‘Referral is not care’: where India’s mental health system breaks after first contact
By Arunima Rajan
A researcher who helped build Tamil Nadu’s state helplines on why detection tools and new services will not close the gap until someone owns what happens after the first call
Saravanan Thangarajan, MDS, MMSc, MBA, a Harvard-trained global health researcher, WHO expert reviewer in sexual and reproductive health and dementia, and former Tamil Nadu public health leader, argues that India’s mental health challenge is not simply a shortage of specialists or treatment options.
The bigger failure often comes after someone asks for help. A helpline may screen them, a counsellor may speak with them, or a hospital may receive their referral, but too often no one takes responsibility for what happens next. People are left to find their own way between services that rarely communicate with one another. AI can help flag distress earlier, Thangarajan says, but it cannot replace trained professionals, local services, or human follow-up. His test is simple: did the person actually receive care, get the support they needed, and remain connected after the first contact?
How did a dentist end up in public health?
It began with dentistry. After postgraduate training, I spent nearly seven years as a faculty member at Sri Ramachandra University, focused on the pain, treatment, and recovery of individual patients.
Then COVID-19 changed the scale of the question. In early 2020, I joined Tamil Nadu’s 104 Health Helpline as a project consultant. Within weeks, my work moved from the clinic and classroom into the state’s emergency response. From there, I became involved in several state and national public health programmes, including the 108 Emergency Ambulance Service, the 102 Mother and Child Tracking System, Aapda Mitra disaster-response training, and Tele-MANAS, India’s national tele-mental health service.
Working across these programmes showed me not only how care is delivered but also why some people reach it quickly while others are delayed, excluded, or lost between services. That experience eventually took me to Harvard. My research now examines mental health, climate change, disability, caregiving, and access to healthcare, questions I had already encountered in the lives of mothers and families across Tamil Nadu.
But why mental health specifically?
Because I saw, from inside the system, how people can still miss the care they need even when good programmes already exist. After the pandemic, emotional distress became much more visible. More people were asking for help, but the services supporting them were not always connected. Tele-MANAS offered mental health support, while the Mother and Child Tracking System followed mothers and children through antenatal check-ups, scans, vaccinations, and access to government maternity benefits. Both programmes were valuable, with trained teams and government support, but they often worked separately.
That made me ask a simple question: if a mother shows signs of distress in one programme, does she receive mental health support through the other? Who checks whether the referral worked? What happens after the first call?
There was also another pressure that received little attention. In India, where extreme heat is becoming part of daily life, the stress it causes was rarely discussed in mental health planning until recently. Heat, financial pressure, caregiving, disability, and difficulty reaching care do not affect people separately. They build on one another.
That is what drew me into mental health. The problem was not only a shortage of services. People already carrying the greatest burden were still expected to find their own way between them.
With therapy costly, many Indians are turning to AI chatbots. What are the biggest gaps in 2026?
Affordability is one of the biggest gaps. People turn to AI because it is immediate, private, and often cheaper than therapy. It may help someone recognise distress or take the first step towards seeking help.
I also work on AI voice-based technology, delivered through a Germany-based neuroscience platform, which examines vocal cues such as pauses, pitch, and rhythm. That may support earlier detection, but detection is not treatment. If a tool identifies risk and there is no trained professional, safe service, or follow-up behind it, we have built a better alarm without building the response.
AI can support mental health care. It cannot replace it.
You call it a systems gap, not a treatment gap. What do you mean?
A treatment gap means care is unavailable. A systems gap means care may exist, but people still struggle to reach it and move from one service to the next.
Tele-MANAS gave people across the country an important way to seek help. But every state differs in language, culture, local services, and the number of trained professionals available. A counsellor may answer the call and recommend further care. The real question is whether the person actually reaches that care and whether anyone knows what happened afterwards.
My research at Harvard revealed another part of the problem. Mothers of children with disabilities reported similar levels of distress by phone and in person. Yet face-to-face conversations uncovered what the scores could not fully show: loneliness, caregiving pressure, family strain, and the difficulty of asking for help.
Finding distress is only the beginning. A system becomes meaningful only when the person is understood, reaches the right support, and is not left to navigate the system alone.
Public mental health workers earn far less than their private counterparts. Isn’t that a problem?
Absolutely. Mental health care depends on trust, judgement, and experience. When skilled counsellors, psychologists, and social workers are poorly paid, it becomes harder for public services to attract them, retain them, and build experienced teams. Patients feel that instability through changing counsellors, interrupted relationships, and broken follow-up.
India does not lack mental health programmes. It has built important national services, including the District Mental Health Programme and Tele-MANAS. The challenge is ensuring that these services have enough trained people, fair salaries, regular supervision, medicines, and crisis support in every district, not merely on paper. Mental health also cannot be treated as a temporary campaign. Funding cycles may end, but people’s need for support does not.
It must become part of everyday healthcare, just like diabetes or hypertension. Primary care and antenatal teams should be able to recognise emotional distress, offer basic help, and know when specialist care is required. But this must be task-sharing, not task-dumping.
Frontline workers are already stretched. Adding another responsibility without training, time, supervision, and fair pay does not strengthen care; it simply moves the burden from an underfunded system to an overworked worker.
Stigma has reduced. But has the infrastructure really improved?
The public conversation has become more open, but stigma has not disappeared, especially when people worry about judgement from their families, workplaces, or communities. There has been real progress. India has expanded district mental health services and created Tele-MANAS as a national way to seek help. By March 2026, Tele-MANAS had handled more than 3.4 million calls. That shows both the value of the service and the scale of the need.
But answering more calls does not necessarily mean that people receive diagnosis and treatment. A national study of Indians age 45 and older found that 97% of those with depression had not been diagnosed. Treatment was also less common in rural areas than in cities.
Infrastructure is not only a clinic, a helpline, or a psychiatrist on a staffing chart. It includes cost, waiting time, medicines, privacy, transport, language, and whether someone trusts the service enough to return. A service can exist and still remain out of reach.
Some founders dismiss therapy as a money-making machine, and the system seems to respond only in crisis. Your assessment?
Therapy is not the problem. The problem begins when emotional distress is turned into a product. Many companies now offer employees a fixed number of counselling sessions, an app, or a wellness package and call that mental health support. But you cannot counsel someone out of chronic overwork, harassment, job insecurity, or a harmful workplace. When the conditions causing distress remain unchanged, therapy can end up asking the employee to cope with a problem the organisation has the power to address.
Therapy should help people heal, not teach them to tolerate what is harming them.
And yes, the public system often becomes most visible during crisis. Attention rises after a suicide, an examination result, a disaster, or a public tragedy. But prevention is possible. After the pandemic, Tamil Nadu used tele-counselling during the high-pressure weeks around board examinations and results from the National Eligibility cum Entrance Test, the country’s medical school entrance exam, to reach about 1 million students, while expanding the team from roughly 40 to 120 staff.
That is what early action looks like. But it cannot appear only when risk peaks. Mental health support must be present throughout the year in schools, workplaces, primary care, and communities.
So what is the fix?
The fix is to stop making people connect the system by themselves. I would begin with those most likely to disappear between services: women, people with disabilities, and the family members who care for them.
A mother may take her child to a hospital, therapy centre, school, and welfare office, yet no one asks how she is coping. A woman with a disability may be sent from one service to another and expected to explain her situation again at every door. The system may say that support exists, but if she has to fight to find it and piece it together, that support is not truly accessible.
Tamil Nadu has begun moving towards more local and coordinated support for people with disabilities. That is the right direction. Mental health support should be available in the same places women and families already use: antenatal clinics, primary health centres, disability services, schools, and community programmes.
Frontline workers do not need to become psychiatrists. They need to notice when someone is struggling, recognise what is urgent, and know exactly where to connect that person. And a referral cannot end with a phone number. Someone must check whether care was actually received.
Technology can help identify distress, but it should not become another dead end. An app or helpline is useful only when it leads to a real person, a nearby service, and follow-up.
Any global best practices worth adapting?
The most useful global practice is not a programme that we can simply copy. It is a way of working: listen before you design.
During a project in Vietnam, I saw how easily we mistake translation for cultural understanding. We can translate every word correctly and still sound like outsiders. Around sensitive subjects such as distress, suicide, and death, the language had to feel familiar to the community, not imported from a manual. Once people feel judged or misunderstood, they stop speaking openly.
That changed how I think about programme design. Do not enter a community asking, “What can we deliver?” Ask, “How do people here describe what they are going through? Whom do they trust? What are they already doing to cope?”
Communities are not waiting to be rescued. People already have knowledge, relationships, and ways of supporting one another. Our role is to strengthen what helps, challenge what causes harm, and provide what is missing. A policy may look excellent on paper. In a village, it matters only when people trust it enough to use it.
That is what I would adapt: not one country’s programme, but the discipline of listening before deciding what another community needs.
Does India need better mental health policies for its ageing population?
Yes, urgently. India often speaks proudly about being a young country, but that will not remain true. We need to prepare for ageing before families are left to manage the consequences alone.
An older person may receive treatment for diabetes, hypertension, poor vision, or joint pain without anyone asking about memory, mood, loneliness, safety at home, or how the caregiver is coping. We treat each condition separately, even though the person experiences them together. We also normalise too much. Withdrawal becomes “old age.” Memory loss becomes “forgetfulness.” Caregiver exhaustion becomes “family duty.” Abuse becomes a private family matter. These are warning signs, not inevitable parts of growing older.
During the pandemic, we showed that healthcare workers could follow people with diabetes and hypertension at home. Those visits could also include a few direct questions: how are you sleeping? Has your memory changed? Do you feel lonely? Do you feel safe at home? And how is the person caring for you coping?
Technology can send reminders and notice changes in routine, but it cannot decide whether an older person is safe or whether a caregiver has reached breaking point. A human professional must remain responsible, and monitoring should never take away the older person’s privacy or control.
India does not need a separate pathway for every problem. An older person’s memory, mood, physical health, safety at home, and the strain on the caregiver should be considered together.
A dementia diagnosis is not complete care unless the family understands the condition, the caregiver receives support, future needs are discussed, and someone continues to follow the person over time.
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