When I returned to India after training and practising psychiatry in the UK, I assumed the hardest part would be bringing world-class mental healthcare home.
I had trained in a system built on strong clinical governance, multidisciplinary teams and evidence-based care. The science was robust, the care pathways were clear, and there was a deep belief that if clinical practice was rigorous, patient outcomes would improve.
That belief has never changed. What has changed is my understanding of what it takes to deliver that science in a country like India.
The first, and perhaps most important, was the idea that India can be treated as a single healthcare market. It cannot.
We often speak about “mental healthcare in India” as though we are designing for one population. In reality, we are designing for hundreds of millions of people living across vastly different linguistic, cultural and socioeconomic contexts. Health literacy varies enormously. So do beliefs about mental illness, help-seeking, recovery and the role of healthcare itself.
A young professional in Bengaluru, a homemaker in Jaipur and a farmer in rural Odisha may all experience depression, but the barriers they face in recognising it, seeking care and staying engaged with treatment can look entirely different.
Similarly, evidence-based treatment for schizophrenia or obsessive-compulsive disorder does not change because someone lives in Kochi instead of Kolkata. But the language we use, the way we build trust, the role of caregivers, and even how we define successful recovery often does.
This creates a fundamental design challenge. The clinical science should be standardised, but the delivery of care cannot be.
And the more we expanded care across the country, the more another reality became impossible to ignore: in India, mental healthcare is rarely centred on an individual alone.
Much of Western psychiatry has evolved around individual autonomy, appropriately emphasising confidentiality and patient-led decision-making. Those principles remain fundamental and should never be compromised.
But in India, families are often not peripheral to care, they are part of the care system itself. They are usually the first to notice behavioural changes, the ones persuading someone to seek help, the people managing medications, financing treatment and supporting recovery long after a consultation has ended.
The question, therefore, is not whether families should be involved. The question is how to involve them thoughtfully while preserving patient autonomy and clinical ethics.
When we recognise families as partners in care rather than passive observers, treatment planning changes. Psychoeducation changes. Relapse prevention changes. In many cases, outcomes improve because the support system around the individual becomes stronger.
The same principle applies to access.
For years, conversations around mental healthcare have focused on increasing the number of psychiatrists or making therapy more affordable. Both are critical. But accessibility is far more complex than either workforce or cost.
Technology has dramatically expanded reach, allowing specialists to consult patients across hundreds of cities. Yet a video consultation alone does not solve for language barriers, digital literacy, stigma or the needs of someone living with severe mental illness.
Different people require different entry points into care, and different levels of care over time. Systems are often built around replication – build one successful model, then reproduce it everywhere. But scale in India rarely works that way.
The goal is to ensure every patient receives the same standard of clinical excellence, while recognising that the journey to achieving that outcome may look different depending on where they live, what language they speak, how much they earn and who supports them.
After twenty years, I have become even more convinced of the importance of evidence-based psychiatry than when I first returned to India. But I have also learned that evidence alone does not build healthcare systems.
Good systems are built by combining scientific rigour with cultural understanding. By recognising that social context is not peripheral to treatment, it is often one of its strongest determinants. And by designing services that are flexible enough to meet people where they are, without compromising the quality of care they receive.
That is the paradox of building mental healthcare in India. The principles of psychiatry are universal. But the practice of psychiatry must always be deeply local.
The sooner we embrace both truths, the better equipped we will be to build a mental healthcare system that truly reflects the country it is meant to serve.