Hit hardest, healed least: disruption and incomplete recovery of public mental-health outpatient services across two COVID-19 waves in India, 2017-2022

Background: The COVID-19 pandemic disrupted healthcare worldwide, but whether mental health was affected differently from physical healthcare, and whether it recovered following successive waves, has not been described from routine administrative data in a low- or middle-income country. Methods: Interrupted time-series analysis of India's routine Health Management Information System (HMIS), April 2017 to March 2022. We extracted monthly counts of mental-illness outpatient visits and adolescent counseling sessions across ~700 districts, projected expected monthly counts from a log-linear model fitted to pre-pandemic trends, and compared disruption and recovery against an index of routine physical-health services. Results: Mental-illness outpatient visits fell to 31.2% of expected in April 2020 during the national lockdown, a collapse deeper than that observed for routine immunisation (48.3%) or institutional delivery (72.1%). During the Delta wave (April-June 2021), mental-health outpatient visits dropped again to 57.8% of expected. In the post-Delta recovery period (July 2021-March 2022), while immunisation and delivery volumes returned to >95% of expected, mental-illness outpatient visits reached only 58.4% of expected, representing a cumulative two-year deficit of 41.6% (~5.8 million missed outpatient visits). Deficits were widespread across states. Conclusion: Public mental-health outpatient services in India were hit harder than physical-health services by the pandemic and showed essentially no post-Delta volume recovery. As India implements its national digital mental health initiative (Tele-MANAS), these data define the large, quantified outpatient deficit that digital and facility-based services must urgently address.