per 100,000 population
0.05 psychiatric nurses per 100,000 population

This severe shortage significantly impacts the implementation of mental health programs and policies, particularly in rural and underserved areas.

8. Best Practices in Mental Healthcare

Several innovative approaches and best practices have emerged in mental healthcare delivery across India and globally that can inform community health nursing practice:

Best Practice	Description	Implementation Examples
Task-Sharing/Task-Shifting	Training non-specialist healthcare providers to deliver basic mental health interventions	NIMHANS Community Mental Health Training Program, MANAS intervention in Goa
Digital Mental Health	Leveraging technology for mental health service delivery	Tele MANAS (National Tele Mental Health Programme), mHealth apps for mental wellness
Community-Based Rehabilitation	Involving community resources in the rehabilitation of persons with mental illness	Banyan’s Home Again program, SCARF’s community outreach in Tamil Nadu
Peer Support Models	Utilizing recovered patients as peer support workers	NIMHANS Peer Support Volunteers, Schizophrenia Awareness Association peer groups
Integration with Primary Care	Incorporating mental health services into primary healthcare	Kerala Mental Health Integration model, Karnataka’s tele-mentoring program
Cultural Adaptation of Interventions	Modifying evidence-based interventions to suit local cultural contexts	Culturally adapted cognitive behavioral therapy, yoga and meditation integration

Global Best Practice: Friendship Bench (Zimbabwe)

The Friendship Bench is a community-based intervention where grandmothers (community health workers) provide problem-solving therapy on wooden benches placed in the grounds of health centers. This approach has shown significant reductions in symptoms of depression and anxiety and has been adapted in various countries. Similar peer-based community interventions could be adapted in the Indian context, particularly utilizing ASHAs and community health nurses.

Recent Innovation: National Tele Mental Health Programme (Tele MANAS)

Launched on October 10, 2022 (World Mental Health Day), Tele MANAS functions as the digital arm of the District Mental Health Programme to provide universal access to equitable, accessible, affordable, and quality mental health care. The program operates through a network of 23 tele-mental health centers of excellence and offers 24/7 counseling services. Community health nurses can utilize this resource for referrals and follow-up support for patients in their communities.

9. Conclusion

The National Mental Health Programme, Policy, and Act together form a comprehensive framework for addressing the mental health needs of India’s population. These initiatives represent a significant shift from institutional, custodial approaches to community-based, rights-oriented mental healthcare. They emphasize the importance of accessibility, affordability, quality, and dignity in mental healthcare services.

For community health nurses, these frameworks provide both opportunities and responsibilities in mental health promotion, prevention, treatment, and rehabilitation. As front-line healthcare providers, nurses play a crucial role in early identification of mental health problems, providing basic psychosocial interventions, ensuring appropriate referrals, and supporting community reintegration of persons with mental illness.

Despite challenges in implementation, the progressive vision embodied in these frameworks has the potential to transform mental healthcare in India. By actively participating in mental health programs, advocating for the rights of persons with mental illness, and continuously enhancing their own mental health competencies, community health nurses can contribute significantly to realizing this vision.

The journey toward comprehensive, accessible, and high-quality mental healthcare in India requires sustained commitment, adequate resources, intersectoral collaboration, and continuous evaluation. With dedicated efforts from all stakeholders, including community health nurses, the goals of the National Mental Health Programme, Policy, and Act can be achieved, leading to improved mental health outcomes and quality of life for all citizens.

10. References

National Mental Health Programme (NMHP). National Health Mission. https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=1043&lid=359
National Mental Health Policy of India. Ministry of Health & Family Welfare, Government of India, October 2014. https://nhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf
The Mental Healthcare Act, 2017. India Code. https://www.indiacode.nic.in/bitstream/123456789/2249/1/A2017-10.pdf
Gupta S, Sagar R. National Mental Health Programme—Optimism and Caution: A Narrative Review. Indian Journal of Psychological Medicine. 2018;40(6):509-516.
Mishra A, Galhotra A. Mental Healthcare Act 2017: Need to Wait and Watch. International Journal of Applied and Basic Medical Research. 2018;8(2):67-70.
Murthy RS. National Mental Health Survey of India 2015-2016. Indian Journal of Psychiatry. 2017;59(1):21-26.
Aneja J, Kumar R, Gupta S, et al. National Mental Health Policy, India (2014): Where Have We Reached? Indian Journal of Psychological Medicine. 2022;44(5):510-515.
Math SB, Basavaraju V, Harihara SN, et al. Mental Healthcare Act 2017 – Aspiration to Action. Indian Journal of Psychiatry. 2019;61(Suppl 4):S660-S666.
Dandona R, Sagar R. COVID-19 offers an opportunity to reform mental health in India. The Lancet Psychiatry. 2021;8(1):9-11.
World Health Organization. Mental Health Action Plan 2013-2020. Geneva: World Health Organization; 2013.