Status of mental health in South Asian countries

The South Asian Association for Regional Cooperation (SAARC) countries comprise 3.4% of the habitable area of the world, and 24% of the world population resides in these countries. In absolute terms, these countries have approximately 1.90 billion people.[1] Three (India––second; Pakistan––fifth; Bangladesh––eighth) out of the eight SAARC countries figure among the top ten most populous countries in the world.[2] All these countries share specific attributes such as a poorly developed industrial base, agriculture-based economies, deficient living standards, and inadequate resources and capacities.[3] In addition, these countries have wide-spread poverty, inequality, and weak public health systems. However, all the SAARC countries share specific cultural attributes and have sound family systems. In terms of mental health professionals, all these countries are characterized by having very few trained psychiatrists and other mental health professionals.[3] The World Health Organization Mental Health Atlas 2020 (for India, data from 2017 were used) suggests that all SAARC countries except Maldives have less than one psychiatrist per 100,000 population.[4,5] The exposure to psychiatry as a subject among undergraduate students in these countries is very poor.[6] The governments in all SAARC countries except Afghanistan spend less than 1% of the total health budget on mental health [Table 1].[4,5] These countries are also characterized by the high prevalence of stigma toward mental illnesses, which acts as a major barrier to seeking mental health care.[3] According to the Mental Health Atlas 2020 data (data available for all SAARC countries except India––for which the latest data were available for 2017 only), all the SAARC countries are also characterized by poor compilation of the mental health data. Fortunately, many SAARC countries have mental health policies and laws, stand-alone or integrated policies or plans for child mental health, adolescent mental health, and suicide prevention [Table 1].[4,5] Table 1: - Mental Health Atlas 2020 of SAARC countries (for India, data were available for 2017 and not for the later years) Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka Total population (UN Official Estimate) 38,041,757 163,046,173 763,094 1,309,053,980 530,957 28,608,715 216,565,317 21,323,734 Total mental health expenditure per person (reported currency) 0.3 USD 0.1 USD 6.9 [BTN] 4 [INR] 43.5 [Maldivian Rufiya] 0.1 [USD] 1947.7 [PKR] – Income group Low Low–middle Low–middle Low–middle Upper–middle Low–middle Low–middle Low–middle Disability-adjusted life years (per 100,000 population) 2042.9 1650.8 1579.4 2443.41 1375.6 1773.7 1601.0 1379.4 Age-standardized suicide mortality rate (per 100,000 population) 5.96 3.85 5.07 16.3 2.76 9.77 9.77 12.89 Availability/ status of mental health reporting Mental health data compiled only for general health statistics in the last two years Mental health data compiled only for general health statistics in the last two years Mental Health specific data compiled in the last two years for public sector Mental Health specific data compiled in the last two years for public sector No mental health data have been compiled in the last two years No mental health data have been compiled in the last two years No mental health data have been compiled in the last two years Mental Health specific data compiled in the last two years for public sector Number of published research articles on mental health (in what time duration?) 16 35 4 – 26 38 65 22 Percentage of mental health research output in total research output within country 9.64% 3.68% 7.02% – 3.75% 5.52% 4.53% 5.71% Percentage of mental health research output of the country in total mental health research output in the region 2.7% 17.9% 2.1% – 13.3% 19.5% 10.9% 11.3% Stand-alone mental health policy or plan Yes, 2019 Yes, 2020 Yes, 2015 Yes, 2014 Yes, 2017 Yes, 2020 No Yes, 2020 Stand-alone mental health law Yes, 2019 Yes, 2018 No Yes, 2017 No No Yes, 2001 Yes, 2017 Stand-alone or integrated policy or plan for child mental health Yes, 2018 Yes, 2019 Yes, 2015 Yes, 2014 Yes, 2016 No No Yes, 2020 Stand-alone or integrated policy or plan for adolescent mental health Yes, 2018 Yes, 2016 Yes, 2019 Yes, 2014 Yes, 2014 Yes, 2019 No Yes, 2019 Stand-alone or integrated strategy/policy/plan for suicide prevention Yes, 2019 Yes, 2020 Yes, 2018 Yes, 2022 No No No Yes, 1996 % of total government health expenditure on mental health by the government 4.2% 0.5% 0.2% 1.3% – 0.2% 0.04% – Number of Psychiatrists 129 270 3 – 17 183 300 123 Psychiatrists per 100,000 population 0.34 0.17 0.39 0.29 3.2 0.64 0.14 0.58 Mental Health Nurses 26 700 9 – 0 123 200 624 Mental health nurses per 100,000 population 0.07 0.43 1.18 0.80 0 0.43 0.09 2.93 Psychologists 133 565 0 – 7 31 100 61 Psychologists per 100,000 population 0.35 0.35 0 0.07 1.32 0.11 0.05 0.29 Social Workers 48 3 0 – 2 – 600 72 Social workers per 100,000 population 0.13 0.002 0 0.06 0.38 – 0.28 0.34 USD = US dollars According to the Mental Health Atlas 2020 data, the SAARC countries contribute to a minuscule of mental health research across the globe.[4] A study that evaluated the mental health research output showed that over the decade of 1992–2001, low- and middle-income countries (n = 152) contributed only 6% of the total mental health research. Further, it was seen that 14 leading high-income countries accounted for 90% of the mental health research.[7] Another study showed that although approximately 15% of the total submissions arise from low-income and middle-income countries, the acceptance rate for manuscripts from these countries was lower compared to high-income countries.[8] A recent attempt to look at academic psychiatry journals originating from SAARC countries showed that out of 20 journals, only three were indexed in PubMed, four were indexed in Scopus, and one was included in the Web of Science. Further, it was noted that most of the journals included in different indexing systems emerged from India.[9] This shows that the research output from SAARC countries is low and the researchers from the SAARC countries face many challenges while publishing their research. When one attempts to look at the research from the South-Asian countries, one of the major limitations is the need for instruments that have been validated in the local socio-cultural background. Most of the research is based on tools developed in Western countries, making generalizing the study’s findings difficult. Although in recent times, some efforts have been made to carry out multicentric studies from India and in the SAARC countries, most of the available research from SAARC countries is from a single center, making it difficult to generalize the findings. In terms of mental health burden till recent times, there was a lack of good quality data on the prevalence of the mental disorder in the community setting in these countries. Recently, National Mental Health Surveys have been done in some of the SAARC countries. The National Mental Health Survey from India estimated the lifetime prevalence of any mental disorder to be 13.7% and the current prevalence to be 10.6%, with mood disorders and neurotic and stress-related disorders among the most prevalent psychiatric disorders. The prevalence of mental disorders was higher among males, those aged 40–49 years, those residing in urban metros, among those who were less educated and had lower family income. The overall treatment gap for psychiatric disorders was 84.5% [Table 2].[10] The National Mental Health Survey of Bangladesh has estimated the prevalence of mental disorders among those aged 18 years or more to be 18.7%. It was further noted that the prevalence of mental disorders was highest among those aged 60 years or more and females. No significant difference was noted in the prevalence of mental disorders among those from urban and rural areas. The various group of mental disorders, depressive disorders (6.7%) were the most common group of mental disorders among adults, followed by anxiety disorders (4.7%), somatic symptoms and related disorders (2.3%), and schizophrenia spectrum disorders (1.0%) [Table 2].[11] The National Mental Health Survey from Nepal suggests that the prevalence of lifetime mental morbidity among adults is 10%, and current mental morbidity is 4.3%. The most common mental disorders are depressive and anxiety disorders. The mental morbidity among adolescents was 5.2%, with neurotic and stress-related disorders being the most common.[12,13] Compared to India, mental morbidity in Bangladesh and Nepal was more in females [Table 2]. Data from the National Mental Health Survey from Afghanistan suggest that the prevalence of major depressive disorder was 4.86 per 1000 population, Generalized Anxiety Disorder to be 2.78, and that of posttraumatic stress disorder was 5.34 per 1000 population in the last 12 months.[14] In terms of suicidal behavior, the prevalence of suicidal ideations during the previous 12 months was 2.2%, that of suicidal ideations in the lifetime was 7.1%, and that of suicide attempts in the lifetime was 3.4% [Table 2].[15] Data from the Maldives collected in 2003 suggest the prevalence of mental disorders to be 29.1%[16] and the National Drug Use Survey of Maldives showed that the prevalence of substance use was 6.64% in males and 2.02% in Atoll, with cannabis being the most commonly used substance [Table 2].[17] Data from the National Survey of Mental Health from Sri Lanka done in 2007 based on screening instruments also suggest that the prevalence of mental disorders is 10%, with somatoform and depressive disorders being the common psychiatric morbidities [Table 2].[18] A good quality national-level data for all the mental disorders could not be found for Bhutan and Pakistan. Table 2: - Mental morbidity as per the National Mental Health Survey Data in SAARC countries India Bangladesh Nepal Afghanistan Maldives Sri Lanka Study NMHS, 2017 NMHS, 2019 NMHS, 2019–2020 NMHS, 2017 Maldives Mental Health Survey, 2003 National Drug Use Survey, 2011–2012 NMHS, 2007 Year of study 2016 2019 2019–2020 2017 2007 Assessment instrument MINI MINI-KID DSM-5 criteria MINI MINI-KID CIDI SF Post Traumatic Stress Disorder (PTSD Check List) PRIME-MD/PHQ -Patient Health Questionnaire Psychosis screening questionnaire CIDI section K questions on PTSD Beck Suicidal Ideation Scale Sample size Adult: 34,802 13–17 years: 1191 Adult: 7270 7–17 years: 2270 Adult: 4474 Adult: 6120 Prevalence of mental morbidity Adult-Lifetime (other than tobacco): 13.67 Adult-Current (other than tobacco): 10.56 Adolescents: 7.3 Adult-Lifetime: 20.2 7–17 years: 12.6 Adult-Lifetime: 10 Adult-Current:4.3 13–17 years: 5.2 29.1% Somatoform Disorders: 3% Major Depression: 2.1% Other Depressive syndromes: 7.1% Panic Syndrome: 0.5% Other Anxiety Syndromes: 0.9% Bulimia: 0.03% Binge eating: 0.2% Alcohol Abuse: 2.8% PTSD: 1.7% Most common psychiatry disorder categories Depressive disorders Alcohol use disorder Neurotic & Stress Related disorder Depressive disorders Anxiety disorder 7–17 years Neurodevelopmental Disorders, Anxiety Disorders Depressive disorders Anxiety disorder 13–17 years Neurotic and stress-related disorders Prevalence in last 12 months Major Depressive Disorder: 4.86 Generalized Anxiety Disorder: 2.78 Posttraumatic stress disorder: 5.34 Any substance addiction 8.22% Prevalence of current drug users Male: 6.64% Atoll: 2.02 Cannabis was the most commonly used substance Mental Disorder Neurotic disorders: 23.3% Anxiety & Depressive Disorder: 5% Epilepsy: 6.1% Somatic disorders: 4% Psychotic Disorders: 1% Factors associated with mental disorders M>F 40–49 years Urban Metro Lower education Widowed Lower-income F>M 50–59 years F>M 40–49 years Suicidality Adult: 1% Adolescents: 1.4% Suicide in a Household: 1% Adult: 7.2% Adolescents: 4.1% SI in past 12 months: 2.2% SI in lifetime: 7.1% Suicide attempt in lifetime: 3.4% Treatment gap 84.5% 91% 77% Non-adherence to treatment 23% Time to first psychiatric consultation 3.2 year CIDI SF = Composite International Diagnostic Interview Short Form, MINI = MINI International Neuropsychiatric Interview, NMHS = National Mental Health Survey Overall, mental health in SAARC countries has been neglected over the years. However, in recent times, there have been certain promising developments in mental health policies and laws in most countries. Still, a lot is to be done. All these countries require increased funding for mental health, human resources, development of information systems for mental health, scaling up of mental health care, and development of culturally relevant research and clinical instruments.[19] As these countries have specific cultural issues in common, there is a need to improve the collaboration between researchers in these countries to learn from each other. The cultural factors can help the mental health professionals to carryout multi-centric studies across the SAARC countries, develop instruments that can be used for research and develop culturally relevant treatment guidelines. The SAARC Psychiatric Federation (SPF) was formed in 2005 during the 57th Annual National Conference of the Indian Psychiatric Society at Chandigarh, India to improve collaboration between mental health professionals in the SAARC countries. An effort was made to start a journal for the federation earlier in 2010, named the ‘South Asian Journal of Psychiatry’, but it was not published regularly. Now, the SPF is starting its journal to allow researchers from the SAARC countries to publish their research. It is hoped that the journal will become popular among researchers and readers! Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.