Review Article

Indian J Med Res 126, September 2007, pp 183-192

Psychiatric epidemiology in India

Suresh Bada Math, C. R. Chandrashekar & Dinesh Bhugra*

Department of Psychiatry, National Institute of Mental Health & Neuro Sciences (Deemed University)
Bangalore, Karnataka, India & *Health Services Research Department, Institute of Psychiatry, London, UK

Received October 18, 2006

Epidemiological studies report prevalence rates for psychiatric disorders from 9.5 to 370/1000
populations in India. This review critically evaluates the prevalence rate of mental disorders as
reported in Indian epidemiological studies. Extensive search of PubMed, NeuroMed and MEDLARS
using search terms “psychiatry” and “epidemiology” was done. Manual search of literature was
also done. Retrieved articles were systematically selected using inclusion and exclusion criteria.
Only sixteen prevalence studies fulfilled the study criteria. Most of the epidemiological studies done
in India neglected anxiety disorders, substance dependence disorders, co-morbidity and dual
diagnosis. The use of poor sensitive screening instruments, single informant and systematic under-
reporting has added to the discrepancy in the prevalence rate.
The prevalence of mental disorders reported in epidemiological surveys can be considered lower
estimates rather than accurate reflections of the true prevalence in the population. Researchers
have focused on broad non-specific, non-modifiable risk factors, such as age, gender and social
class. Future research focused on the general population, longitudinal (prospective), multi-centre,
co-morbid studies, assessment of disability, functioning, family burden and quality of life studies
involving a clinical service providing approach, is required.

Key words Epidemiology - mental health - prevalence - psychiatric disorders

Psychiatric epidemiology has gone through various
stages of growth over the past five decades in India,
starting from the first psychiatric epidemiological study
by K.C. Dube1, in 1961 at Agra, to the development of
tools like the Present Status Examination (PSE) 2 and
the Indian Psychiatric Survey Schedule (IPSS)3. A major
advance in psychiatric epidemiology is the development
of reliable and valid diagnostic interviews.
Many epidemiological studies conducted in India
on mental and behavioural disorders report varying
183
prevalence rates, ranging from 9.54 to 370 per 1000
population5. These discrepancies are not specific to
Indian studies but are also seen in international studies
like the Epidemiological Catchment Area Program and
the National Comorbidity Survey6,7. This discrepancy
will impact planning, funding and health care delivery.
Providing accurate data about the prevalence of mental
disorders in the community would help to justify the
allocation of scarce resources and planning of health
services.
184 INDIAN J MED RES, SEPTEMBER 2007
Psychiatric epidemiology lags behind other
branches of epidemiology due to difficulties
encountered in conceptualizing, diagnosing, defining a
case, sampling, selecting an instrument, lack of
resources and stigma8. The descriptive epidemiological
studies have undergone unprecedented growth in India,
but at the same time advances with respect to cost-
effective, analytical and prospective experimental
epidemiological studies have been minimal8. A major
challenge for psychiatric epidemiologists is to increase
the relevance of their research with regard to their
counterparts in preventive psychiatry and to the policy
makers8. Researchers have expressed reservations about
the comparison of various epidemiological studies
because of methodological differences. However, at
present one has to rely on available studies to generalise
the findings. Hence this article attempts to critically
evaluate the (overall) prevalence rate of psychiatric
disorders as reported in epidemiological studies from
India. This review also attempts to answer the following
questions (i) What are the reasons for wide variation in
the prevalence rate in India; (ii) Is the prevalence rate
of psychiatric disorders stable or changing? (iii) What
is the cost of treating psychiatric patients?; and (iv) What
should be the focus of future epidemiological studies?.
Methodology
Extensive search was done of NeuroMed (1982-
1997) and MEDLARS for published Indian psychiatric
epidemiological studies. The search terms included
“psychiatry” “prevalence”, “community”, and
“epidemiology”. Attempts were also made to retrieve
Indian epidemiological studies published in
international journals through PubMed using search
terms “psychiatry” and “epidemiology”. Extensive
manual search of issues of the Indian Journal of
Psychiatry, NIMHANS Journal (before 1982 and after
1997) and Indian Journal of Medical Research was also
done. Cross-references of the psychiatric prevalence
studies were also reviewed.
Inclusion criteria were: general population studies
either urban, rural or mixed from India; community
study design involving door-to-door/house-to-house
enquiry of families and random sampling of families;
inclusion of all psychiatric disorders or at least priority/
major mental disorders. (Various researchers have used
this term to assess schizophrenia, manic depressive
psychosis, organic psychosis, epilepsy and mental
retardation in the community); and covering all age
groups.
Studies were excluded if those were: specific
syndrome/illness/disorder studies; hospital or clinic
based studies; and particular age group studies.
Only data published in scientific journals were
considered because of logistic reasons. This is one of
the main limitations of this review. Only 16 prevalence
studies (Table I) fulfilled the inclusion criteria.
However, an attempt was made to summarize other
studies like high-risk/special population, cost-effective
analysis, incidence, follow up and meta analysis
separately to have a comprehensive picture of
epidemiological studies till date.
Evaluation of prevalence in each study was done
on the following parameters; definition of a “case”,
screening and diagnostic instrument used, diagnostic
break-up assessed, methods of arriving at the diagnosis,
sampling method, location of study, general population/
high risk population study and number of informants
used to collect data.
What are the reasons for wide variations noted in
the prevalence rates of psychiatric epidemiological
studies?
Defining a case: Inherent limitations in defining clinical
cases in epidemiological studies are: (i) the definition
of mental disorder fails to provide a clear boundary
between psychopathology and normality; (ii) the
concepts “clinical significance” and “medical necessity”
are difficult to operationalize and to assess reliably; and
(iii) lay interviewers do not have the experience
necessary to judge clinical significance6,23. Defining a
case was one of the factors which contributed to the
huge variation in prevalence rate. If the threshold for
defining a case is very low then prevalence rate will be
very high5,24. Earlier studies had difficulty in defining a
case, when clear-cut diagnostic criteria were not
available, but Indian researchers used a broader
diagnostic classification such as psycho-neurotic,
schizophrenia, epilepsy, depression, mental deficiency,
miscellaneous group9-11,25. Researchers have also used
case definitions as per WHO technical report series no.
185, 196015,26,27, WHO International Classification of
Diseases (ICD) (1965 R), Diagnostic and Statistical
Manual of Mental Disorders (DSM) of American
Psychiatric Association (APA)196814, and 1965 ICD12
for diagnosis.
The ‘presence of a disorder’ implies ‘need for
treatment’ in a clinical population; however, in
epidemiological studies these differ. For example, in
 MATH et al: PSYCHIATRIC EPIDEMIOLOGY IN INDIA 185

Indian culture, people suffering from social phobia are
generally considered shy and it is not considered that
they require treatment. To determine the presence of a
disorder, the need for treatment, distress, dysfunction,
disability and availability of resources need to be
established6,28. Indian researchers made attempts to
overcome this difficulty by assessing the positive cases
on screening by qualified psychiatrist(s) for final
diagnosis by using their clinical judgment. However,
minor mental disorders which could not be tapped on
screening were missed. Considering the difficulty of
defining a case and diagnosis, Indian researchers made
all attempts to overcome them by assessing all positive
cases on screening.
Screening instruments: The majority of the
epidemiological studies considered two-phase sampling
for assessing prevalence1,4,13,14,17. The first step was to
screen the population for mental illness using a
screening instrument and the next step was to confirm
diagnosis. Screening instruments can be self-reported,
observer-rated, or based on information from an
informant. Self-reported ratings are highly dependent
on the co-operation of patients and their ability to
understand either written or verbal instructions.
Observer-based ratings can be time-consuming, and lay
interviewers can misinterpret the severity and impact
of the illness7,23. Hence the use of self-reported and
observer-rated tools was not possible in our population.
The most common method used by Indian researchers
was based on information from one or more informants.
Screening scales or instruments included
exploratory questions, and symptoms or diagnostic
checklists for screening the community for possible
mental illness, with positive cases referred for more
extensive evaluation. Psychosis becomes less and less
common at greater distances from the hospital patient,
and in the community the epidemiologist is faced with
large numbers of respondents who present with fewer,
minor and non-specific symptoms 29 . Indian
epidemiological studies were largely inadequate to tap
the most non-psychotic disorders like panic disorder,
social phobia, obsessive compulsive disorder, sexual

Table I. Prevalence of psychiatric morbidity

Investigator Year Centre Location Sampling Tool Population Prevalence/1000
4
Surya 1964 Pondicherry U H-H MHSQ(P) 2731 9.5
Sethi et al9 1967 Lucknow U H-H QAPF 1733 72.7
Dube1 1970 Agra M H-H DCP 29.468 18
Elangar et al10 1971 Hoogly R H-H CHM & DCP(2) 1393 27
Sethi et al11 1972 Lucknow R H-H CHQ & CHM 2691 39.4
Verghese et al12 1973 Vellore U SRS MHIS & DCP as per ICD (1965) 1887 66.5
Sethi et al13 1974 Lucknow R 3SPS PSQ & DCP as per DSM-II (1968) 4481 67.0
Thacore et al14 1975 Lucknow U H-H PHQ & DCP 1977 81.6
Nandi et al15 1975 West Bengal R H-H HS, QS & CRS as per ICD (1965 R) 1060 102.8
Nandi et al16 1979 West Bengal R H-H HS, SESS, CDS & CRS 3718 102
Shah et al17 1980 Ahmedabad U H-H MHSQ & DCP 2712 47.2
Mehta et al18 1985 Vellore R S-S IPSS & DCP 5941 14.5
Sachdeva et al19 1986 Faridkot R H-H HS, SESS & CDS 1989 22.12
Premarajan et al20 1993 Pondichery U RS IPSS & DCP as per ICD-9R 1115 99.4
Shaji et al21 1995 Erankulam R H-H IPSS, SESS, CRS & DCP, ICD-10 5284 14.57
Sharma et al22 2001 Goa M SRS RPES & DCP as per ICD-9 4022 60.2
U- urban; R- rural; H-H- house to house survey; S-S – systematic sampling; SRS – stratified random sampling
3SPS- 3 stage probability sampling; RS- random sampling, ICD- international classification of diseases
DSM-II- diagnostic and statistical manual of mental disorders.
Tools: MHSQ= Mental health Screening Questionnaire,
QAPF=Questionnaire for the assessment of psychiatric state of the family,
DCP = Diagnosis confirmed by a psychiatrist(s) CHM = Case history method
CHQ = Case history questionnaire IPSS=Indian Psychiatric Survey Schedule
SFQ=Social functioning questionnaire MHIS=Mental health item sheet,
PSQ=Psychiatric screening questionnaire PHQ=Psychiatric health questionnaire,
HS=Household schedule QS=Questionnaire Schedule,
CRS=Case record schedule, CDS = Case detection schedule,
SESS=Socio-economic status schedule RPES= Rapid psychiatric examination schedule
186 INDIAN J MED RES, SEPTEMBER 2007

dysfunctions, substance use etc., in the community.
Earlier studies prepared their own screening
questionnaire, which was applied to the entire
population to be studied without testing their validity
for high-risk populations such as the children, the
elderly and substance users, thereby missing mental
disorders during the initial screening4,9,10,14. This was a
major drawback of these studies, which might have led
to under-reporting of mental disorders.
Issac and Kapur30, in their study on cost-effective
analysis of three different methods of psychiatric case
finding in the general population, answered the
difference in prevalence reported by various researchers.
Comparison of cases in various diagnostic categories
identified through screening by using questionnaires and
confirming the diagnosis by a psychiatrist (Method-1)
missed out on depression, possession disorder, neurotic
disorders, somatisation disorder and substance
dependence during the initial screening. This was later
picked up by using the Indian Psychiatric Survey
Schedule (IPSS)3, schedule in the general population
(Method-2). Major mental disorders that were identified
were almost similar with both methods. Cost-effective
analysis of the above two methods revealed that using
the IPSS was 10 times more expensive. This study
clearly demonstrated the significant difference in
prevalence rates: 76/1000 in method-1 and 344/1000
on method-2.
Determining which screening instrument should be
selected must always follow an analysis of the
underlying purpose of whether this instrument can be
applied to the chosen sample and to all age groups31.
Sensitivity rather than the specificity of the screening
instrument is very important in prevalence studies to
avoid false negatives. However, further essential criteria
in determining choice of the scale are, cultural
relevance, validity, time available and the person who
is to carry out the rating. Instruments such as the Self
Reporting Questionnaire (SRQ) and General Health
Questionnaire (GHQ)31 have been used successfully for
screening purposes in epidemiological studies32.
Informants: A family informant is one who reports about
his/her illness as well as on other biological relatives. It
takes 30 to 90 min to administer the screening
instrument, depending on the size of the family and the
presence of family illness. There is agreement that
compared with direct interviews, the family history by
one informant method underreports illness and using
two or more informants can partially correct this
problem33. Utilizing data from multiple informants
provides a more valid assessment of the disorder in
studies related to mental health problems34,35. However,
in certain epidemiological studies, the investigators
interviewed only the head of the family or the housewife
or any other responsible family member for data
collection9,11,18,19,21,22. This will lead to responder bias
since the chances of under-reporting symptoms of
psychiatric disorders are very high especially for minor
mental disorders. But whenever researchers assessed
all the family members or used multiple informants to
collect data, the prevalence rate was found to be twice
that of the single informant method14-16,20. This is one
of the main reasons that can account for discrepancies
in the psychiatric prevalence rate reported in India.
Sampling methods: Another important methodological
issue is the sampling approach. In order to properly
estimate the prevalence of mental disorders, it is
essential to choose the sample in a manner that will
accurately reflect the general population. Eighty per cent
of researchers had used the house-to-house survey
method9-11,14. In the design of studies of people with
mental disorders, it is necessary to consider the
likelihood of not being able to access people who are
hospitalized due to illness, homeless people, wandering

Table II. Special/high-risk population studies

Investigator group Year Centre Location Sampling Tool Population Prevalence/
1000
Carstairs & Kapur5 1973 Kota R H-H IPSS & SFQ 1233 370
Nandi et al26 1977 West Bengal R H-H HS, QS & CDS 2918 58.2
Nandi et al39 1978 West Bengal R H-H HS, QS & CDS 1259 47.6
Nandi et al37 1980 West Bengal R RS HS, SESS, CDS & CRS 4053 50.3
Nandi et al43 1980 West Bengal M H-H HS, SESS, CDS & CRS 1862 129.9
Sen et al38 1984 West Bengal U H-H HS, SESS, CDS & CRS 2168 48.7
Banerjee et al41 1986 West Bengal U H-H HS, SESS, CDS & CRS 771 51.9
Nandi et al40 1992 West Bengal U H-H HS, SESS, CDS & CRS 1424 47.75
Abbrevation- As given in the foot note of Table I
 MATH et al: PSYCHIATRIC EPIDEMIOLOGY IN INDIA
mentally ill patients and people who are not available
for other reasons like occupation 36 . Only a few
studies12,13,20,37 have used the random sampling method.
Researchers have sampled special population like
urban slum dwellers38, uprooted communities39 and
tribal communities 40, to study the effect of stress5,
urbanization 41 and to compare prevalence across
cultures26,37. Studies done on high risk populations
yielded a high prevalence rate5. On plotting the studies
on the Indian map, studies were found to be concentrated
only in certain areas like West Bengal (40%) and UP
(10%), which led to difficulty in generalizing the
findings. The extent to which findings from one cultural
unit can be generalised to other populations is still open
to debate. Can we generalise findings from one State to
another or from one ethnic group to another within the
same country? Multi-site studies are the answer42. Hence
we decided to highlight the studies on various special
populations (Table II). Variations seen in prevalence
(47.6 to 370) were huge on comparing with Table I
(general population) (9.5 to 102.8).
Disability: Mental disorders often result in profound
burden of illness and disability. The World Health
Organization has determined that mental illness is one
of the largest contributors to disability worldwide45,46.
The disability-adjusted life years (DALY) measure
combines burden from premature mortality with that
from living with disability, and provides a
comprehensive assessment of the burden of illness.
When the loss of life and ability are estimated using
DALY, more than 10 per cent of the total burden of
human disease and loss are attributed to mental
disorders. The overall DALYs burden for mental
disorders is projected to increase to 15 per cent by the
year 2020 and this increase is proportionately larger
than that for cardiovascular diseases46. Assessment of
disability in social and occupational functioning is
necessary in epidemiological studies24.
Caregiver’s burden: The family, as a unit of the society
forms an integral part of the care giving system for
persons with mental illness, especially in our country.
The demands of being involved in the care of a seriously
mentally ill patient have serious impact on the
caregiver’s health. The costs that families incur in terms
of economic hardships, social isolation and
psychological strain, are referred to as the family
burden47,48. It is our duty to treat the patient and also to
evaluate the mental state of the caregivers, since in our
community family members are the caregivers.
Research has clearly demonstrated the burden of mental
187
disorders on individuals, families, communities and
health services globally. If the impact of mental illness
on the economy is assessed by combining all the costs
like health care cost, loss of wages and patient/family
costs, then the magnitude of the impact of mental illness
becomes evident. Psychiatric illness has disabling
consequences49. The contribution of Indian researchers
towards the burden assessment schedule (BAS) is
noteworthy 50 , and can be applied in future
epidemiological studies.
Systematic under-reporting: A survey of an urban
community in southern India, found that one-third of
people with schizophrenia had never accessed any
treatment resources 51 . Even after the diseased
individuals and their families were offered treatment, a
third of them remained untreated52. The important
question remains as mental health professionals, how
can we reduce this stigma against mental illness in the
mind of the public? The question is important because
how the public perceives mental illness will decide how
our services will be utilized by the society53.
Mental disorders are highly stigmatized conditions
that many people want to keep private because of their
embarrassment or fear of discrimination54. In the case
of patients seeking professional treatment, there is
reason to believe that self-reports will be complete and
honest. However, this is not the case in epidemiological
surveys, where patients do not seek help. It is not
surprising then that concerns have been raised that
under-reporting is a very serious problem in surveys of
this sort55. Even when clinicians carry out interviews,
methodological research has shown that some
respondents are less liable to disclose embarrassing
information when they are aware that their interviewer
is a mental health professional 56. The problem of
systematic under-reporting continues to be a major
challenge for the future of psychiatric epidemiology in
India.
Is the prevalence rate of psychiatric disorders stable
or changing?
Does globalization (liberalization) play any role on
the mental health of the individuals? Does changing
family structure (joint family to nuclear) influence the
psychiatric morbidity? Unfortunately we do not have
any long-term epidemiological studies to answer these
questions.
A 10 yr follow up study reported that there was not
much change in the prevalence rates over a decade
188 INDIAN J MED RES, SEPTEMBER 2007
Table III. Follow-up studies on prevalence of psychiatric disorders in India
Investigator Year Centre Location Sampling
Nandi et al57 1986 West Bengal R H-H
(1972-1982)
Nandi et al58
(1972-1992) 2000 West Bengal R H-H
Abbrevation- As given in the foot note of Table I
(prevalence rate in 1972 was 84.9 and in 1982 it was
81.9)57. This was further reinforced by the 20 yr follow
up study, where prevalence rate in 1972 was 116.8 and
in 1992 it was 105.258 (Table III). These two studies are
milestones in psychiatric epidemiology looking at the
same population cross-sectionally at two points. Though
the prevalence rate did not change, the morbidity pattern
(affective illness had increased) changed significantly.
However, researchers and policy makers should exercise
caution before generalizing the findings to whole
country. Reason being follow up studies had small
sample size and were on rural population.
Adding to the existing unmet needs of mental
health, changing health scenario in India has led to
imminent epidemic of non communicable diseases along
with the unmet agenda of controlling infectious
diseases59. Life style disease (like obesity and substance
use) and stress can increase the risk of several leading
causes of death like cardiovascular diseases, cancer,
diabetes, metabolic and endocrine disorders among
others. In the management of non communicable and
life style diseases, mental health component plays a
crucial role. Psychiatric co-morbidity is common in non
communicable diseases and chronic medical conditions.
This co-morbidity further adds to the prevalence of
mental health disorders.
What does the meta-analysis of epidemiological
studies of psychiatric disorders report?
A meta-analysis of 13 epidemiological studies
consisting of 33,572 persons, who met the following
criteria; door-to-door survey, all age groups included
and prevalence rate for urban and rural being available60,
reported a total morbidity of 58.2 per 1000. Though
meta-analysis has its own limitations, this was the first
attempt to analyze the epidemiological studies. Another
meta-analysis of 15 epidemiological studies reported a
total morbidity of 73 per 100061. This study included
15 studies on the basis of having similar design which
were conducted in three phase/steps. The difference
noted in the two available meta-analyses was due to
Tool Year Population Prevalence/
1000
HS, SESS, CDS & 1972 1060 84.9
CRS 1982 1539 81.9
HS, SESS, CDS, CRS & 1972 2183 116.8
DCP 1992 3488 105.2
the methodology of selecting the papers for the analysis.
Earlier study had a criterion of door to door survey,
whereas the latter had a criteria of studies being
conducted in three phases/steps.
What do the international epidemiological studies
report?
NIMH-Epidemiological Catchment Area study62 of
US reported psychiatric morbidity as follows: one month
prevalence of 151/1000 population; life time prevalence
of 322/1000 population; one year incidence of 60/1000
population. National Co-morbidity Study of US63
reported 12 months prevalence of 277/1000 population
and life time prevalence of 487/1000 population.
Compared to these studies it is clear that prevalence rates
and incidence rates reported in India are very low.
Possible reasons for this difference may be (i) Indian
epidemiological studies did not adequately measure
psychiatric morbidity; (ii) The psychiatric prevalence
rates are truly low in India; and (iii) Combination of both
the above factors. Available evidence supports the first
possibility of the under-reporting by Indian
epidemiological studies because of poor sensitivity of
the screening instrument, high-risk populations (children
and adolescents, elderly) were not assessed, neurotic
disorders and substance use disorders were not assessed
adequately, stigma and single informant method would
have lead to under-reporting. However, the possibility
of genuine low prevalence of psychiatric disorders in
Indian population cannot be disregarded because of low
rates of substance use in general population compared to
western countries and good outcome of psychiatric
disorders due to various factors like religious, cultural,
social and family support. Answer to this question can
be obtained through multi-centred studies involving
various countries with prospective design using single/
common research protocol.
What is the economic cost of treating psychiatric
patients?
Macro-economic commission report of 2005 64
considered prevalence rate of 65/1000 population
 MATH et al: PSYCHIATRIC EPIDEMIOLOGY IN INDIA
(average of two meta-analysis-60, 61) and projected the
prevalence rate for next two decades. However, if we
consider prevalence of individual mental disorder and
add, the overall prevalence rate will be approximately
115-130/1000 population.
Even if we consider 65/1000 population as
prevalence rate, then 6.5 crores populations require
professional help. If each patient requires INR 300 per
month for the treatment, the total cost required per
month will be 1,950 crores INR and per year will be
23,400 crores INR. If we do not address this issue by
investing in mental health, the indirect costs in terms
of loss of wages by the patient, disability and then
families facing social isolation, burden, stigma and
psychological strain will be enormous.
Discussion
In majority of the studies the researchers were able
to assess major mental disorders accurately, but minor
mental disorders were not assessed adequately. Indian
researchers made attempts to overcome the difficulty
of diagnosis by assessing the positive cases on screening
by qualified psychiatrist(s) for final diagnosis by using
their clinical judgment and available diagnostic
guidelines at that time, thus avoiding clinician bias in
diagnosis.
Prevalence rates of psychiatric disorders not only
vary across the populations, but also in the same
population from time to time. In addition, weak
agreement at the level of diagnosis and systematic
under-reporting continue to threaten the credibility of
estimates of prevalence65. Prevalence rates can vary
markedly with screening instruments used, changes in
the assessment questions used in community surveys,
minor changes in diagnostic criteria (thresholds for
defining mental disorders), number of informants, and
sampling methodology24.
With the exception of one study1, all the past
epidemiological studies have surveyed a population less
than 6000. This raises a query whether the findings can
Table IV. Incidence studies done in India
Investigator Year Centre Location Sample
Nandi et al26 1976 West Bengal R H-H
(1972-1973)
Nandi et al27 1978 West Bengal R H-H
(1972-1973)
Abbrevation- As given in the foot note of Table I
189
be generalized to even one State in a country like India,
which is well known for its geographical, linguistic and
ethnic diversity. Mental health care priorities need to
be shifted from psychotic disorders to common mental
disorders like depression, anxiety disorders, somatoform
disorder, etc., which are also associated with high
disability in all measures49.
The available evidence suggests that though there
has been no increase in prevalence rate of psychiatric
disorders in the past few decades in India, the changing
health scenario has led to imminent epidemic of non
communicable diseases59 and psychiatric co-morbidity
being common in non communicable diseases and
chronic medical conditions provides indirect evidence
of rise in psychiatric prevalence.
Scope of the future epidemiological studies: Most of
the past epidemiological studies were descriptive in
nature. Thus the future epidemiological studies should
be more analytical and experimental. High-risk
individuals (survivors of disaster, people suffering from
chronic general medical conditions, the destitute and
homeless) with modifiable risk factors need to be
identified and included in the studies. The effects of
modifying risk factors on prevalence rates have to be
explored. Studies to document the impact of organizing
mental health services and preventive strategies are
required. There is a need to study the effect of global
socio-economic policies like liberalization and
privatization, the fast growth of information technology,
life style changes and its impact on the mental health
of individuals. The effectiveness of various techniques
and programmes of stress management and life skill
implementation on individuals also need to be included
as a part of epidemiological studies.
These is a need to determine the quality of life,
co-morbidity, disability and burden of various mental
disorders66. Longitudinal/prospective (experimental)
epidemiological studies need to be carried out in which
the natural course of all the disorders in the community
can be studied and modifiable risk factors are identified
Tool Year Population Prevalence/ Incidence/
1000 1000
HS, QS & CDS 1972 1060 102.1 17.6
1973 1078 107.6
HS, CDS & CRS 1972 2230 110.3 16
1973 2250 108.4
190 INDIAN J MED RES, SEPTEMBER 2007
and targeted for interventions. It is also vital to study
the factors (barriers) affecting better service use, the
role of culture and religion in help-seeking behaviours
and modifying the identified factors, which may help
in better delivery of mental health care at the
community level. Mental health care priority also
requires to be shifted from mental hospitals to primary
health centres59. Systems need to be set up to carry
out small area estimations for needs assessment and
programme planning. Remaining challenges include
the refinement of diagnostic categories and criteria and
using accurate assessment tools for studying disorders
of children, adolescents and the elderly in community
surveys8. By applying valid instruments and proper
sampling techniques, generalization of the results can
be achieved. Systematic under-reporting in
epidemiological surveys of mental disorders must be
evaluated so that the accurate prevalence can be
assessed. The translation of these estimates from the
community to policy, however, is exactly what most
critics challenge67.
As only two incidence studies 25,27 are available
(Table IV), there is a need to carry out more incidence
studies in representative populations. Prevalence studies
need to be repeated in a given area to evaluate the
effectiveness of intervention programmes like the
District Mental Health Programme, school or college
mental health programmes, life skills programmes and
other preventive programmes68.
Conclusions
Considering the facts of systematic under-
reporting, collecting data from single informant, use
of low sensitivity screening instruments, poor
sampling methods, assessing only priority mental
disorders and changing health scenario indicates that
the prevalence of mental disorders as reported in
Indian epidemiological surveys can be considered
lower estimates rather than accurate reflections of
the true prevalence in the population. This should be
kept in mind especially for policy making and for
mental health care planning. Mental health care
priorities need to be shifted from psychotic disorders
to common mental disorders and from mental
hospitals to primary health centres. Future research
needs to focus on the general population, longitudinal
(prospective), multi-centre, co-morbid studies,
assessment of disability, functioning, family burden
and quality of life studies involving a clinical service
providing approach.
Acknowledgment
Authors thank Dr N. Girish, Department of Epidemiology,
National Institute of Mental Health and Neuro Sciences (Deemed
University), Bangalore, for his valuable suggestions and inputs and
Dr Maria Christine Nirmala for her valuable comments on the
manuscript.
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