Viewpoint

School Mental Health Program in India—

Issues and Possible Practical Solutions
Vijaya Raman1 and Shanti Thomas1

W
education-based initiative to support
orldwide, an estimated 13%
the mental health and wellbeing of chil-
of youth under 18 years of
dren and young people from birth to
age have significant mental
school-leaving.7 Evaluations indicated that
health problems.1,2 Also, a significant
these programs probably work best in the
percentage of mental health issues have
long run if they are integrated into the
their onset below 25 years of age. Global-
school system and run with the support of
ly, during this period, the children spend
both the school management and the local
much of the time in school. Hence, it
community.
stands to reason that children and ado-
lescents can be reached early in schools SMHPs in India:
than in any other setting for health pro-
motion, prevention of disease, and inter- An Introduction
ventions. India has the largest number of children
and adolescents in the world.8 The Gov-
School Mental Health The outcomes in all of these were posi- ernment of India has given emphasis to
Program (SMHP) tive, though the long-term outcome has developmental delays and developmen-
to be evaluated. In addition, the School- tal disorders as part of the School Health
Models Globally Based Support (SBS) program was begun Program under the ‘Ayushman Bharat’
Several preventive school-based mental in the United States with the goals of scheme. This document specifically men-
health interventions have proven to have increasing the capacity to recognise and tions behavior disorder (Autism), Learning
some level of efficacy. Some examples are meet the mental health needs of children Disorders, and Attention Deficit Hyperac-
the Positive Behavior Interventions and and improve academic and social/ behav- tivity Disorder. In the health promotion
Supports (PBIS)3, Skills for Life (SFL)4, ioral outcomes.6 section, substance use, internet safety and
and MindMatters.5 Two of these inter- A series of SMHPs initiatives by the literacy, meditation, and yoga are covered
ventions were developed in high-income Australian government aimed at the pro- along with a broad category of mental
countries (the United States and Australia), motion of mental health and prevention health.9
and the third (SFL) was developed in a of and early intervention for psychiatric The Central Board of Secondary
lower-middle income country (Chile). problems This is now a single national Education (CBSE) recommends that all

Dept. of Psychiatry, St. John’s Medical College, Bangalore, Karnataka, India.

1

HOW TO CITE THIS ARTICLE: Raman V and Thomas S. School Mental Health Program in India—Issues and Possible Practical Solutions.
Indian J Psychol Med. 2023;45(3):283–288.

Address for correspondence: Vijaya Raman, Dept. of Psychiatry, St. John’s Medical Submitted: 27 May. 2022
College, Sarjapur Road, Bangalore, Karnataka 560034, India. Accepted: 06 Mar. 2023
Email: vijaya.r@stjohns.in Published Online: 17 Apr. 2023

Copyright © The Author(s) 2023

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCESS THIS ARTICLE ONLINE
Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) Website: journals.sagepub.com/home/szj
which permits non-Commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the Sage and Open Access pages (https://
DOI: 10.1177/02537176231165033
us.sagepub.com/en-us/nam/open-access-at-sage).

Indian Journal of Psychological Medicine | Volume 45 | Issue 3 | May 2023 283

 Raman and Thomas
secondary and senior secondary schools interest among the school managements, student-led activities with social messages in
should employ a counselor and engage and cooperation of parents and children newspapers). Some [e.g., Gurukulam Project
in psychological exercises toward build- alike. and Our Responsibility to Children (ORC)]
ing students’ self-concept, self-image, and Zippy’s friends program, adapted from looked at selective prevention. This review
the ability to withstand pressures. It also the United Kingdom for use in Goa, was also identified some indicated prevention
suggests developing a sense of curiosity in launched in 2004 with the partnership of a programs such as the Childline program,
students – both of the self and the environ- Non-Governmental Organization Sangath. Help Desk program, and Jyothirgamaya
ment – as a central aspect of the learning Pre-schoolers (5-7 year olds) were taught project. All these programs have had reason-
process.10 problem-solving, coping, and to identify able success, according to the authors of the
There have been several reviews of the emotions, integrate emotional and lan- review but the lacunae continue to be in the
Indian SMHPs that discuss the issues and guage development. Teachers were trained domain of human resources for sustaining
possible solutions11,12 Some specific issues to carry out this program in schools.16 the programs and the lack of inter-agency
about children in schools include their Unarv, in Thiruvananthapuram, Kerala, coordination in carrying out the plans.
inability to seek help for themselves, their is a district-level adolescent SMHP with In 2021, the Indian Psychiatric Society,
difficulty in trusting adults to help them a three-tier approach, where two teach- Kerala Branch, launched a training program
(especially if they have had bad experi- ers from every high school and higher christened ‘Sneha Kavacham’ to address
ences with adults at home), and, of course, secondary school are trained annually digital addiction, with the target audience
the reluctance to divulge issues in the through workshops. A study found that being students, teachers, and parents.21
school setting for fear of being victimised. this is a sustainable model in a low- Another review of SMH activities in
In addition, in India, there are additional resource setting. 17 Maharashtra traced its origins to the
considerations of language, culture, geo- SHAPE (School HeAlth Promotion and early 1930s.22 The paper discusses various
political issues, and family diversity. This Empowerment) program was designed programs and facilities available for
paper attempts to evaluate the current by Sangath, an NGO in Goa, for 5th to mental health education in the state,
programs with a view to offer practical 12th class students.18 This intervention including awareness programs, camps,
solutions that can be implemented more was found to be feasible and acceptable and early intervention. It recommends
easily in order to improve outcomes. in the school setting, with positive out- that there is an acute need to work on the
A comprehensive review concluded comes in health-related behaviors. existing setup and available resources by
that SMHP in India ‘is running with a Conduct of SMHP by trained lay enriching SMH activities.
piecemeal approach’, and for all practi- counsellors have also been found to be All the above programs had a preven-
cal purposes, it is non-existent for most well implemented, like in the ‘Strength- tive and treatment approach, with a
school-going children. The authors opined ening Evidence-base on scHool-based long-term promotive component woven
that “the sporadic efforts (such as conduct- intErventions for pRomoting adoles- into some of them. Some of them have
ing some sensitisation program for school cent health program’ (SEHER)19 in Bihar, been formally evaluated for their efficacy,
teachers) are praiseworthy; however, they which is a low-cost approach utilising and it would be interesting to know the
are insufficient for a comprehensive and the service of a trained teacher and lay long-term outcome of these initiatives.
sustainable SMHP.”13 counsellor. This study found no signifi-
cant differences between lay counsellors Possible Barriers to
Some Current SMHPs and professionals in improving social
Implementation
skills among adolescents.
The Help Desk Program under Sarva Often, when students are identified in
In Kerala, in recent years, many inter-
Shiksha Abhiyan (SSA)14 offers a dropbox schools as potentially struggling with
ventions have been made available that
facility (where children can get support mental health issues, they are referred
specifically focus on the mental wellbeing
for their problems confidentially) and out to professionals in the community
of children. A review revealed over 15 pro-
trained teachers to identify psychologi- for treatment. While well-intended,
grams providing mental health services at
cal issues and counselling. this approach is largely unsuccessful if
various levels.20 This included government,
The Life Skills Training Program15 initi- families face challenges such as language
private, and non-government organisations.
ated by the National Institute of Mental barriers, cost, lack of transportation, or
Some programs included universal preven-
Health and Neurosciences (NIMHANS), lack of flexibility with their jobs leaving
tion (e.g., Clean Campus Safe Campus that
Bengaluru, involved training secondary them unable to make appointments.
focused on reducing access to drugs; Thangu
school teachers as “life skill facilitators” The Indian mental health system has
project that oriented teachers to provid-
for teaching life skills to students and a an acute shortage of trained mental
ing psychological support; Santhavanam
teachers’ orientation program in which health professionals to deal even with
project that empowered parents, teachers,
they were taught the skills to identify psy- severe mental illness. They are also
and students; Souhrida Clubs that provided
chological problems, counsel, as well as mostly located in cities and larger towns,
leadership training; Ullasaparavakal that
refer the students to mental health profes- making them inaccessible to most chil-
focused on life skills lessons by teachers;
sionals (MHPs) when required. However, dren and families.
Thalir program that focused on sensitisation
the Life Skills module was not imple- Schools in India are also somewhat
on mental health/ ill health, by mental health
mented by schools for various reasons, reluctant to be involved in running these
professionals, for parents, teachers, and chil-
including lack of human resources, programs. The reasons may be many,
dren; and Nallapadam that published model
284 Indian Journal of Psychological Medicine | Volume 45 | Issue 3 | May 2023
 Viewpoint
such as the lack of personnel for such school, and community and requires a Given the constraints in human re-
activities and a conflict for the school transformed mental health system. In sources for implementing mental health
across the different roles it sets for itself. India, we may not be ready for this as yet. programs in Indian schools, the possibil-
Also, not being funded for these activities We also do not have screening tools that ity of parental involvement as volunteers
gives them less motivation to conduct are acceptable for use all over the country. must be attempted, and parents can be
such programs. provided training according to the roles
Stigma is often cited as a reason for not Scarcity of Human they are expected to play. It is also a fact,
seeking mental health treatment or fully however, that poverty and lack of educa-
participating in it. Other barriers such
Resources and Trained tion prevent parents from being active
as lack of dedicated physical space, non- Force (Alternatives to partners with schools.
cooperation of the school management, Overburdening Teachers)
the reluctance of teachers to refer chil- Use Other Professionals
dren in need of help, non-availability of a Many long-term SMH projects overcame
the difficulty of lack of enough trained We propose that a nurse may be
counsellor regularly on campus, and lack
force by training the teachers to conduct appointed to deal with both the medical
of privacy are all possible reasons.
the programs25,,. However, teachers may and psychological needs of children
Some Practical Suggestions perceive this as an additional responsi- in the school setting. It will serve to
bility with the existing academic and destigmatise mental health issues. There
to Overcome the related activities. Hence, it would be are some suggestions that this will be
Stumbling Blocks unfair to add this extra burden on them. acceptable to the children, parents,
Child and adolescent psychiatrists have teachers, and school management.29 A
Involvement of Mental an important role to play in developing manual has been developed to describe
Health Professionals in human resources and training layper- a school nurse’s role in mental health.
sons and other paraprofessionals to do This provides various options, including
SMH-Related Activities the onerous job of identifying, treating, screening and assessment, identifying
It would be helpful for mental health and also preventing mental health issues problems and providing an appropriate
professionals at all levels to involve in the school-going children. response, and playing preventive roles by
themselves in SMH-related activities by In addition, usually students do not sensitising children, parents, and teach-
publicising them on social media, writing prefer to discuss their issues with teachers, ers about mental health promotion.30
articles for laypeople in the lay press, and due to difficulties for both the parties: Teach- They can also play a role in obtaining
giving talks on the radio, television, and ers have to play the dual role of teacher and consent for treatment, processing the
in virtual media as well. This would play counsellor, while it is difficult for students child’s and family’s access to mental
a major role in sensitising people about to perceive them in a role other than the health care, and ensuring confidential-
mental health issues and promote accep- authoritarian one they usually play. Teach- ity, which will enhance compliance. To
tance of consultations and treatments ers can be trained, however, to recognise facilitate mental health work, school
with mental health professionals. Often, the early warning signs like school absen- nurses need to be trained and supported
such plans remain either as a theoreti- teeism, poor self-care, a decline in academic to develop interpersonal skills and net-
cal concept in an individual’s mind or performance, poor social interaction, etc., as works. They will also need access to a
on paper as a document that records the these may indicate the beginning of major local mental health team to refer.
proceedings of a meeting. child and adolescent psychiatric disorders. There are school health programs in
A proactive approach is needed in As already discussed, some emerging pro- India that use school health nurses for
the form of commitment to helping grams use trained laypersons with good general health awareness and inter-
schools at the individual level and also acceptability and accessibility.26 vention and these have been varyingly
incorporating SMH into the agenda for successful.One study showed that services
the state, zonal, and national bodies.23 Form Strong Parent–Teacher to address the school environment –
Physical presence of professionals may including preventive, promotive, ther-
be difficult, but sharing expertise is not.
Associations apeutic and rehabilitative services - are
Being on the advisory boards of schools In the West, parents are encouraged to supposedly available in Government
and colleges could be a good starting be volunteers in their children’s schools. schools on paper, but these are not uti-
point. Sharing of information, capacity Parental engagement with the school, lized by either the students or the school
building, and peer supports should help which has primarily been studied about personnel. Shortage of staff and a lack
decrease stigma in schools as well. children’s school achievement, has of awareness of such facilities being
generally shown a positive association available are often cited as reasons.31
Screening in Schools between the two.27 Including pediatricians in this endeavor
A study in the Caribbean countries will be helpful as they are probably the
A study from Gujarat concluded that
found an association of parental involve- first point of contact for any health,
mental health screening should be incor-
ment with lower levels of loneliness, including mental health, concerns. The
porated into the school health program
anxiety, suicidal ideation, and depres- stigma will also be far less if a pediatri-
protocol.24 Such screening needs to be
sion among school-going adolescents.28 cian is involved in sharing information,
done with the involvement of the family,
Indian Journal of Psychological Medicine | Volume 45 | Issue 3 | May 2023 285
 Raman and Thomas
sensitising children and their parents, The issue in India appears not to be number of mental health professionals
and even giving talks in schools includ- a case of paucity of available financial in our country and the enormity of the
ing mental health aspects to general resources but more of a problem with population needing help. Team effort
physical health. the allocation of available resources and must be enlisted to support this cause –
roadblocks at the various levels - from this should include teachers, parents,
Address Stigma the funding authority to the point of paramedical personnel, nurses, doctors,
actually disbursing funds for the deserv- especially pediatricians, psychologists,
It is important to remember that much of
ing programs at local levels. psychiatrists, psychiatric social workers,
the resistance to seeking help for mental
counselors, senior alumni of the school,
health problems is due to misinformation. Use Online Resources and people in the management. Unless
In one study, about 70% of higher second-
With the increased use of technology some combination of professionals
ary school teachers who were shown a
in all spheres of education, it is only comes together for this endeavor, it is
case vignette on depression acknowl-
natural that some degree of psycholog- unlikely to succeed.
edged having personal and perceived
ical services can also be provided online.
stigma toward the case. The negative atti-
There are definite advantages of this
Role of Child and
tude toward people with mental illness
was quite evident. Teachers who were medium as it ensures confidentiality, Adolescent Mental
younger, male, or in urban schools or improves accessibility, and also promotes Health Professionals in
had less teaching experience had higher children’s confidence to confide their dif-
stigma.32 It is important to provide accu- ficulties. Their areas of concern may be School Mental Health
rate information in the form of holding to do with peers, school (both academics Child and adolescent mental health pro-
poster, quiz, and essay writing competi- and issues with teachers) or family. Sup- fessionals are uniquely positioned to
tions on themes to do with mental health porting schools to develop websites to respond to the growing public health
to sensitise children, teachers, and parents. share information about mental health challenges associated with mental dis-
This would encourage children and adoles- and also providing them with details of orders arising early in life that will first
cents who need help to reach out. Getting possible ways to seek help for these con- be observed in the school setting. Some
mental health professionals to speak to cerns could be a logical step for SMHP.34 authors recommend that, to meet these
children and parents during annual day While e-counseling should not be con- challenges, the field must consider some
programs or parent-teacher meetings may strued as the first choice when dealing changes. They outline four consen-
also serve the purpose of sensitisation. In with severe psychological challenges, it sus priorities for child and adolescent
the current scenario, online sessions can can be a practical and viable adjunct.35 mental health over the next decade37—
also be planned as part of the school day. An Australian study evaluated a increase the workforce, reorient mental
Liaising with the media to promote pos- web-based mental health service that health services to incorporate broader
itive mental health education and close offered screening, psychological therapy, public health needs, increase research
interaction of mental health professionals and monitoring in an attempt to help and training and incorporate newer
with parents and teachers in a common counselors manage time and provide research findings into practice, and, most
forum, wherein a mental-health-oriented additional supervision to students. It importantly, increase efforts at advocacy.
approach rather than an illness-oriented concluded that, although the service
approach is adopted, are also suggested. helped reach a larger number of stu-
Road Map for Initiating and
Sharing of information, capacity building, dents, greater support and resources
and peer supports should help decrease are needed to facilitate the already chal- Expanding SMH Services
stigma in schools as well. lenging and demanding role of school It is important to have a clear vision about
counsellors.36 the scaling of mental health services in
Manage Financial In the wake of the COVID-19 pan- the school setting. A tier system will be
demic, some schools have provided a helpful guide. Tier 1 could be the uni-
Constraints avenues to discuss mental health issues versal screening of all children at various
Involving governmental and non- online, but this is still very rare. Schools time points – like at the time of entry into
governmental agencies and the private can put together a list of mental health preschool, primary school, and secondary
sector would be good ways to address professionals that their students and school. This could be done using simple
financial constraints. Better utilisation families can access and display it on their screening instruments. Tier 2 would
of the available resources is another websites and notice boards and even include children identified as having diffi-
important way to solve the financial include such information in routine par- culty and needing support, but this could
crisis.33 Looking for different ways to ent-teacher meetings. be support provided at the school level by
raise funds for the adequate implemen-
a nurse, teacher, or parent and can be pro-
tation of a program, like approaching Need for Team Effort vided in an individual or group format.
members of the local clubs – like the
Rotary or Lions clubs - who can conduct Mental health is of concern to all and Tier 3 includes children needing pro-
some recreational programs or even raise should not just be restricted to relying on fessional help and support from locally
funds through their members would mental health professionals. This is espe- available mental health professionals.
also be helpful. cially important considering the small Every school could have a directory of

286 Indian Journal of Psychological Medicine | Volume 45 | Issue 3 | May 2023

 Viewpoint
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of Ministry of Health & Family Welfare thehindu.com/news/national/kerala/
Declaration of Conflict of Interest and Ministry of Human Resource & mental-health-literacy-important-
Information in this article includes the view- Development, Government of India, minister/article36935376.ece (October 11,
points of the authors and there are no conflicts April 2018. 2021).
of interest that may influence the perspective of
10. Central Board of Secondary Education 22. Gujar K and Pingale V. School mental
the model.
(CBSE). Life skills education in class VII. health programme in Maharashtra—
Circular no. 11/04 of 2004, http://cbse. Today and way ahead. Ann Indian
Funding
gov.in/circulars/2004/Circulars_11.html. Psychiatry 2017; 1: 4–7.
The authors received no financial support for the (accessed, 2014 Jan 27, 2014). 23. Hossain MM and Purohit N. Improving
research, authorship, and/or publication of this
11. Patnaik KP and Nebhinani N. School child and adolescent mental health in
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Mental Health Program: Scenario in India: Status, services, policies, and way
India. J Indian Assoc Child Adolesc Ment forward. Indian J Psychiatry 2019, 61: 415.
ORCID iD
Health 2020; 16(1): 1–12 24. Mangal A, Thakur A, Nimavat KA,
Vijaya Raman https://orcid.org/0000-0003- 12. Kumar D, Bharath S, Hirisave U, Agarwal Dabar D, and Yadav SB. Screening for
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S, and Shah H. School mental health common mental health problems and
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