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 Table of Contents  
Year : 2020  |  Volume : 25  |  Issue : 2  |  Page : 143-145

Three tier mental health-care service delivery during COVID-19 pandemic in India

1 Department of Public Health, Indian Institute of Public Health Gandhinagar, Vadodara, Gujarat, India
2 Department of Public Health, Parul Institute of Public Health, Parul University, Vadodara, Gujarat, India

Date of Submission25-Jun-2020
Date of Decision04-Jul-2020
Date of Acceptance08-Aug-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Apurvakumar Pandya
Indian Institute of Public Health, Opp. Air Force Headquarter, Gandhinagar-Chiloda Highway, Near Lekawada Bus Stop, Gandhinagar-382 042, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmhhb.jmhhb_70_20

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The world is concerned about managing COVID-19 pandemic and its consequences. The COVID-19 has not only affected physical health and the economy but impacted the mental health of people globally. It has created a parallel epidemic of psychological distress. Experts envision a gigantic influx of patients needing mental health care, with needs far greater than the nation's existing public health systems can deal with. This paper discusses Indian scenario of mental health issues fueled by COVID-19 pandemic and strategies to address mental health emergency by adopting unconventional sustainable measures and formally integrating mental health into public health preparedness and emergency response plans of the country.

Keywords: COVID-19, India, mental health services, three-tier mental health-care delivery

How to cite this article:
Pandya A, Saha S, Kotwani P, Patwardhan V. Three tier mental health-care service delivery during COVID-19 pandemic in India. J Mental Health Hum Behav 2020;25:143-5

How to cite this URL:
Pandya A, Saha S, Kotwani P, Patwardhan V. Three tier mental health-care service delivery during COVID-19 pandemic in India. J Mental Health Hum Behav [serial online] 2020 [cited 2022 Dec 9];25:143-5. Available from: https://www.jmhhb.org/text.asp?2020/25/2/143/309974

Despite continuous efforts in controlling the spread and mitigating the impact of the COVID-19 pandemic, by intensifying testing, stricter lockdown norms, treatment of infection, quarantine of affected people, developing drugs, vaccine and treatment protocols, there is difficulty in containing the disease. In this age of social media, people are overloaded with misinformation which is creating fear, anxiety, and stress.[1],[2],[3] This also fuels violent behavior within the household as well as community. Reported incidents have been observed such as community members breaking barricades, beating police personnel, and frontline workers.[4],[5]

A huge proportion of India's workforce is employed in the informal and unorganized sector. The employees of such sectors are struggling for food, shelter, and livelihood due to nationwide lockdown for containing COVID-19 pandemic. Moreover, due to the uncertainty of the situation, they are heading toward their native on the foot.[6] Although the Government had started special trains for migrant workers, however, long waiting time and long journey were making them impatient. This has led to agitation among them.[7] Experts believe that the return of migrants may have fuelled spread of the virus in rural hinterlands.[8] In the rural areas, people without livelihood struggled to survive. Similarly, the health of pregnant women and malnourished children were badly affected during the lockdown. Many state governments have initiated the distribution of essential food items through the public distribution system during the lockdown. However, the quantity and quality of the food item distributed in unknown. All these uncertainties often lead to depressed feeling, anxiety, sleep difficulties, and self-harm.

The WHO has also expressed its concern related to the impact of the pandemic on the mental health of the vulnerable population.[9],[10] Various studies speculate that new measures such as self-isolation and quarantine, social distancing have affected usual activities, the livelihood, that resulted in increased loneliness, anxiety, depressed feeling, harmful drug use, and sleeplessness.[10],[11],[12],[13] The lockdown has increased cases of domestic violence with women and children as well.[1],[14],[15],[16] Suicide incidents are also increasing.[17] Cases of suicidal ideation and suicides related to COVID-19 pandemic have been reported recently.[18],[19],[20] Few studies have recorded rising psychological symptoms among the health-care workers.[12],[21]

  Social Stigma Top

Many people who have a history of being exposed to COVID-19-infected individuals or have travelled abroad are not coming forward for testing due to social stigma. Fear of hospitalisation and isolation compel them to hide their risk status and avoid testing for COVID-19 and they show reluctance to seek medical support. Since years, it is observed that stigma has negatively impacted HIV prevention, TB prevention, and many viral outbreaks such as Ebola and SARS.[22],[23],[24],[25] Many have died due to this pandemic, and it seems that many more will lose their lives in days to pass. In this scenario, providing psychological support is crucial to the people with infection and families who have lost their dear ones.

  Vulnerable Population Prioritizing Mental Healthcare Top

The WHO has highlighted about the vulnerable population for COVID-19 pandemic.[10] However, in the Indian scenario, not only elderly, health-care workers or people with chronic disease are vulnerable but also migrants who are stuck and are travelling in groups, malnourished children, pregnant women with anaemia or chronic health condition, specific population groups such as transgender, sex workers, orphan children, and police personnel. All of the above-mentioned vulnerable group requires guidance and counselling to deal with the crisis. Addressing mental health needs is equally important for population infected with COVID-19 disease and those vulnerable to the disease.

  Mental Health Care Response Top

The Government of India has started a telephonic helpline for psycho-social support. Besides, online resources are also available but are scattered. Accessibility of these services to all the segments of the society, including vulnerable population, is questionable. In this crisis of lockdown amid COVID-19 pandemic, mental health professionals face challenge due to sudden surge in cases with psychological disturbances. Most efforts go into dealing with people who require basic guidance, lifestyle-change to manage themselves; hence, the biggest challenge is the missing-out of people who have a diagnosable mental illness and need urgent support.

The acute shortage of mental health specialists in a country makes it impossible to extend mental health services to the entire mass. For example, as per the WHO (2016), India has only 0.29 psychiatrists, 0.069 psychologists, 0.796 psychiatric nurses, and 0.065 psychiatric social workers per 100,000 population.[26]

While we welcome the temporary tele-mental health services (psychosocial support telephone helpline) to improve access to care and address the psychological effects of quarantine and isolation, we believe that tele-mental health should not be seen as a temporary fix in times of emergency; rather, it is a safe, convenient, cost-effective, scalable, and sustainable method of healthcare delivery[27],[28],[29] should be integrated into the public health system.

  Towards Sustainable Solution Top

Strengthening of and expanding the existing human resources and integrating mental health into public health response to COVID-19 pandemic appear to be the two major solutions. Mental healthcare services through the primary health-care system (particularly, health and wellness center) and tele-psychiatry or e-mental health services can be tapped.[30],[31] A bottom-up three-tier system for mental health care has potential to amalgamate these two solutions into the current public health system. [Figure 1] depicts a bottom-up three-tier mental health-care system.
Figure 1: Bottom-up three-tier mental healthcare system

Click here to view

At the primary level (First-tier), community-based frontline health workers, and volunteers who will be trained on lay counseling and psychological first-aid. Frontline workers will be enabled to provide screening, basic counseling, and psychological first-aid during their regular home-visits while volunteers can provide support through tele-mental health. The district mental health programme can be utilized to provide mental health care at the primary care level and support follow-up of high-risk cases identified during Tier II and III to ensure medicines reach to patients either patients receive medicines from the respective primary health center, a psychiatric unit at district hospitals or sent to patients' doorstep. Delivering first-tier services using a combination of tele-mental health platform as well as in-person consultation by frontline health workers has the potential to increase reach and offer preventive mental health services assisted with standard screening tools. Those screened positive for moderate-to-severe mental disorders or those already suffering from the disorders should be referred for professional counseling through psychologists, nurses, and social workers working in Mental Health Sector, which will form the second-tier of the system. In cases where the patients cannot be managed only by therapeutic counselling and require medical attention and management, will then be referred to a psychiatrist (i.e., third-tier of the system). This layering of mental health professionals will reduce the ever-growing challenge of increased burden on specialist through task-shifting and adopting the gate-keeper approach. Such three-tier mental health-care model should be continued in the post-pandemic era as a measure toward postdisaster crisis prevention by providing long-term support to reduce psychological distress and prevent further mental health problems after the pandemic.

Along with three-tier mental health care, comprehensive digital mental health campaign for creating awareness and reinforcing positive behaviors can improve uptake of services. Nationwide strategic planning and coordination team for mental health support should be established for effective implementation, monitoring, and improvising the services.

The way forward

Hope that three-tier mental health care can be an opportunity to address public health emergency by adopting unconventional sustainable measures and formally integrating into public health preparedness and emergency response plans of the country.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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