Rs 19,000. That is how much Avani Tiwari was quoted after a single session of therapy in January for her depression. This was over and above the Rs 1,500 for the consulting session and would include light medication and lab tests for vitamin deficiency, thyroid and allied hormone tests.
The result? Avani never went back for any more sessions with the therapist.
“I barely earn enough to manage my monthly expenses in Mumbai. How will I be able to afford such expensive therapy,” she added. Tiwari occasionally calls free online helplines since she finds regular face-to-face sessions to be out of her financial reach.
Amidst a renewed focus on mental health issues after actor Sushant Singh Rajput’s death by suicide, a lot of discussion centered around access to medication. Many advocated those suffering from psychological issues to reach out for help.
But, the reality is that treatment for anxiety, depression and allied psychological diseases is unaffordable, and out of reach, for most in India.
Let alone admission into a healthcare facility which comes with its own stigma, a one-hour session with a qualified therapist would cost no less than Rs 800. How many Indians would be able to afford this?
Also, one would need to take 20-30 sessions on an average before seeing an improvement in their emotional health.
One may contest this claim by saying that why not take an insurance cover. Technically, health insurance should cover outpatient (OPD) expenses like therapist consultation, diagnostic tests and pharmacy bills. However, those dealing with mental health ailments say that they don't get any such cover to meet their needs.
Why is insurance not covering mental health ailments?
Under the Mental Healthcare Act 2017, offering insurance for mental health ailments has been made mandatory by law. The Act says that every insurer has to offer medical insurance for treatment of mental illness on the same lines as insurance for physical illness treatment.
S Prakash, managing director of Star Health Insurance told Moneycontrol that there is no option but to cover mental health ailments as well. He added that it is mandated by the Insurance Regulatory and Development Authority (IRDAI).
“All insurers are expected to cover mental illness as this is to be treated as any other disease. Insurers are also required to publish their underwriting policy on mental illness. I believe that if there is any health assessment to be done, insurers can do that and decide. But an insurer cannot say no,” he added.
On May 16, the Supreme Court issued a notice to the insurance regulator (IRDAI) seeking the latter’s response on coverage of mental health ailments in policies. Though it is mandated, covers are still not widely available. SC was responding to a petition where it was stated that insurers were refusing to cover mental health treatment.
Special covers for ailments like cancer, diabetes, cardiovascular disorders (heart diseases) are easily available. But, no specialised cover for mental health exists. However, if a hospital rejects a hospitalisation claim of any mental health ailment, the policyholder can file a formal complaint since this is illegal.
The head of underwriting at a private general insurer told Moneycontrol that while the industry is mandated to cover hospitalisation, waiting periods can be chosen by the insurer and also certain terms.
“Due to the absence of adequate claim data on mental health ailments in India, niche products covering OPD for mental health are not available. We also exercise caution and seek complete medical history for those with pre-existing conditions may find it tougher to buy a product,” he added.
The common caveats are up to four-year waiting period for coverage of treatment, minimum hospitalisation duration (three to five days) to be eligible as well as exclusion of some components.
Insurers also ask the proposed policyholders to disclose complete medical history for coverage under health plans. If any past cases of psychological-ailment related hospitalisation is declared, there are chances of either rejection from coverage or 30-35 percent higher premiums quoted.
Alpes Panchal, a Mumbai-based consultant psychiatrist and de-addiction specialist also agrees.
He said that if there is any inpatient based procedure for psychiatry problems the insurance does not cover it, neither does it cover tests or further psychiatry OPD consultations.
The demand-supply gap in psychological ailments
The Section 18 of the Mental Healthcare Act, 2017 says that every person shall have a right to access mental health care and treatment from mental health services run or funded by the government. If the government fails to provide the right to access mental health care to everyone, then it is the responsibility of the government to reimburse the costs of treatment.
In reality, this never happens.
According to this National Mental Health Survey 2016, about 130 million people require mental health services. Mental disorders are not only highly prevalent and disabling medical conditions but also have huge treatment gap. The treatment gap is defined as the percentage of individuals with mental illness who are not on treatment.
Another issue of serious contention is that the treatment gap for mental disorders according to NMHS ranged between 70 percent and 92 percent across different disorders. This huge treatment gap raises serious questions regarding the accessibility, affordability, and acceptability of the available mental health services.
In India, there is also a wide gap between availability of qualified professionals for those seeking immediate access to such services.
According to the World Mental Health Atlas (2014), there were 0.3 psychiatrists per lakh of population in India. Psychologists and psychiatric social workers were even fewer.
The median number of psychiatrists in India is only 0.2/100,000 population compared to a global median of 3 per 100,000 population. Similarly, the figures for psychologists, social workers, and nurses working for mental health are 0.03, 0.03, and 0.05/100,000 population.
India currently has 9000 psychiatrists, 2000 psychiatric nurses, 1000 clinical psychologists, and 1000 psychiatric social workers. The country would need an additional 30,000 psychiatrists, 37,000 psychiatric nurses, 38,000 psychiatric social worker and 38,000 clinical psychologists.
According to a study published in the Indian Journal of Psychiatry, it will take 42 years to meet the requirement for psychiatrists, 74 years for psychiatric nurses, 76 years for the psychiatric social worker, and 76 years for clinical psychologists, for providing care for 1.3
The same goes for the hospital beds as well. In India, approximately 56,600 public psychiatric beds (35,000 psychiatric beds in mental hospitals, 10 beds each in 723 district hospitals, and 30 beds each in 479 medical colleges) exist for a 130 crore population.
In the mental hospitals, a substantial proportion of the psychiatric beds is occupied by the homeless mentally ill. As per international standards the estimated requirement would be 50 beds per 1,00,000 population.
As per the above estimate, India requires 650,000 psychiatric beds for 1.3 billion population, but available psychiatric beds are only 56,600. The deficit is approximately 600,000 public psychiatric beds.
But, what about the access to basic consultation itself?
There is a stark difference in the way the public sector and private sector functions. If it is an organised setup, there will be an easier access to services.
Soumitra Pathare, one of India's leading psychiatrists and Director at Pune-based Centre for Mental Health Law and Policy said that broadly speaking organised public sector is good.
“They have access to support, access to healthcare including mental healthcare. So that group of people probably have some access to help of some kind,” he added.
As against popular perception, Pathare said that in the private sector the access to healthcare is largely restricted to large employers with only large employers able to provide such assistance.
In the medium and small-scale enterprise (MSMEs), he doesn’t think that mental healthcare services are provided, while in the unorganised sector there is absolutely no facility available.
Indians also have access to online counselling services. However, the 'free versions' of these initiatives do not have any experts and once you opt for a professional help, the charges could go up to Rs 12,000 per month since these doctors are based in other countries.
If you choose a domestic entity, private sector entities and independent therapists charge between Rs 800-2,500 per session. Only after two to three months of consistent therapy would the patient see any results. However, the costs are too high to bear.
While in government hospitals mental health services are provide at subsidised prices, they are either unable to meet the demand or not easily accessible.
There is lack of awareness and poor insurance coverage for the treatment of mental disorders. Medical practitioners also told Moneycontrol that there is a high level of misinformation as well.
“Not everyone needs to be admitted to an asylum but that seems to be the general perception. I have often seen family members are not supportive and discourage the affected from getting help from experts,” said a Mumbai-based psychologist.
Apart from the regular therapies/counselling sessions usually held once or twice a week, additional medical intervention may also be required for some patients.
For instance, if someone is going for Repetitive transcranial magnetic stimulation (rTMS) for depression will have shell out Rs 75,000-80,000.
Mental health treatment is prolonged and involves continuous visits to the doctor, tests like MRI or CT scan and some other tests, counselling, medication and changes in the medication.
Are some states better off than others?
When it comes to the treatment, affordability is a combination of income and cost, and availability of service.
Industry experts said that affordability and accessibility in Kerala and Tamil Nadu are much better than states like Uttar Pradesh and Bihar because of broadly structural issues like low income levels and very few public sectors and even smaller private care services.
If you or someone you know needs help for mental health issues, call any of these helplines: NIMHANS toll-free number 0804611000, Mpower and BMC joint helpline 1800-120-820050, Vandrevala Foundation 1860-2662-345 or Aasra 9820466726
This is the second part of a three-part series on the mental health crisis in India. The first part spoke about the stigma attached around mental health and how the lockdown could be aiding it. The last part tomorrow will examine the role of companies in helping employees cope with such issues.