Implementing integrated mental health and substance use disorder services in Indian primary care: a multi-state CFIR-based qualitative study

Abstract

Integrating mental health & substance use disorders (MSUDs) care into other NCDs remains a priority for bridging India’s wide treatment gap. While national programs such as District Mental Health Programme and Ayushman Bharat have laid foundational pathways, translating policy into everyday practice continues to face substantial challenges. This study explored how mental health services are being implemented across seven Indian states, using the Consolidated Framework for Implementation Research (CFIR) to unpack the multilevel factors influencing sevice delivery. We undertook a qualitative implementation study in Assam, Gujarat, Haryana, Karnataka, Madhya Pradesh, Odisha, and Punjab. The data included 211 in-depth interviews and 28 focus group discussions across seven states for the following cadres: medical officers (MO), community health officers (CHOs), Accredited Social Health Activists (ASHA), nurses, clinical psychologists, patients, caregivers, and policymakers. A combination of CFIR framework-guided and inductive thematic analysis was used to generate both cross-cutting and site-specific insights. While most respondents supported mental health integration in principle, they reported barriers such as strained frontline capacities, absence of structured protocols, stigma-related avoidance, limited availability of medicines and inconsistent referral pathways. Training uptake was uneven, and consultation times were often too brief to manage mental health needs effectively. However, promising practices were identified, e.g. Gujarat’s “Therapeutic Thursdays,” Haryana’s use of teleconsultation, and community mobilization efforts in Odisha and Assam. Increased Workload, lack of mental health-specific incentives, and digital infrastructure gaps were common challenges. Engagement from local champions (Individuals who dedicate themselves to supporting, marketing, and ‘driving through’ an implementation) was perceived to help adress structural gaps, but was rarely systematized. This study highlights how integration efforts are shaped by the depth of contextual dynamics. Strengthening digital tools, clarifying referral pathways , and reinforcing the health workforce through supervision and incentives are urgent priorities. ClinicalTrials.gov - CTRI/2024/08/072748, registered on 20th August 2024, (http://ctri.nic.in).