Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414

https://doi.org/10.1007/s00127-018-1647-2

REVIEW

India’s response to adolescent mental health: a policy review

and stakeholder analysis
Kallol Roy1 · Sachin Shinde1 · Bidyut K. Sarkar1 · Kanika Malik1 · Rachana Parikh1,2 · Vikram Patel1,3

Received: 20 July 2018 / Accepted: 12 December 2018 / Published online: 3 January 2019
© The Author(s) 2019

Abstract
Purpose Mental health problems and suicide are the leading cause of mortality in young people globally. India is home to
the largest number of adolescents in the world. This study was undertaken to assess the policy environment for addressing
adolescent mental health in India.
Methods We conducted a review of 6 policies and programs and 11 in-depth interviews with key stakeholders. The findings
were analyzed using the policy triangle analysis framework (i.e., context, content, actors and process).
Results There is no conformity of the age ranges addressed by these documents nor are vulnerable groups explicitly rec-
ognized. Stress, anxiety and depression were commonly identified as mental health concerns and diverse platforms such as
community, family, school, digital and health facility were recommended to deliver preventive and treatment interventions.
Some interventions specifically targeted some social determinants (like safe and supportive schools) but many others (like
social norms) were not addressed. Preventive interventions were recommended for delivery through peers and other non-
specialist providers while treatment interventions were recommended for delivery in healthcare facilities by specialist health
professionals. There was very little engagement of young people in the development of these policies or in their implementa-
tion, except for peer educators mentioned in one policy. Stakeholders identified several major challenges in implementing
these policies, notably the lack of inter-sectoral coordination and fragmentation of governance; budgetary constraints; and
scanty human resources.
Conclusions Although there are now several policy instruments testifying to a comprehensive approach on adolescent mental
health, there are gaps in the extent of engagement of young people and how these will be operationalized that may limit their
impact on addressing the burden of mental health problems in young people in India.

Keywords Adolescent · Mental health · Policy · Review · India

Introduction and psychosocial functioning, and contribute to premature

mortality through their association with suicide and acci-
Mental health and substance use problems are the leading dent related mortality, both the leading causes of death in
cause of years lived with disability (YLD) among adoles- this age group [1]. Further, more than half of the burden
cents and young people (10–23 years) accounting for 22.9% of mental disorders in adulthood has its onset in adoles-
of the total global YLDs [1]. These problems have signifi- cence. However, evidence shows a lack of comprehensive
cant adverse impacts on individual, family and society and policy response to the mental health needs of adolescents in
are frequently associated with poor academic, occupational, both low- and high-income countries [2]. The recent Lancet
Commission on adolescent health and well-being [3], sug-
gested that the focus of health policy needs to expand from
* Vikram Patel infectious diseases to non-communicable diseases, including
Vikram_Patel@hms.harvard.edu mental health and substance use.
1
Sangath, Porvorim, Goa, India India is home to the largest number of adolescents in the
2 world, comprising about a fifth of its population (243 mil-
Vrije University, Amsterdam, The Netherlands
lion) [4]. A meta-analysis reported that 6.5% of the com-
3
Department of Global Health and Social Medicine, 641 munity samples and 23.3% of school samples experienced
Huntington Avenue, Boston, MA 02115, USA

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406 Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414

significant mental health morbidity [5]. Suicide is the lead- were identified: the National Youth Policy (NYP), 2014;
ing cause of death in older adolescents [4]. There has his- National Mental Health Policy (NMHP), 2014; National
torically been little explicit attention to adolescent mental Mental Healthcare Act (MHA), 2017; and Rashtriya Kishor
health in India but, in the past decade, both mental health Swasthya Karyakram (RKSK; National Adolescent Health
and adolescent health have received increasing attention in Program, 2014). Interviews with key informants (see
policy and programs. Convergence of policy attention to below) led to the identification of two more policies and
these focus areas and successful implementation of policies, programs—Sarva Shiksha Abhiyan (SSA), 2014 concerned
promise to reduce the burden of mental disorders not just in with education and Yuva Spandana (YS), 2015 concerned
adolescents but would also make significant contributions with adolescent welfare in the state of Karnataka. Though
to the global burden of mental health disorders. The goal of we identified a range of other adolescent health programs
this paper is to map the policy and program environment for and policies such as the Kishori Shakti Yojna, Balika Sam-
adolescent mental health in India, with the specific objec- ridhi Yojna and the Rajiv Gandhi Scheme for Empower-
tives of addressing the following research questions: ment of Adolescent Girls by Ministry of Women and Child
Development, these policies and programs were not selected
1. How are adolescent mental health issues addressed in because they did not address mental health. Ultimately, six
policies and programs? documents were included in the review. Apart from YS, no
2. What are the strengths and gaps of these policies and other regional documents which focused on youth or adoles-
programs with regard to their context, their content, cent well-being were found. Additional sources, including
the process of their development and the extent of their scientific articles and reports pertaining to the selected six
implementation? policies and programs were identified to retrieve relevant
3. What are the recommendations for impactful implemen- information regarding policy and program development and
tation of these policies and programs? implementation.

Key informant interview (KII)

Methods
We chose stakeholder analysis as an additional method
We conducted two concurrent studies: a review of key poli- for policy and program analysis. Stakeholder analysis can
cies and programs documents, and semi-structured inter- be used to understand about relevant actors, their inten-
views with key informants. tions, interrelations, agendas, interests, and the influence
or resources they have brought or could bring on decision-
Policy and program review making processes during policy development [7]. As a
cross-sectional view of an evolving picture, the relevance
In our study, policies refer to an organized set of values, of stakeholder analysis for predicting any change and man-
principles and objectives for improving health and reducing aging the same for a policy or a program in the future is
its burden in a given population. It further defines a vision time-limited; it should be complemented by other methods
for the government and states the level of priority that needs of policy analysis [8], which was the rationale for our under-
to be assigned for a particular health domain. On the other taking a policy review and stakeholder analysis concurrently.
hand, programs are referred as a set of interventions with a We first approached members of the Technical Advisory
focused objective for the promotion of health, and preven- Group of the RKSK and, using snowball sampling, identi-
tion, treatment and rehabilitation of health problems. A pro- fied other experts in adolescent health in India. Ultimately,
gram usually focuses on a specific health priority and must 11 key informants agreed to participate. The interview guide
be adequately designed, budgeted for, monitored and evalu- addressed the perceptions of adolescent mental health in
ated [6]. We identified documents that addressed (key words) India; and views regarding the policies and programs which
‘adolescent and young people’, ‘youth’, ‘health’ or ‘mental addressed adolescent mental health concerns, in particular
health and well-being’ in the past 10 years on India’s Official the strengths and gaps in their implementation. All inter-
websites of the Ministry of Human Resources Department, views were conducted in English and audio-taped; and later
Women and Child Development, Youth and Sports affairs, transcribed verbatim. On an average, the interviews lasted
and Family Health and Welfare were searched to extract full for 45 min.
text documents of programs and policies. Policy makers or
other stakeholders of identified policies and programs were Data analysis
contacted in parallel to obtain their expert views on exist-
ing policies and programs in India focusing on adolescent We applied the ‘policy analysis triangle’ framework [9] to
health and mental health. Initially, four national policies analyze the policy and program documents. This framework

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Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414 407

recommends analytical attention to four inter-related aspects policy documents and key informants. In the final stage of
of a policy, i.e., the context; the content; the actors; and the analysis, each chart was examined separately, and a process
process. These categories were further operationalized for of mapping and interpretation was undertaken (i.e., estab-
analysis. For example, the issue of context was explored in lished charts were used to explore the range and nature of
terms of the types of mental health problems and their deter- phenomena and any emerging associations between sub-
minants while the content was explored in terms of the strat- themes were identified in order to explain the findings).
egies and resources to address these problems. The actors Saturation was defined at a point during coding, when two
were defined in terms of identification of major providers authors (KR and SS) agreed that no new codes were emerg-
and their roles. The policy process was defined as focusing ing [11]. The final thematic framework is shown in Fig. 1.
on participatory decision-making and policy implementa-
tion, particularly related to youth involvement.
A five-stage thematic analysis approach was used for Results
analysis of the selected policies and programs and key
informant interview transcripts [10]. First, all the policy Three national policies, two programs (one national and
documents and interview transcripts were read a number of one regional program), and one national act were selected
times to ensure adequate immersion in the data and relevant for the review. The NMHP and the MHA focus on mental
notes were made in each policy and program document and health while the SSA has specific focus on universal basic
transcript. Upon achieving familiarization with the data, the elementary education to children between the ages of 6 and
next stage involved identification of a thematic framework. 14 years. The RKSK is the only specific policy related to
The themes covered in the policy triangle framework and adolescent health and has the vision that adolescents are
interviews provided the initial framework, which was refined able to realize their full potential by making informed and
based on the additional themes and subthemes inductively responsible decisions related to their health and well-being.
derived from the data sources. In the third stage, the policy The youth policies (NYP and YS) focus on holistic devel-
and programs and interview transcripts were indexed/coded. opment of young people. Table 1 presents the summary of
In the fourth stage, data were organized or “charted” accord- each policy and program, its goals, its rationale and process
ing to each theme/sub-theme to include data from different of development. Of the 11 key informants (4 females and

Development & implementation of adolescent health policies in India

Context Content Actors Process of Implementation

Development

- Age range - Determinants of - Providers for - Coverage

mental health intervention - Stakeholder engagement
- Mental health delivery - Human resources
issues - Mental Health - Youth engagement
Interventions - Platforms for - Governance
intervention
delivery - Budgetary constraints

- Convergence with other programs

Fig. 1  Overview of thematic framework

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 Table 1  Summary of the reviewed policies and programs
408

Policy and program Description Need and rationale Process of development Goal/s Youth engagement in policy
development

13
Sarva Shiksha Abhiyan National Elementary Educa- To provide basic education to Consultations with State To achieve universal access No specified role of youth in
(SSA)—2011 tion Program children despite their socio- Education Secretaries, edu- to education and retention policy development
economic backgrounds cationists, representatives of students; bridging gender
and physical status, and of teacher unions, voluntary and social class gaps in edu-
constitute a sound school organizations and civil soci- cation; and enhancement of
environment for their overall ety organizations, led by the learning levels of children
development of the child Ministry of Education
National Youth Policy National Youth Development To generate awareness among Multiple rounds of consulta- To empower youth to achieve No specified role of youth in
(NYP)—2014 Policy youth and various stakehold- tions across the country their full potential and policy development
ers in India about the overall were organized, led by the through them enable India
development of youth and Ministry of Youth Affairs to find its rightful place in
their contribution to nation and Sports; no details avail- the community of nations
building able about these consulta-
tions
National Mental Health National Mental Health To draft a set of guidelines for A policy group of experts To decrease the treatment No specified role of youth
Policy (NMHP)—2014 policy mental healthcare in India constituted by the Minis- gap, disease burden and engagement in policy devel-
with focus on disease bur- try of Health and Family extent of disability due to opment
den, treatment, management Welfare, and comprising mental illness, taking in to
and provision of services mental health professionals account the Indian socio-
and persons representing cultural realities, promoting
the lived experience and integrated, evidence-based
families synthesize evidence care and effective provision
and conducted five regional of quality services
consultations with diverse
stakeholders
Rashtriya Kishor Swasthya- National Adolescent Health To create a holistic approach Extensive consultative process To envisage adolescents in No specified role of youth
Karyakram (RKSK)—2014 Program for adolescent health- with many organizations and India to be able to realize engagement in policy devel-
care with a special focus experts led by the Minis- their full potential by mak- opment
on nutrition, sexual and try of Health and Family ing informed and responsi-
reproductive health care, Welfare with support from ble decisions related to their
non-communicable diseases, UNFPA health and well-being
substance misuse, injuries
and violence in India
Yuva Spandana (YS)—2015 State (Karnataka) Youth To ensure that the state Desk review and stakeholder To reach, engage and Youth from schools and col-
Program government works col- and expert consultations led empower youth of Karna- leges were invited to share
laboratively with the recom- by the Department of Youth taka to facilitate their overall their views on their needs
mendations mentioned in Empowerment and Sports, development
the national youth policy of Government of Karnataka,
India and implements it for in collaboration with the
the well-being of youth of Centre for Public Health,
the State NIMHANS
Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414
 Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414 409

7 males), four were members of the TAG of the RKSK,

engagement in policy devel-

Youth engagement in policy five were senior researchers in adolescent health in leading

To entitle the rights of people No specified role of youth

institutions and two were members of the leading UN agency
working with the Government of India on adolescent health
(United Nations Population Fund—UNFPA).
development

opment

The context

Adolescents are referred in a variety of ways in these docu-

ments, notably through terms like the young, youth, ado-
with mental illness to health

Rights of Persons with Dis-

that the law is aligned with
with dignity, and to ensure

the UN Convention on the

lescents and young adults. The RKSK defines the period of

and social care and a life

adolescence as 10–19 years of age and ‘young people’ as

abilities (UNCRPD)

10–24 years of age; the NYP defines ‘youth’ as 15–29 years

of age while the MHA defines ‘minor’ as those persons
below the age of 18 years. While key informants strongly
recommended the need for recognition of phases of ado-
Goal/s

lescence, notably the marked developmental differences

between early and late adolescence, this was not evident in
health professionals, persons
are implemented across vari- with lived experience, fami-
diverse mental health stake-

any of the policies or programs.

lies and policy makers, led
holders, including mental

by the Ministry of Health

National Legislation on Men- To formulate laws and legisla- Extensive engagement of

“We need to have sub-sets for adolescents just like

Process of development

and Family Welfare

child health has done, neonatal, infant, child, etc. This

helps to channelize treatment for each identified sub-
set. For an adolescent, there is no specialist as such. It
is just the Pediatrician, the pediatricians are also not
sure till what age do they check these children, is it
12 or 18 years? Nothing is specified in the policies.”
(Senior researcher)
in India and ensure that they
tion with correspondence to
mental health care practices

ous sectors, stakeholders,

‘Stress’, ‘anxiety’ and ‘depression’ were identified as

the ‘common mental health problems or difficulties’ in the
Need and rationale

reviewed policies/programs and even by the key informants.

and institutions

The policies recognize that addressing suicide attempts and

suicidal tendencies among adolescents is crucial (NYP)
and that bullying (including cyber bullying) seems to be
increasingly linked with adolescent suicide (RKSK). These
policies also recognize that use of tobacco (cigarette/bidis
and chewing tobacco and tobacco products), alcohol, and
other intoxicants is common among the young people in
both rural and urban areas (RKSK, NYP). Learning diffi-
culties are acknowledged only in SSA. There is no mention
tal health care

of disruptive behavior disorders. The documents explicitly

Description

recognize that adolescent well-being is strongly affected by

social and educational determinants operating at the indi-
vidual, family and community levels, for example bullying,
safe and supportive schools. Other social determinants such
as social norms and parental conflict are less acknowledged.
Mental Healthcare Act

“Normal pressure like daily stress, peer pressure,

Table 1  (continued)
Policy and program

parental pressure, academic pressure, etc., creates

(MHA)—2017

mental health issues for adolescents. Depression,

anxiety, aggression and suicidal tendencies are major
mental health concerns among adolescents.” (Senior
researcher)

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410 Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414

The content and actors mentioned in two documents. The RKSK mentions the
role of the PE serving to sensitize adolescents on health
We broadly classified adolescent mental health interven- issues and facilitating referral to health services. A mobile
tions as either preventive or treatment. Table 2 provides app (‘Saathiya Salah’) has been designed to guide PE with
an overview of the mental health interventions and their key information on adolescent health. The YS program
recommended delivery agents. Most interventions were proposes two cadres of providers, i.e. ‘Yuva Parivartha-
intended for delivery on the community platform, notably kas’; YP—meaning change agents of youth; and ‘Yuva
preventive interventions such as substance use awareness Mithras’; YM—meaning friends of youth. They serve as
generation camps and group meetings at teen clubs. These psychosocial support service providers in the state (Kar-
interventions were generally delivered through non-spe- nataka). The only mental health intervention at the family
cialist providers including youth volunteers, Peer Educa- level was guidance sessions regarding adolescent health
tors (PE), Accredited Social Health Activists (ASHA) and concerns provided by YM and YP (YS program).
Auxiliary Nurse Midwives (ANM). Youth engagement is

Table 2  Mental health interventions for adolescents in India: recommendations of the reviewed policies and programs
Platforms Content Delivery agents

Community Preventive ANM, ASHA, Peer educators, youth volunteers—(RKSK,

1. Educating adolescents about mental health concerns NYP)
through ­Sablaa and ­NYKSb teen clubs—(RKSK, NYP)
2. Peer Education (PE) program to build awareness about
mental health and other adolescent health concerns—
(RKSK)
3. Awareness generation on ill—effects of drug/substance
abuse (NYP)
Treatment
1. Conducting individual and group support/guidance ses- Yuvasamalochaka and Yuvaparivarthakas—(YS)
sions for youth and their families—(YS)
Digital Preventive –
1. ‘Saathiya Salah’ mobile app acts as cost-effective infor-
mation platform for the adolescents (RKSK)
Treatment –
1. Providing telephonic guidance (Individual and group) for
youth and their families—(YS)
2. Saathiya Helpline (in the app) as an e-counselor (RKSK)
Family Preventive Medical Officer or ANM—(RKSK)
1. Conducting group/individual sessions with parents to
sensitize them on adolescent health needs—(RKSK)
School Preventive Teachers and skilled trainers—(NMHP; SSA; and RKSK)
1. Life skills education—(NMHP; SSA; and RKSK)
2. Educating adolescents about mental health concerns
through classroom teaching as per curriculum—(RKSK)
Treatment Doctors, ANM, pharmacist—(RKSK)
1. Screening children for mental health problems and other
health problems (RKSK)
Healthcare facility Treatment ANM, ASHA, dedicated counsellor, Yuvasamalochaka and
1. Providing counselling services at AFHC and providing Yuvaparivarthakas (YS), and Medical officer—(RKSK)
referrals to specialist whenever required—(YS and RKSK)
2. Treating new and referral cases and emergency cases at Psychiatrist, Pediatrician—(RKSK, NMHP)
district and specialist hospitals
a
Sabla is a centrally sponsored program of Government of India which was initiated to enable adolescent girls for self-development and empow-
erment by provision of various facilities like health checkup and referral services, nutrition and health education, counseling/guidance on family
welfare, life skill education
b
Nehru Yuva Kendra Sangathan (NYKS) is an autonomous organization of the Ministry of Youth Affairs and Sports, India. It is the largest grass
root level apolitical organization in the world, catering to the needs of more than 8 million non-student rural youth enrolled through 2.95 lakh
village based youth organizations called Youth Clubs in the areas covering education and training, awareness generation, skill development and
self-employment, enterprise creation, thrift and cooperation, besides development of the body through sports and adventure and mind through
sustained exposure to new ideas and development strategies

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Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414 411

At the school platform, life skill education through class acknowledged as this component was delivered through
room curricula was a key preventive intervention mentioned local NGOs in these states. In Meghalaya, Kerala and Kar-
in NMHP and SSA. Teachers or skilled trainers were the nataka, the functioning of AFHCs as expected was attrib-
delivery agents. Signs and symptoms of many mental disor- uted to availability of infrastructure, political willingness
ders first appear during adolescence and thus school teachers and dedicated human resource.
must be well trained in mental health promotion and pay
“Meghalaya has a very interesting model of adolescent
individual attention to them (NMHP). Treatment interven-
friendly health clinic… the staff in the clinics are very
tions dominated at the healthcare facility platform and were
dedicated, the privacy is maintained, and confidential-
delivered at various settings, i.e., at Adolescent Friendly
ity is assured to adolescent clients. These clinics are, a
Health Clinics (AFHC), Primary Health Centre (PHC),
place where one will feel like going in. They have tried
Community Health Centre (CHC) and district hospitals.
to convert it into a non-health setting environment…
These interventions were delivered by specialists and trained
In West Bengal the system is in place, they have 420
professionals like doctors, counselors and nurses. The focus
counselors who were trained by the NGOs like CINI
was to provide adequate guidance and care to adolescents
and Center for Catalyzing Change.” (Member of the
who approach directly or were referred to these facilities.
TAG of the RKSK)
Process of policy and program development Common reasons mentioned for poor implementation
were the fragmented governance and lack of inter-secto-
These policies and programs were developed through mul- ral collaboration, budget constraints, and scanty human
tiple rounds of consultations with experts from government resources. A few states such as Delhi, Gujarat, Karnataka
as well non-government organizations including multiple and Kerala had taken initiatives to integrate mental health
stakeholders such as law makers, health, mental health pro- into general health care. However, the lack of inter-sectoral
fessionals and teachers. However, details on the selection collaboration and convergence were the major challenges,
of the experts, number of rounds of consultation that had with various interventions falling into the domains of diverse
taken place, and duration and nature of these consultations departments and ministries such as education, health,
were lacking. The role of youth engagement in process of women and child development and youth development, with
development was not clearly addressed in any of the policy/ little effort to coordinate their activities. Concerns were also
program. expressed about the hierarchical structure of personnel at
center and state level.
Challenges to implementation of policy The concerns were mainly related to inter-personal chal-
and programs lenges of working in the central and state government.
Central government officials would have meetings with
This theme was mainly addressed through the key inform- minimal involvement of state government officials and later
ant interviews. The key informants expressed concern about forward their recommendations for implementation at the
the patchy implementation of the policies and programs, as state level. The state government officials felt left out during
reflected in the lack of details on the scope and delivery of these decision-making activities, which further stalled the
the proposed mental health interventions. implementation process. If these activities are well managed
and streamlined, then this could lead to a more mutually
“There is a lack of clarity on mental health as a public
respectful and effective working environment at state and
health issue. There is not enough information available
central government levels.
on the issues faced by the adolescents. Definition of
the problems are very important and then the policies “No particular ministry is involved, it is usually
should be written. For adolescents there is no such the health ministry and health department which is
information available. Pediatricians are still the main involved in the mental health policy development. All
doctors for adolescents. Dermatologists have specific ministries have different mandate; the basic tendency
interest. Gynecologists are there for other problems of all personnel is of achieving targets made for the
but not for mental health or nutrition…there is lack ministry. All the senior managers are too focused on
of awareness on and absence of specialized care for their targets. Then there are ego hassles amongst senior
adolescent mental health issues.” (Member of fund- authorities.” (Member of funding agency)
ing agency)
The fragmentation of governance between center and
However, state level variations were also described, states also affected budgetary allocations which were, in
for example the better delivery of the PE component any event, relatively modest for the proposed goals of the
of the RKSK in Madhya Pradesh and West Bengal was documents. The central government framed guidelines and

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412 Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414

designed interventions without any consultation with state “Human resources for implementing mental health
government officials. Unaware of these central government programs in our country has been a consistent issue,
directives, the state governments do not seek funds from the next being the ruling political party and its commu-
the central government or make adequate allocations from nication within and across various departments. For a
their own budgets for implementing adolescent mental moment let’s say even though there is a strong political
health initiatives. will to implement a program, the next big issues arise,
where is the money to recruit resources for implemen-
“There is no clear communication between center
tation?” (Senior researcher)
and states about what policy is developed or how will
the funds be used for its implementation. Every year
the center declares new initiatives for adolescents but
Discussion
then the state is unaware of how to implement them.”
(Member of funding agency)
This paper describes the approach taken in current policies
Two major human resource challenges were mentioned. and programs in India to address the mental health of adoles-
The first was regarding front-line providers, and the chal- cents, and the challenges in implementing these policies and
lenges were the restricted salary structure which were programs. We employed the health policy analysis frame-
either set too low to retain these providers. The second work, widely used in other areas of health [9], to analyze 6
challenge was regarding the lack of clearly defined pro- policies and programs and concurrently interviewed 11 key
cedures for the recruitment and training of new provid- informants to identify challenges in the implementation of
ers specifically recruited for adolescent health (under the the documents. As in the wider field of adolescent and youth
RKSK). health, there is no conformity of the age ranges addressed
by these documents, with some adopting the orthodox
“Salary structure for adolescent health service pro-
WHO definition of adolescence, while others extending the
viders remains always a question. Offering them Rs.
age range as recommended as being more developmental
12000–15000 is not what they would like to work on.
wise accurate [12]. While mental health is acknowledged
More remuneration is required.” (Member of fund-
in health, education and adolescent health documents, and
ing agency)
adolescent mental health in mental health documents, there
“RKSK guidelines had mentioned two counsellors is inadequate depth (for example, in addressing the full
to be placed at the facilities but nothing more was range of mental health problems) and detail (for example,
explained about it in the guidelines, such as the eligi- on addressing the major barriers in implementing the pro-
bility criteria, qualification of the counsellors, expe- posed interventions).
rience, etc. Until it is well defined how can someone Stress, anxiety and depression were the most frequently
implement or work on that? We need very highly identified mental health problems. On the other hand, psy-
qualified counsellors to respond to the issues of ado- choses, substance use disorders and self-harm, which are
lescents”. (Member of the TAG of the RKSK). less common, but often much more serious and enduring, are
poorly addressed [13]. Similarly, while some of the social
These human resource challenges were compounded by
determinants of mental health are discussed, for example
the lack of trained mental health professionals and unclear
school attendance, attainment and supportive school envi-
policy guidelines for their recruitment and sustainability.
ronments, others related to families, communities, social
“There is dearth of mental health professionals in norms and childhood experiences are most omitted. There
this country… existing mental health policy people is also little acknowledgement of principles of equity and
is scanty, 2 or 3 people are expected to run a mental social justice, for example in the different needs of adoles-
health policy for 1300 million people, even these peo- cents in rural regions, those in vulnerable or marginalized
ple lack sound training in mental health, then how can contexts (such as homeless or sexual minorities), those liv-
we expect to make them run a successful MH policy ing with disabilities and those who experienced neglect and
or program. There is an issue of institutional capacity abuse in childhood. The bulk of interventions were preven-
in terms of quality and quantity… we need a special tive in nature, with a dominance of school-based curricula,
technical resource group for mental health to opera- and most had little details on implementation or the ration-
tionalize the same.” (Senior researcher) ale for their selection. Interventions targeting families or
provision of psychosocial interventions for adolescent with
Across all these themes, a recurrent cross-cutting find-
mental disorders were poorly described, even in the spe-
ing was the lack of clear communication within and across
cific documents pertaining to mental health or adolescent
various ministries and departments.
health. While task-sharing with front-line providers (such

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Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414 413

as ASHA workers) was a frequent recommendation, the of other sectors, including skills building initiatives such as
training, supervision and financing models to enable this distance learning programs, capacity building by health care
role, or their coordination with other platforms of delivery providers from diverse disciplines such as mental health pro-
for addressing more intensive interventions, were largely fessionals and pediatricians, and the mobilization of youth
ignored. The lack of youth engagement in the development leaders and change agents.
of the documents and their limited role, in the form of peer The limitation of this study was the possible exclusion
educators, in the delivery of interventions, or governance, is of some key documents and informants on account of the
another major finding. Technology enabled interventions are snowball sampling procedure. However, the rapid satura-
few, and include the Saathiya salah app to enable peer educa- tion of our interview findings suggests we were unlikely to
tors with information to discuss health concerns and provide have missed a key theme in our results. While there have
appropriate guidance, referral and telephone counselling. been important achievements in national health indicators
Apart for the limitations of the existing policies and pro- in India, e.g., on child mortality, and on social development
grams, the lack of alignment across them and the fragmen- indicators, e.g., delayed age of marriage, which will have
tation of governance of adolescent mental health between beneficial impacts on adolescent health, there is also a need
ministries and departments, are likely to pose major barriers to simultaneously address the specific determinants of ado-
to their effective and efficient implementation. Despite the lescent ill-health and their consequences. We recommend
plethora of policy and programs, there are severe budget- a broader, life-course approach, to addressing these needs,
ary and human resource constraints which greatly limit the with interventions starting from childhood and extending
deployment of the proposed interventions. Many of these into young adulthood, the active engagement of young peo-
challenges in the implementation of policy and programs, ple in the design and delivery of the interventions, and the
such as lack of inter-sectoral collaboration and role of gov- coordinated involvement of diverse sectors and platforms for
ernance, budgetary constraints and scanty human resources, prevention and treatment. Equity must be a guiding principle
are similar to those reported in the context of other health throughout: one size does not fit all and contextual realities
policies [14, 15]. At the heart of these challenges is the weak and specific sub-group vulnerabilities should be considered
technical capacity, poor motivation, inefficient management while framing and implementing policies. Interventions
practices, and fragmentation of governance of health. This should be prioritized based on their evidence, scalability and
results in lack of clarity of mandates and roles, particularly equity. While it is too early to recommend specific digital
for population and community-based interventions, and con- interventions, the rapid growth of this technology and their
sequent gaps in delivery. Within the decentralized health embrace by adolescents clearly indicates the need to develop
governance framework in India, coordination is both hori- and evaluate their utility in promotion and prevention (e.g.,
zontal (between ministries and departments) and vertical through information provision and counselling), but also to
(from center to state to district). Addressing these systemic regulate those elements which are potentially harmful. Treat-
challenges, as envisaged in the National Health Mission, ment interventions should ideally be integrated in routine
will be an essential structural strategy to address adolescent health care and made easily accessible, for example through
mental health. Human resource shortages could be addressed school-based delivery of counselling interventions.
through community health workers, lay counsellors and The national adolescent health policy (the RKSK) is
peers, all of whom are numerous and relatively lower cost potentially the most appropriate policy for such a coordi-
than professional health care providers. The greater success nated and integrated approach, but must work closely with
that some states have had in implementing programs with the education and mental health policies to ensure efficiency
such providers through NGOs offers an example of how gov- and alignment of all proposed interventions, from pooling of
ernments can partner with civil society. financial resources to selection of interventions and human
Going forwards, policies and programs need to be better resources management for delivery of interventions. India
aligned with evidence-based practices emerging from both is home to the largest number of adolescents and young
scientific studies and program implementation experience. people in the world and a coordinated effort to correct the
While this evidence, often generated by NGOs working in deficiencies in the existing policies and to coordinate their
partnership with governments or academic institutions, pro- implementation to optimize coverage and impact will have
vide robust support for the acceptability and effectiveness national and global impacts on addressing the burden of
of interventions delivered in community and school settings mental and substance use disorders in adolescents.
by non-specialist providers, policies and programs need to
systematically address the barriers to the scaling up of such Acknowledgements We thank the stakeholders who participated in
the interviews. We would also like to appreciate the contributions of
findings. This requires, for example, sustainable strategies Mahima Sapru, Rooplata Sahu and Joya Jahangir Tamboli for conduct-
for training, supervision and monitoring the roll-out of such ing the interviews. This work was supported by the Wellcome Trust
interventions which, in turn requires the active engagement through a Principal Research Fellowship granted to Prof. Vikram Patel

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414 Social Psychiatry and Psychiatric Epidemiology (2019) 54:405–414

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