By Nazmin Saikia
Sanitation is commonly discussed in terms of diarrhoea, child stunting and infectious disease control. But an expanding body of evidence shows that inadequate sanitation—the lack of a private, safe, usable toilet and reliable water—also has profound, measurable effects on mental health. In India, where national sanitation drives have dramatically reshaped infrastructure over the last decade, gaps remain. Those gaps are not just physical; they are psychological. This article summarises the data on India’s mental-health burden, the trajectory and limits of the Swachh Bharat Mission, and peer-reviewed evidence connecting poor sanitation and WASH (water, sanitation and hygiene) insecurity to anxiety, depression, fear of violence, and reduced well-being. All statements below are drawn from published reports and peer-reviewed research.
The scale of the mental-health burden in India
Mental health conditions are common and costly. The World Health Organization (WHO) reports that India’s burden of mental-health problems amounts to 2,443 disability-adjusted life years (DALYs) per 100,000 population, and estimates that the economic loss from mental-health conditions in India between 2012–2030 will total roughly US$1.03 trillion. WHO also highlights high suicide rates in the country and emphasises that nearly 15% of Indian adults require active intervention for one or more mental-health issues. These figures show mental illness is a major public-health and economic challenge for India. (World Health Organization)
The National Mental Health Survey (NMHS, 2015–16) — the largest national epidemiological study of psychiatric morbidity — estimated that a substantial portion of the population experiences mental disorders, with a large treatment gap. Later analyses and surveys point to ongoing high prevalence of depressive and anxiety disorders, and a growing recognition of student and youth mental-health crises in urban India. (PMC)
India’s sanitation revolution — progress, scale, and unanswered questions
The Swachh Bharat Mission (SBM), launched in 2014, is one of the world’s largest sanitation campaigns. Government reporting and independent reviews note enormous output: over 100 million household toilets were constructed between 2014–2020, and open defecation (OD) rates fell sharply in many parts of the country. Analysts credit SBM with rapidly expanding toilet coverage and altering social norms around latrine use. (siwi.org)
Yet assessments also show uneven progress and persistent challenges. Peer-reviewed analyses and development-economics reviews point to remaining sanitation gaps—particularly around sustained toilet use, public and institutional sanitation (schools, markets, transit hubs), maintenance of facilities, water supply reliability, and inequalities across states and marginalised groups. Researchers caution that counts of “toilets built” do not automatically equate to safe, private, consistently usable sanitation for all. (Frontiers)
How poor sanitation translates into mental-health harm: the evidence
Multiple peer-reviewed studies, across India and comparable contexts, identify plausible and measurable pathways by which sanitation insecurity damages psychological well-being:
Shame, stigma and social anxiety. Lack of a private toilet can induce shame—especially for women—when forced to defecate in the open. Repeated exposure to shaming or fear of being seen increases stress and undermines dignity. A cross-sectional study in rural Odisha found women with inadequate sanitation reported higher levels of perceived stress and symptoms consistent with poor mental health. (PMC)
Fear of physical or sexual violence. Going out early or late to open-defecate exposes women and girls to the risk or fear of assault. Studies linking WASH-related violence to depressive symptoms show that both the experience and the constant worry about violence are associated with worse mental-health outcomes. This mechanism is documented in cross-national WASH studies and India-specific research. (BMJ Open)
Chronic stress from water and sanitation insecurity. When households limit water or food intake to avoid the need for sanitation during the day, or delay defecation because facilities are unsafe or unsuitable, these coping behaviours create chronic stress. Large surveys and qualitative work demonstrate how daily uncertainty and constrained bodily autonomy contribute to anxiety and reduced quality of life. (PLOS)
Loss of dignity and social participation. Inadequate sanitation affects social life, schooling and work—factors that are protective for mental health. For older adults, recent research has even linked inadequate toilet access with higher rates of depressive symptoms in ageing populations. (PMC)
Collectively, these studies show that sanitation deficits operate not only through disease pathways but also through social, safety and dignity channels that raise the population burden of anxiety, depression and distress.
Who is most affected?
Evidence consistently points to women, girls, the elderly and poorest households as bearing the brunt of sanitation-linked psychological harms. Women face compounded risks—sexual violence, social stigma and the mental load of managing household water and sanitation. Marginalised communities, including Scheduled Castes and Tribes, often live in environments with fewer functional facilities and social support, increasing exposure and reducing coping options. Elderly people with mobility constraints report particular vulnerability to both physical and mental harms when toilets are inaccessible or unsafe. (PMC)
What the data imply for policy and programming
The intersection of sanitation and mental health requires integrated, evidence-driven policy. Key policy implications are:
Measure use and safety, not just toilets built. Monitoring systems should capture whether toilets are private, functional, supplied with water, and perceived as safe—particularly at night and by women. SBM’s construction figures are impressive, but follow-up on sustained, safe use remains essential. (IFPRI)
Prioritise gender-sensitive WASH interventions. Designing facilities with privacy, lighting, locks and secure approaches reduces fear and can directly lower anxiety and PTSD-related symptoms among women and girls. Complementary community work must address norms, gender-based violence prevention and psychosocial support. (PMC)
Integrate mental-health screening in WASH programs. On World Mental Health Day and beyond, health outreach associated with sanitation campaigns should include screening for anxiety and depression and clear referral links to local mental-health services (tele-counselling, community mental-health workers, district hospitals). Given the NMHS documented a large treatment gap for mental disorders, co-located services would leverage contact points created by sanitation outreach. (PMC)
Protect institutional sanitation (schools, healthcare facilities, transit hubs). Children and students face learning disruptions and shame when school toilets are absent or unusable. Ensuring reliable school sanitation supports attendance and mental well-being. (Frontiers)
Address water reliability and maintenance. Toilets without water supplies remain unusable; investments must include supply chains, desludging and operation/maintenance financing. Long-term functionality reduces chronic stress linked to intermittent access. (Carolina Digital Repository)
Promising programmatic approaches and evidence gaps
Some interventions combine hardware with community engagement and show stronger outcomes than infrastructure alone. Behaviour-change communication, women’s sanitation committees, and rapid grievance redressal have improved sustained use in several pilots. Yet more rigorous evaluations are needed on whether these combinations measurably reduce anxiety, depression or other mental-health endpoints at scale.
Research gaps remain: longitudinal studies are scarce (to demonstrate causality rather than correlation), and mental-health outcomes are often secondary measures in WASH studies. India’s research agenda should prioritise prospective evaluations and include mental-health metrics in national WASH monitoring. (PMC)
Conclusion: sanitation is a health and dignity issue—and a mental-health issue
India’s Swachh Bharat Mission transformed the sanitation landscape in a relatively short period, and millions benefited from access to household toilets. But building toilets is only the first step. Where sanitation systems fail—through lack of privacy, unsafe approaches, poor maintenance, water shortages or continued social exclusion—the cost is not only infectious disease but psychological harm: shame, fear, chronic stress and depression.
Addressing this invisible burden requires integrated policy: better metrics (use and safety), gender-sensitive design, mental-health links in WASH programs, and long-term funding for maintenance and behaviour change. If India is to deliver on the promise of dignity, cleaner environments and healthier lives, policymakers and practitioners must recognise that cleanliness without safety and dignity will leave minds unwell.
References (selected)
WHO — Mental health: India. World Health Organization. (WHO India page summarising DALYs, suicide rate, economic cost). (World Health Organization)
WHO — Depression (WHO India fact summary). (World Health Organization)
National Mental Health Survey (NMHS) India 2015–16, NIMHANS. Report and analyses on prevalence and treatment gap. (indianmhs.nimhans.ac.in)
Caruso BA, et al., “A cross-sectional study of sanitation access and mental health among women in rural Odisha, India,” BMC Public Health / PMC (2018). (PMC)
Jayaweera RT, et al., “Associations between WASH-related violence and depressive symptoms,” BMJ Open (2022). (BMJ Open)
Kimutai JJ, et al., “Evidence on the links between water insecurity, inadequate sanitation and mental health risk,” PLOS ONE (2023). (PLOS)
Recent Indian study linking toilet access to depression among older adults (2025). (PMC)
SIWI — “Revisiting the Clean India Mission for World Toilet Day 2022”: overview of SBM scale and achievements. (siwi.org)
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