Mental Health Survey Paper
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MENTAL HEALTH ACT - The White Paper (2021)
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Following training, each FDC was trained in general interviewing skills, understand survey procedures, administration of different survey instruments, obtaining consent and interview, documentation using hand-held devices and checking completeness of data collected. The detailed steps of data collection followed in each state as per the sampling strategy is provided in Fig 3. A specific digital application was developed for data collection, real time entry and regular uploading of data.
The FDCs, collected data using hand held digital computers eliminating the use of paper and pen, and allowing direct transfer to the central database thus avoiding errors due to manual data transfer. A three-tier monitoring mechanism was adopted at the field, state and central levels to ensure quality of data collection. At the field level, spot checks were performed by the state teams as well as the field data supervisor. This included observation of interviews conducted by the field data collectors and review of their data monitoring forms. The central team from NIMHANS conducted fortnightly review meetings with the state teams on an e-platform using video conferencing facilities to review progress of each state; appraise them about the quality of data collected and the receipt of uploaded data on to the NMHS server.
Data received was checked for coverage, completeness, quality, errors, duplication and adequacy. Identified errors and duplicates were classified and corrected in consultation with the state teams. A separate log was maintained for all corrections and modifications to the data. This digital data management met ethical standards of human research and was approved by the ethics committee of NIMHANS as part of the protocol. Instruments for quantitative component of the survey could not adequately capture granular information in a few vital areas like the regional nature and patterns of drug use and abuse, homeless mentally ill, stigma, health care utilization, under reporting and diverse cultural understanding and terminologies of mental illness in different areas.
Thus, A qualitative component was included to capture information on these pre-identified domains to supplement the quantitative survey. A structured interview guide with a standard set of questions, probes, and lead points for both the KII and the FGD was developed for the qualitative survey. A separate manual on the conduct of qualitative survey with clear standard operative procedures for conduct of interviews and FGDs were also developed and field tested along with the master protocol for the survey [ 24 ].
In each state, 4—5 FGDs with mental health care providers, community members and others in each district centre and 1 in state capital drawn from both public and private institutions was completed. One KII at the state capital was conducted that included psychiatrists or specialists, pharmacists, state representatives, the police, legal and welfare sector, representatives from a local NGO and media. The findings in each state were summarized in a structured format and reported along with the photograph of the deliberations. Current Point prevalence was reported for all diagnostic groups, while life-time prevalence ever in the life of an individual in the past for select conditions like bipolar disorders and psychotic disorders were reported as they were captured by MINI.
As the primary objective of NMHS was to arrive at estimates of mental morbidity at both national and state levels, adjustment for non-responses inherent in such large surveys had to be factored. The National pooled estimates were calculated using the functionality of applying weights weights on in the Statistical Package for Social Sciences The NMHS was carried out during —16 across 12 states which included 43 districts, 80 sub-districts, clusters, households and individuals.
Overall household response rate was Data collection was started on 2 nd October after all preparations and planning in place in western state of Gujarat and completed on 10 th June in the central state of Madhya Pradesh Table 1. The characteristics of the surveyed population are provided in Table 2. The overall sampling frame consisted of districts from 12 states with 43 districts chosen randomly. Districts selected in five states had a metro city within the same districts while new districts with a metro city had to be selected in seven districts. Individuals aged 18—29 years formed the predominant age group in the survey. The sample proportion was similar to the national proportions as per census [ 41 ] across all age groups, place of residence and literacy status.
The National Mental Health Survey of India —16 is a nation-wide representative survey conducted by adopting a uniform, standardized scientific methodology to arrive at estimates of mental morbidity and their related characteristics in India. The unique nature of the NMHS is its comprehensiveness, and that it provides vital information on the burden, treatment gap, health care seeking, service utilization patterns, disability status and impact of these disorders utilizing both quantitative and qualitative research methods. Furthermore, it also examined the preparedness and response to deliver mental health care to populations by examining mental health systems; all at one point of time. The strength of the NMHS is that it overcame prevailing limitations of previous studies like small and varied sample sizes, limited populations, different time periods, different screening and diagnostic instruments, diverging statistical analyses and interpretations [ 8 , 11 , 12 , 14 , 30 , 45 ].
Lately year onwards , there have been attempts to conduct large scale surveys using validated instruments like the Composite international diagnostic interview schedule CIDI , Structured clinical interview for DSM-IV axis 1 disorders SCID-1 and General health questionnaire in few select countries [ 46 — 53 ]. Globally, the sample size varied from in Lebanon [ 49 ] to 63, in China [ 52 ]. NMHS is by far the largest in India and the second largest mental health survey undertaken in terms of sample size. This was accomplished by undertaking a pilot study, determining adequate sample size, scientifically determined sampling methods, inclusion of urban-metro-rural populations, utilizing valid and uniform study instruments that were translated into local languages, adopting standardized procedures for training and data collection across all study sites at one specified time period, thus ensuring representativeness, uniformity and standardization in a large and diverse country like India.
The sampling distribution was similar to the population distribution of census of India [ 41 ]. Furthermore, the socio-demographic characteristics of those surveyed and not surveyed were observed to be similar. Implementing a large scale nation-wide survey required a strong coordination and networking of professionals and administrators for implementing several activities in a timely manner. NMHS established a robust mechanism to develop, guide, supervise and coordinate all its activities. Multi-disciplinary teams with the right mix of experience and expertise were identified at different levels and brought together to achieve the stated objectives of the NMHS Fig 1.
In parallel, the policy makers were also part of the conceptualization, planning, process and progress of survey that is extremely essential for translating research to actionable programs. In India, there has been a shift from small scale surveys to large scale surveys, comprehensively looking at problems or diseases of public health importance [ 54 — 56 ] in recent times.
However, there was no such survey done for mental health problems in India, except the World Mental Health Survey undertaken 10 years ago. The NMHS is an attempt to bridge this gap and to look at epidemiological characteristics and patterns almost 10 years later. NMHS moved beyond prevalence estimates to also identify the current treatment gap, health care seeking and service utilization patterns, along with an assessment of mental health systems in surveyed states of India. The survey comprehensively examined almost all mental health problems of public health importance including substance use disorders.
Epilepsy was included as part of the survey since, epilepsy has traditionally been part of service delivery in the National Mental Health Program as well as recommended under the WHO mhGAP programme [ 57 ]. Additionally, the NMHS also focused on delineating service utilization patterns, disability status, the impact of mental disorders on individuals and families and the prevailing stigma in society. The focus on inclusion of assessment of current status of delivery of mental health services and systems with a focus on requisite human, financial, physical and other resources was felt essential by policy makers and programme managers for mental health service delivery. Previous mental health surveys on prevalence of mental disorders in India have used variety of case detection tools from unstructured to highly structured ones , each with its strength and limitations as well as a 2-step methodology of screening by different categories of data collection teams and evaluation through different methods ranging from interviews to structured diagnostic tools.
The MINI is a structured diagnostic interview instrument for screening and diagnosing mental disorders both as per the DSM IV TR [ 58 ] and ICD— 10[ 31 ] and available on a digitised platform in different Indian languages, which required adaptation in a systematic manner. In the past, the MINI has been used in population based mental health surveys and has an acceptable level of clinometric properties [ 59 , 60 ]. The MINI adult version was found suitable for the community based epidemiological survey as against MINIplus[ 23 ] which is more suited for in-depth clinical interviews [ 16 , 29 , 61 , 62 ].
Furthermore, as the MINI uses an algorithm to provide the diagnosis, it was considered appropriate for utilisation under National Mental Health Survey. This was also tested for applicability in the field during the pilot survey in Kolar [ 19 ]. The NMHS utilized digital technology for the survey by using hand-held tablets for data collection and adapting online transfer of data from different locations. The digital hand-held tablets used for data collection reduced use of paper, saved time on data entry and reduced errors during data collection and entry with all the skip logics in place. Digital devices ensured speed, facilitated online data transmission, and helped in providing regular feedback for data collection teams.
The pilot survey revealed that use of digital devices are also cost effective for eliminating the use of paper version in diverse field conditions. The fortnightly e-meetings with the state teams ensured discussion on progress, monitor and troubleshoot issues related to the survey. The NMHS had certain barriers and challenges as well. This survey is not without limitations. However, the selected 12 states in phase 1 were representative of different regions in the country and the remaining will be covered in the next phase of NMHS.
The national estimates from these 12 surveyed states are likely to mirror the burden in the remaining states. However, a pilot study of adolescents aged 13—18 years was conducted in 4 states of India to aid development of appropriate methodologies for future studies. However, the fact that it has been widely translated and used in the Indian setting, prompted its choice.
However, recognizing its importance, a qualitative component was included in the NMHS. In conclusion, the scientific, uniform and standardized methodology adopted by NMHS of India —16 will reveal the burden of mental disorders, gaps, challenges and barriers in health seeking for mental health problems along with a status assessment of mental health systems in the country at the same time. This data will serve as evidence to strengthen and implement mental health policies and programs for the coming years as well as enhance investment in mental health care in India.
NMHS also provides a framework for conducting similar population based mental health surveys and other public health problems in many low and middle-income countries that face a disproportionate burden in their populations. The authors would like to express their sincere gratitude to the Ministry of Health and Family Welfare, Government of India for the constant direction, support and funding this survey. Most significantly, our sincere thanks to community members for their cooperation and participation in the survey. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Understanding the burden and pattern of mental disorders as well as mapping the existing resources for delivery of mental health services in India, has been a felt need over decades.
Data Availability: All relevant data are within the paper. Introduction Robust and good quality data is an essential pre-requisite to plan, develop, implement, monitor, evaluate and strengthen mental health services globally and especially in Low- and Middle-Income countries LMICs like India. The broad objectives of the NMHS were Estimating the prevalence and burden of mental disorders in a representative population of India Identifying the current treatment gap, existing patterns of health care seeking and service utilization patterns, along with an understanding of the impact and disability due to mental disorders in India, and Assessing mental health care resources and facilities in the surveyed Indian states for planning and strengthening mental health services in India The NMHS was planned in three phases with the first phase being implemented in 12 representative states followed by surveys in the mega cities.
Preparatory phase Pilot study. Development of protocols and guidelines. Project management The overall project management organogram is provided in Fig 1. Download: PPT. Fig 1. Project management—organogram with roles and responsibilities of different teams. State study and data collection teams The selection of states for Phase 1 of the NMHS was based on representation for different geographical regions of India north, south, east, west, central and north-east , as well as the availability of interested partners to implement the survey as per protocols. Study instruments The study instruments included: 1] A sociodemographic questionnaire developed to collect household and individual details based on the questions from the household questionnaire of the Census of India [ 26 ].
General household information collected included household number, cluster type rural, urban and metro , period of residence in the current location, address, family composition, contact numbers of family members, income from all sources and usual source of treatment during illness. A unique ID was generated for each member in the household for further data capture.
For each of the surveyed members, details of socio demographic information gathered included age in completed years, gender, education, occupation, income and marital status of the individual. The MINI overcomes the impediment of two stage interviews needed in population based mental health epidemiological surveys [ 23 , 28 — 30 ], provides ICD —DCR [ 31 ] compatible diagnostic categories, takes lesser time and was found easy to administer following systematic training to the data collection team. Further, the MINI had the advantage of being available in multiple Indian language versions and had a digital version for administration on tablet computers.
The fact that it has been widely translated and used in the Indian setting, prompted its choice. September 30, Primary Care Collaborative. September 13, Primary Care Collaborative. September 22, Startups List. April 23, The country may be at a mental health breaking point. In addition, more than a third of Americans who responded that they had contracted COVID also indicated they were still living with the physical and emotional side effects of the virus.
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