Maharashtra’s public healthcare system is facing an acute dearth of mental health professionals with more than half of the posts of psychiatrists vacant. Of the 177 sanctioned positions of psychiatrists in 34 districts across the state, 91 are yet to be filled, data obtained by Hindustan Times from the Directorate of Health Services (DHS) has revealed.
These vacancies are across the state’s four regional mental hospitals located in Thane, Pune, Nagpur and Ratnagiri, as well as in all the district hospitals, which also house the teams of the District Mental Health Programme (DHMP) funded by the Centre and Prerna Prakalp, the state’s programme to address farmer suicides.
According to the DHS, of the 85 sanctioned positions of Class I psychiatrists, 69 are currently vacant. All the 33 posts of Class II psychiatrists are filled. Under the DHMP, which is a part of the Centre’s National Mental Health Programme (NMHP), there are 41 sanctioned posts, but only 30 are filled while 11 remain vacant. Seven out of the nine posts under the Prerna Prakalp programme are also currently vacant.
At a time when the Covid-19 pandemic has exacerbated mental health issues, a shortage of mental health professionals in Maharashtra will have an impact on patients going undiagnosed and untreated. While a few may seek help from private practitioners, many would fall in the gap and never seek medical help at all.
“We have been constantly trying to fill the vacant posts, but many of the psychiatrists who come for interviews don’t eventually take up the postings,” said Dr Sadhana Tayade, director of DHS. “In order to tackle the shortage of psychiatrists, we have started mental health training for MBBS doctors from the primary health centres in districts,” she said. This training began in November 2019, Tayade said.
One of the possible reasons for the vacancies could be that the salary bracket of psychiatrists in Maharashtra is lower than the Centre’s. The classes indicate seniority, work experience and qualification but some of the Class I positions have been vacant for the past several years. “Class I psychiatrists at the National Institute of Mental Health and Neurosciences (NIMHANS) that falls under the Union Health Ministry will have starting salaries of about ₹1.5 lakh,” said Dr Arun Marwale, president of the western region of Indian Psychiatric Society, an organisation of psychiatrists in India with over 7000 members. In Maharashtra, the salaries of Class I psychiatrists start from ₹85,000 and Class II starts from ₹65,000. “Because of the lower pay, many psychiatrists prefer getting jobs in the private sector,” he said.
Marwale said that the government should also ensure that postings are given in the doctors’ home districts. “Often, a doctor from the Marathwada region gets posted all the way in Konkan or vice versa. If the government shows some consideration in giving postings closer home, more doctors will be willing to join,” he said.
Many psychiatrists HT spoke to said that their duty often includes administrative work. “Instead of attending to psychiatric patients, I spend more time visiting courts for medico-legal cases, visiting jails and giving out disability certificates,” said a Class II psychiatrist in a district hospital in the Marathwada region. District hospitals have one post of Class I and Class II psychiatrist each. But since he joined in 2016, there has been no Class I appointment.
“Mental health ailments have increased tremendously over the years but the government is perhaps still not seeing the issue of vacant posts of psychiatrists as priority,” said Dr Javed Attar, a psychiatrist who has a private practice in Latur’s Udgir taluka since the past 11 years. “Contrary to popular belief, more patients have started coming forward to seek medical help after recognising signs of mental distress. Having more psychiatrists will help cater to this increased burden of mental illnesses,” said Attar.
“A large number of people with mental illnesses, especially in rural Maharashtra are below the poverty line. When government facilities lack specialists, the patients are forced into the private sector, which they cannot sustain, and eventually drop out of the treatment,” said psychiatrist and Ramon Magsaysay Awardee Dr Bharat Vatwani. “The pandemic has worsened the financial status of people, and in absence of strong government health services, we are at the risk of an enormous number of patients dropping out of treatments or not being diagnosed at all,” he said.
In a first, DHS analyses footfall at district mental health OPDs during the pandemic
s the pandemic tore through the globe starting March last year, with Maharashtra facing a high daily caseload and case fatality ratio compared to the rest of the country, the state’s medical machinery deployed most of its attention to containing the spread of Sars-CoV-2. This year, the state has also launched heightened efforts to ensure vaccination of all adults. In November, officials at the Directorate of Health Services (DHS) collated the number of people accessing mental health Out Patient Departments (OPDs) during the pandemic.
And, in a first, they also collected the type of conditions that people were seeking help for. This was done to understand the pattern of patient footfall and design better interventions.
The data collated by the DHS revealed that persons with schizophrenia topped the footfall in OPDs in the state: they formed 22.3% of the total footfall between April 2020 and March 2021 and 26.3% of the footfall between April and September 2021. The footfall is an indication of persons with previous diagnoses as well as those who are newly diagnosed. The footfall of those with anxiety disorders in both time periods was 14.6% and 12.7%, and the data showed an uptick in the footfall of persons with major depressive disorders — 9.9% to 12.7%. State officials said that the trend was similar in regional mental health hospitals, where persons with schizophrenia account for nearly 40% of the admissions even during non-pandemic times.
Need for care
The World Health Organization defines schizophrenia as a chronic and severe mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self and behaviour. Common experiences include hallucinations (hearing voices or seeing things that are not there) and delusions (false beliefs).
However, a high OPD turnout or admissions do not necessarily mean a higher incidence of schizophrenia in the state.
According to data from the Global Burden of Disease Study published in The Lancet Psychiatry, nearly 3.5 million people had schizophrenia in India in 2017. However, compared to other mental health diseases, its prevalence was still lower. The data showed that the prevalence of depressive disorders and anxiety disorders was around 3.3% and bipolar disorder was around 0.6% while the prevalence of schizophrenia was around 0.3%.
A 2018 study carried out among youth in rural and urban parts of Pune showed that the prevalence of depression, anxiety, and stress among them was 54%, 60%, and 44%, respectively. Another 2020 study conducted among the farmers in the Vidarbha region showed that anxiety, insomnia and somatic problems were highest reported by farmers. In effect, the studies carried out in communities reveal that anxiety and depressive disorders are higher. The turnout at the OPD indicates otherwise — and there’s a good reason for it.
“Schizophrenia patients get identified more easily compared to those with other mental health ailments, and are therefore more likely to be brought in for medical intervention,” said Dr Sadhana Tayade, DHS director. “This is a common trend we have observed, even as the overall burden of mild to severe depression, anxiety disorders are likely to be much higher in the state compared to schizophrenia. The Covid-19 pandemic has further worsened the situation,” she said.
Identifying the problem
In 2019, the mahila mandal (local women’s organization) at Kalambi village in Nagpur received an unusual letter. A 39-year-old farm labourer man wrote to the local body complaining about his 21-year-old wife.
“She wanders off, sometimes for days altogether. When she comes back home, she refuses to recognise me. She verbally abuses me for no reason. She refuses to cook, or do any household chores. I have no choice but to leave her,” he wrote. The organization responded by calling the couple for counseling. During one of the sessions, the farm worker said, the counselor noticed that his wife was talking to herself and was oblivious of what was happening around her. “The mahila mandal member told me that I should reconsider my decision to leave her and asked me to seek psychiatric counseling for her,” he said.
In July that year, the man took his wife to the OPD of the rural hospital in Kalmeshwar, 10 kilometres from their village. The psychiatrist diagnosed her as having a condition called schizophrenia, which affects people’s interpretation of reality, and started her on medication. The farm worker continued to take his wife to the OPD, open to persons with mental health conditions on the first Tuesday of every month, even after the pandemic hit in March 2020. Three months ago, the doctor reduced her dosage.
“Had the member of the mahila mandal not pointed it to me, I would have never known it was a mental health issue,” the husband said.
“Relatives are more likely to get schizophrenia patients to seek medical advice as compared to patients with other mental health illnesses,” said psychiatrist Dr Bharat Vatwani, who runs the Shraddha Rehabilitation Foundation in Karjat. Vatwani, who won the prestigious Ramon Magsaysay Award in 2018 for his treatment and rehabilitation work, specialises in schizophrenia.
“In most other mental health issues, the patient’s own productivity starts getting affected. It takes some time for the impact to be felt by the family. But in schizophrenia, the patients often drift into their imaginary world and their behaviour has an immediate impact on the family, often disturbing the emotional equilibrium of the members. Therefore, these patients are more likely to be brought in for medical help and relatives often take the lead,” Vatwani said.
“The classic symptoms of schizophrenia make the disorder more visible, while other mental health patients struggle to verbalise their agony,” said psychiatrist Dr Sanjay Kumawat, who practices in Thane and Mulund and has worked with the state health department for nearly three decades. “There are many more patients of depression, anxiety, phobias, and other mental health issues that have increased over the years but are falling in the gap. A large number of these patients are perhaps not getting any medical support,” he said.
The importance of treatment
The DHS data is eye-opening in other ways. For one, it mapped the different kinds of mental health conditions that persons were seeking help for. It also revealed that the footfall was not constant.
For instance, there was an uptick in persons with bipolar disorders seeking treatment (4.6% to 5% between the two time periods), as well as those diagnosed with mental retardation and even persons with addictions. The OPD’s also saw a lot of patients with epilepsy and dementia which are not mental health illnesses.
“In some cases, relatives misunderstand symptoms of epilepsy and dementia as mental health disorders and seek OPD consultations. Such cases are counselled and directed to neurologists,” said an official attached to the state’s mental health programme. “A few patients of epilepsy and dementia may have underlying mental health issues such as anxiety, depression among others. Such patients are started on treatment at the OPDs,” she said.
Tayade said that the DHS is keen to spread awareness about the need for early diagnosis and treatment to reduce admissions. “If mental health issues are treated early, patients don’t reach the chronic state where they may have to be admitted. We are in the process of intensifying our awareness campaigns so that people come to OPD early and start treatment instead of waiting until their disease progresses,” she said.
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