The demand-side challenges in public mental health: A narrative study in a rural South Indian community

In the context of public mental healthcare delivery in India, in contrast to the often highlighted challenges related to the supply side, the demand-side challenges (DSC) are rarely examined systematically.

To assess the DSC in patients with psychiatric disorders and their caregivers in a rural South Indian community.

This study was conducted as part of a larger implementation research in which all adults in a predefined catchment area were screened for mental disorders, followed by confirmation of diagnosis by mental health professionals. The patients were counseled about (a) the need to start/resume/continue treatment and (b) the availability of services at the nearest health facility. DSC were evaluated by a targeted question to the patient/family members on reasons for not accessing/continuing treatment.

Among the 268 confirmed treatment-naïve patients at baseline, only 6 (0.02%) could be convinced to contact a treatment facility within the next 8 weeks. Regarding DSCs, for all disorders put together, factors related to the illnesses themselves (aggression, hostility, intoxication with substances, absence of insight, and, in instances specific to substance use, lack of motivation to stop its use were present in almost all (98.7%) patients. Lack of perceived dysfunction/disability (42.3%) and poor awareness (24.9%) formed the other two common factors. Disorder-wise breakup showed that poor awareness was predominant in Common Mental Disorders (CMDs; 60%). Illness-related factors predominated in Severe Mental Disorders (SMDs; 66.6%) and Substance Use Disorders (SUDs; 98.7%). Lack of perceived dysfunction mattered next for SUDs (42.3%), followed by poor awareness (24.9%). For SMDs, family support-related factors (47.9%) ranked second, followed by poor awareness (25%).

DSCs significantly contribute to the treatment gap. Merely making the treatment available and accessible will not be sufficient for people to accept it. Aggressive and sustained public health measures/campaigns need to be incorporated to effectively tackle DSCs.