Addressing mental health challenges among adolescents in Himachal Pradesh: evaluating the impact of adolescent friendly health clinics

INTRODUCTION

Mental health embodies a state of profound well-being, empowering individuals to effectively navigate life's challenges, harness their capabilities, excel academically and professionally and actively engage within their communities. It serves as a fundamental pillar of overall health and wellness, shaping the fabric of our society. Recognized as an inherent human entitlement, mental health is indispensable for personal growth, community resilience and socio-economic progress.¹ However, mental health disorders disrupt this delicate balance, inflicting distress and impairing one's ability to function optimally. Ranging from commonplace afflictions like anxiety and depression to more severe conditions such as schizophrenia and bipolar disorder, these disorders exact a toll on various aspects of an individual's life, from personal relationships to professional endeavors.

Despite strides in awareness, mental health remains ensnared by pervasive stigma and discrimination, erecting formidable barriers to help-seeking behaviour and equitable access to care. Confronting these barriers necessitates fostering empathy, dispelling misconceptions and championing inclusivity and support for those grappling with mental health challenges. The burden of mental illness remains disproportionately high among vulnerable communities, with global treatment coverage persistently lagging behind. The enduring mental health ramifications stemming from recent global occurrences, including the COVID-19 pandemic, geopolitical shifts and environmental transformations, underscore the necessity for coordinated care strategies to provide psychosocial support to those affected.² Mental disorders rank within the top 10 contributors to global health burden, with anxiety and depressive disorders emerging as the most prevalent across diverse age groups and geographical regions.

In 2020, 28% more individuals encountered anxiety and depressive disorders due to the COVID-19 pandemic compared to 2019, representing 12% of the world's population, while 71% of global anxiety disorder burden could be alleviated with optimal treatment, contributing to 15% of total years lived with disability in 2019.³ Among young individuals, neuropsychiatric disorders stand as a significant contributor to health-related burdens, comprising 15–30% of the disability-adjusted life-years lost in the initial three decades of life. Despite the widespread acknowledgment of the significance of promoting and preventing mental health issues in children and adolescents, a substantial disparity exists between the demand for services and the available resources.⁴

To address these concerns, the government of India has undertaken various policy initiatives, resulting in some progress. For instance, policy-level actions such as the introduction of the first Mental Health Policy in 2014 and the enactment of the Mental Healthcare Act in 2017, replacing the Mental Health Act of 1987, have provided overarching guidance on broader issues related to mental health promotion. Additionally, programmatic efforts have focused on expanding the capacity of the mental health workforce by establishing centres of excellence and scaling up District Mental Health Programmes under the National Mental Health Programme.^6,7

Similarly, Adolescent Friendly Health Clinics (named Nayi Disha Kendras in Himachal Pradesh) are centres established under the Rashtriya Kishor Swasthya Karyakram program to provide comprehensive healthcare services to adolescents. Approximately 18.6% of Himachal Pradesh's population falls within the age range of 10 to 19 years.⁵ Recognizing the significance of family involvement in adolescent mental health care, Adolescent Friendly Health Clinics facilitate collaboration between mental health professionals and families to tailor treatment plans, emphasizing communication, collaboration and empowerment for improved outcomes and holistic well-being.

The primary objective of the current study is to examine the operations of adolescent friendly health clinics through an analysis of adolescent OPD data highlighting the various mental health issues for which the adolescents seek counselling for.

METHODS

This study is a retrospective, observational, descriptive analysis based on secondary data obtained from National Health Mission (NHM) adolescent health reports. The dataset was maintained in Microsoft Excel and comprised records of both female and male adolescents, categorized into two age groups: 10–14 years and 15–19 years. Data pertaining to adolescent mental health challenges were collected over a three-year period, from January 2021 to December 2023. The study aimed to analyze the prevalence and distribution of mental health challenges among adolescents across age and sex categories.

RESULTS

Number and functioning of Adolescent Friendly Health Clinics (NDKs)

Adolescent Friendly Health Clinics also called Nayi Disha Kendras, a state initiative initially launched at tertiary and secondary healthcare levels, have expanded to Primary Health Centres due to their popularity. With 103 Kendras across various districts (Figure 1), they cater specifically to adolescents, offering tailored healthcare services and a dedicated team comprising medical officers, counsellors, nurses and others. These Kendras provide comprehensive care, including de-addiction services, along with informative materials and regular training sessions. They offer clinical, counselling and referral services, with online reporting mechanisms for monitoring. Collaborating with other sectors and NGOs, they conduct awareness initiatives and outreach camps on topics such as sexual health, substance abuse prevention and mental health. Additionally, the government provides online consultation services through Telemanas for discreet access to mental health support.

Mental health of adolescents

Roughly 11000 of adolescents suffer from mental health issues like stress, depression, suicidal tendencies, and other mental health issues among the adolescent who were registered in adolescent health friendly clinics. Stress cases were maximum with 53% followed by adolescents suffering from other mental health issues, followed by depression 14% and adolescents with suicidal tendency 5% as highlighted in Figure 2. The primary factors contributing to the burden of mental health appear to stem from various challenges including restricted availability of mental health services, a scarcity of mental health professionals, inadequate awareness about mental health issues, societal stigma, lower levels of literacy, economic hardship and families' reluctance or inability to provide care for their members struggling with mental illness.⁶

Trend of mental health issues among adolescent

The data shows that adolescents experiencing stress, depression and other mental health issues have been increasing for both girls (Figure 4) as well as boys (Figure 3) in number from January 2021 to December 2023 except for suicidal tendency which shows slightly less cases in 2023. This might be attributed to increased awareness and acknowledgment of mental health issues among adolescents, leading to more individuals seeking help and approaching the adolescent health friendly clinics.

Additionally, the associated stressors of COVID-19 pandemic, such as social isolation, academic pressures and family challenges, likely exacerbated existing mental health concerns among adolescents. The rise in virtual learning and decreased social interactions may have also contributed to feelings of loneliness and anxiety among young people. Adolescent friendly health clinics have thus played a vital role in increasing accessibility, reducing reluctancy and have enabled more adolescent seeking counselling.

If authors look at the distribution of cases in adolescent boys and girls according to the age groups, the number of cases were found more in 15-19 years than in 10-14 years in both the genders.

DISCUSSION

Mental health issues persist as a significant challenge, warranting continued attention and intervention efforts to ensure well-being and resilience among individuals and communities. Amidst societal stigma and resource disparities, fostering awareness, promoting access to mental health services and cultivating supportive environments remain crucial steps towards mitigating the impact of these enduring challenges.

Even in countries like USA, significant efforts are done to provide mental health care. In a survey, a total of 230 070 adolescents aged 12 to 17 years were interviewed from 2005 to 2018 and it was found that the proportion who reported receiving care was stable over time.⁷ The prevalence of mental health disorders among children and youth in nearby South Asian countries also stand high as China with 17.5% prevalence and the figure have been rising over recent years.⁸ In another study carried out in Bihar and Uttar Pradesh, it was found that depression rates were higher among married female adolescents aged 15-19 years (49.6%) compared to unmarried males aged 10-19 years (36%) and female adolescents aged 10-19 years (42.4%). Furthermore, adolescent males who had ever seriously considered attempting suicide were 8.44 times more likely to have minimal to mild depression and 22.74 times more likely to have moderate to severe depression.⁹

A cross-sectional study was conducted among adolescents in secondary schools of Delhi from January 2012 to March 2013 by Watode et al. Among the 397 students surveyed, 87.6% were positive for stress, with no statistically significant association observed between gender or parents' education level and stress. Stressors identified included academics, parental pressure, teacher expectations and peer interactions.¹⁰ Thus, we see that stress level are comparable at higher levels in both adolescent girls and boys.

In a survey conducted within the community, involving individuals aged 15–24 years from Himachal Pradesh, the prevalence of depression was found to be 6.94%. It's worth mentioning that in this study, depression was assessed through a series of questions focusing on symptoms like loss of appetite, disruptions in sleep patterns, feelings of apathy and worthlessness, as well as a decreased interest in daily activities and work.¹¹ The percentage is quite less than our findings of 14% which may be attributed to increased reporting and awareness among the adolescents.

During the COVID-19 nationwide lockdowns, adolescents have experienced both acute and prolonged stress due to parental anxiety, disruption of their regular routines, heightened instances of family violence and being confined at home without or with limited interaction with peers, teachers or opportunities for physical activity.¹² According to the adolescent health fact sheet by Himachal Pradesh, rate of suicide per one lakh population (all ages) has seen an increasing trend from 2019 to 2021 with a significant rise in cases in 2020 and this data is comparable to national data which has also seen an increasing trend. In a study done by Thakur et al, it was reported that among school going adolescents, 30.9% had suicide ideation. This percentage is much more than our study results which is 5%.

Discussing problems with parents, having good relations with school teachers and helpful classmates lowered the odds of having suicidal ideations. On the contrary, adolescents having worrying issues in family, verbally or physically abused and body image conscious had increased odds of suicidal ideations.¹³ It is noteworthy that in 2023, in our study, the cases of suicide ideation have decreased a bit. A meta-analysis found that approximately 13.4% of children and adolescents worldwide are affected by some form of mental disorder.¹⁴ As high as 90% of individuals with mental health disorders in India experience a treatment gap, indicating a significant disparity in access to care.¹⁵ Through offering counselling services, adolescent health friendly clinics is increasing footfall and empowering individuals to manage their mental health challenges and integrate into society. Moreover, they contribute to reducing stigma through awareness campaigns and outreach services.

Limitations

This study is based on secondary NHM programmatic data and is therefore subject to limitations related to data completeness, reporting accuracy and potential underreporting due to stigma and variable screening practices. The use of aggregated anonymized data limited individual-level analysis and assessment of disease severity or risk factors. As a retrospective descriptive study, causal associations could not be established and the observed trends may partly reflect improved awareness and reporting rather than true changes in prevalence.

CONCLUSION

Addressing mental health issues among adolescents is crucial for their holistic development and long-term well-being. By promoting destigmatization, providing accessible mental health services and fostering supportive environments, we can empower adolescents to seek help and develop healthy coping mechanisms. Collaborative efforts from governments, communities and healthcare providers are essential in creating a culture where mental health is prioritized and supported. Awareness at all levels, including anganwadis, primary schools, middle schools and senior secondary schools, is crucial to ensure adolescents develop a clear understanding of the concept of good mental health. Participation of parents, siblings, friends and family members is must to provide a healthy environment for the adolescent to dwell. Investing in adolescent mental health not only benefits individuals but also contributes to healthier communities and societies overall, emphasizing the importance of proactive interventions to ensure a brighter future for our youth.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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