Today, there is a price to everything! My interest in mental health costs spurred as a result of trying to find an answer to a simple question, “what should be the cost for seeking help?” It emerged as a result of multiple conversations, trying to frustratedly understand why we weren’t making real progress despite there being numerous efforts.
Friends of mine who regularly attend therapy, still pay a thousand rupees, for a consult, and that is barely scratching the surface of the total amount they have to spend. We can still afford it, what about those who cannot, the ones who we are really trying to target by raising awareness? With the rates of reported cases of mental illness in India only escalating, I believe that there is an urgent need to expedite this process. We need to quickly shift priorities from doing something to doing something now, like insuring out patient therapy. This will help empower individuals to address mental health concerns, with the same persuasion, as they would have addressed physical health concerns.
In 2017, following the Mental Health Care Act, the Insurance Regulatory and Development Authority of India (IRDAI), took a progressive step and issued a notice in August 2018 directing all insurance providers to include specific mental illnesses as part of their existing insurance schemes. However, this momentum has been restricted to policy and legislation, and not translated into actual implementable mechanisms, therefore delaying accessibility to even those individuals who actively seek intervention.
So I sought to understand the lived experiences of people seeking these services to see what it was like for them. I looked at three areas which seem to be influencing their out of pocket expenses- the cost of therapy and medication when required, the frequency of both and the current accessibility to financial aid that allows one to continue these services.
In this case, value or what we call money well spent would be realised only if the person seeking services believes that s/he is able to appreciate the benefits at a reasonable cost; reasonable being key. On the flip side, even though an individual might perceive a particular service as being of ‘value’, due to high pocket expense, s/he might prefer to discontinue. Turns out, I was right.
I had reached out to individuals seeking mental health services, as well as their care-takers to understand how much they have to spend to take care of their mental health. These people ranged from 15-50 year olds, belonging to urban middle class families living in Delhi, Vishakhapatnam and Hyderabad. Some were students, some children and their parents and some working professionals who’ve even had to quit their jobs because of the illness. I started looking at the out of pocket expense they incurred which was calculated, as an average of their monthly spend on mental health services. This is what I found-
Undoubtedly, mental health services were expensive, but it didn’t just end there! This expense was extremely layered, and specific. There was a significant difference in expenses, not only across different mental health diagnoses, but also across people. Rest assured, no two individuals even with the same diagnosis will be spending the same amount. Different diagnoses had different associated costs like medication and how long therapy could go on. Certain diagnoses like schizophrenia and bipolar disorder had extremely long durations of treatment, which could even last for several years. Owing to high spending for such diagnoses, these mental illnesses can be doubly heavy on the pocket. Therefore, apart from the already prevalent stigma, illnesses like schizophrenia and bipolar disorder came with an additional financial burden. This means that it’s quite likely that this perceived cost then is negatively contributing to an already existing stigma.
It was quite evident that all of the people I spoke to were convinced that the suggested treatments were working and proving effective. Or maybe, they were in a position of privilege to be able to afford it. But to me, this clearly highlighted the existence of an extremely niche demographic, and how mental health services are only affordable for some. It was apparent that the reach of quality mental health service is targeted to an urban, upper-middle class demographic that is capable of financially investing in private health care (where majority of the trained mental health professionals are found), as opposed to someone who is perhaps more vulnerable and for whom seeking the same level of treatment becomes a luxury.
The costs calculated above account only for the visible costs associated with diagnosis and treatment in the healthcare system. It does not consider hidden costs incurred by the individual in question and (or) the care-giver due to being absent from work, care-taking, etc. As per my calculations, for an average urban, upper middle-class Indian, the monthly out of their own pocket expenditure for mental health intervention is INR 4000. To better understand the consequences of such a high cost, I consulted with practising professionals across different private establishments in urban areas. Each of them arrived at the consensus that due to high out of pocket expenditure, there was a noticeable disparity in the nature of clients they received. There was a homogeneous influx of clients from the urban upper middle-class population.
As per World Health Organisation report of 2019, India only spends 4 rupees per citizen for their mental health needs.
Not only this, considering mental health consultation is a service-oriented sector, perceived cost of care, negatively pushes clients into a comparative tendency. This can easily lead to one of two outcomes: First, acknowledging the need for therapy and attending the first session is often 80% of the work done. However, clients constrained by limited finances, are often compelled to compare doctor’s fees, instead of qualifications and experience which becomes important for therapy. As a result, clients may never even take the first step towards seeking help. Then second, due to uncertainty or limitations in finances, high out of pocket expense might coerce clients to irregularly end services or drop out.
To this, I sought further input to understand what practising professionals believed could be the relevance of mental health insurance for India. Naturally, all of the practising professionals agreed on the efficacy of mental health insurance to improve financial accessibility. At the same time, they believed that the cost for mental health services should not be completely waived off, and there must exist at least a base, minimal fee. This would ensure that individuals consider this base, minimal fee as an investment that would bring them returns. The perceived value of therapy would extrinsically motivate individuals to invest themselves in progress. Offering mental health services for free would mean that individuals become more likely to take it for granted and not put in as much effort.
The rationale seems to be quite simple. Greater the figure, greater is the value assigned to mental health services and lesser the figure, lesser the value assigned to it.
And to most of us, the former is more appealing. But greater figure(s) also account for high out of my pocket expense. I believe that improving accessibility is an uphill challenge, but the most important stake-holders right now are the mental health professionals themselves. As per me, they are the only who have accessibility to resources and all the facts needed to make an informed decision. They are aware of the situation on ground and engage in a diverse range of conversations. The question of how to move forward and empower individuals should therefore be initiated by professionals, keeping in mind the best interest of the patient. Arguably, there is the critique of service-oriented sectors being profit-driven. But we can move forward only if we extend a certain trust and believe that professionals would be able to address how a policy for insurance must be tailored, to be implementable in a way that empowers everyone, especially the patient.
So, what should be done? It becomes important to think about who should determine the value of this treatment- the State, the private sector, the practising professional or the patient?
Dedicated to all those who reached out to us for affordable mental health services and to the ones who've had to drop out of therapy because they couldn't afford it. For any mental health related assistance, you can write to us at hello@thoughtpudding.com
Author: Shreya Upendra, a student of Psychology, Media & Sociology at Symbiosis School of Liberal Arts talks about the struggle of her friends trying to afford therapy as well as those of people she met during her research.