Among the many challenges India faces, the most underappreciated is the ongoing mental health crisis. Mental illness is India’s ticking bomb. An estimated 56 million Indians suffer from depression and 38 million from anxiety disorders. For those who suffer from mental illness, life can seem like a terrible prison from which there is no hope of escape; they are left forlorn and abandoned, stigmatized, shunned, and misunderstood.
India accounts for more than a third of the female suicides globally, about a fourth of all male suicides and suicide remains the second leading cause of death among young Indians, creating as many casualties as road traffic accidents and deaths through childbirth. Yet, the government has spent less than one per cent of the health budget on mental healthcare (0.06 per cent to be precise, falling short of the lowest OECD country’s share by a factor of 10). This expenditure has been almost entirely on doctors, drugs, and hospitals in urban areas. Unsurprisingly, between 70 to 92 per cent of those affected by mental health issues have received no care from any source, of any kind.
There are only 43 mental hospitals in the country, and most of them are in disarray. Six states, mainly in the northern and eastern regions with a combined population of 56 million people, do not have a single mental hospital.
Most government-run mental hospitals lack essential infrastructure, treatment facilities and have a sickening ambience. Visiting private clinics and sustaining the treatment, which is usually a long-drawn-out affair, is an expensive proposition for most families.
Most government-run hospitals do not have psychiatric drugs and visiting a private counselor and sustaining the treatment ~ usually a long-drawn-out affair ~ is an expensive proposition for most families. The ignorance and the callous attitude of the government towards psychiatric ailments, coupled with social stigma, dissuade most from seeking help.
These factors are compounded by the existing treatment services. India has 0.3 psychiatrists and two mental health workers for every 100,000 individuals. The “treatment gap” of medical professionals remains one of the largest in the world. If someone must travel to a government facility, it requires taking time away from work. Then there is the cost of transportation, food, accommodation, the treatments and medication, and follow-up care. It is not something the average Indian can afford.
The fact is that poor mental health is just as bad as or even worse than any kind of physical injury. Left untreated, it can lead to debilitating, life-altering conditions. Medical science has progressed enough to be able to cure, or at least control, most mental-health problems with a combination of drugs, therapy, and community support. Individuals can lead fulfilling and productive lives while performing day-to-day activities such as going to school, raising a family, and pursuing a career.
The lack of recognition of mental ill-health propels families to seek support from a range of stakeholders before they reach professional care. Most seek help from faith healers or try alternative therapies. When that yields no improvement, they approach the local doctor. The medicines prescribed cost them the rest of their savings with no noticeable effect. It is only then that they are guided to a specialist. Many valuable years of intervention time are lost in the process.
Although mental illness is experienced by a significant portion of the population, it is still seen as a taboo. Depression is so deeply stigmatised that people adopt enforced silence and social isolation. In villages, there are dreadful recorded cases of patients being locked up in homes during the day, being tied to trees, or even being flogged to exorcise evil spirits. Stories of extreme barbarity abound in tribal cultures. In some societies, family honour is so paramount that the notion of seeking psychiatric help is anathema.
Many a time, mental health problems are either looked down upon or trivialized. These man-made barriers deprive people of their dignity. We need to shift the paradigm of how we view and address mental illness at a systemic level. Tragically, support networks for the mentally ill as well as their caregivers are woefully inadequate. There is an urgent need for an ambience of empathy, awareness, and acceptance of these people so that prejudices dissipate, and patients can overcome the stigma and shame.
India’s Mental Healthcare Act 2017 that replaced the archaic Mental Health Act 1987 is a piece of very progressive legislation for people with mental disorders and sensitive to the social impact of mental illness, like stigma and poverty.
Fundamentally, the Act treats mental disorders on the same plane as physical health problems thus stripping them of all stigmatizations. It mandates that every citizen has the right to adequate treatment and says insurance companies must cover mental health services. Conceptually, the Act transforms the focus of mental health legislation by emphasising the provision of affordable and quality care, financed by the government, through the primary care system for the mentally ill.
India has interplay between poverty, gender insensitivity stress and discrimination, and mental health. People living with a mental illness face many impediments to their recovery and restoration to full functioning. Medication appears an easy option. But more important is to solve the psychological problems and the cultural issues. The Banyan ~ a Chennai-based mental health organization that provides comprehensive services for the mentally ill living in poverty and homelessness ~ has reported one in every three homeless individuals suffers from a mental illness. Poverty and mental illness are thus interlinked in a vicious and self-fortifying cycle: poverty increases the risk of mental health conditions and conversely, those living with mental health conditions are more likely to slide into poverty. India needs to take a broader view for addressing the problems of the mentally ill. Social exclusion, unequal opportunity, and income disparity could aggravate mental illness, especially for vulnerable groups, like poor, homeless women.
Mental healthcare initiatives are presently focused on a narrow biomedical approach that tends to ignore socio-cultural contexts. Community mental health services can offer a mix of clinical, psychological, and social services to people with severe, moderate, and mild mental illnesses. Also, counseling can make a profound difference and build resilience to cope with despair. Providing psychoeducation to the patients’ families can also help.
There have been some encouraging innovations in India in community-oriented mental healthcare led by voluntary organisations that are both impactful and replicable. Dr. Vikram Patel, who is a professor at the London School of Hygiene and Tropical Medicine and co-founder of the Goa-based mental health research non-profit Sangath has been at the forefront of community mental health programmes in central India.
The programme is designed to establish sustainable rural mental health support to address issues relating to stress and tension that abet suicide, alcohol abuse, and depression in the rural community.
It deploys health workers from within the community, some with no background in mental health. These workers are trained to raise mental health awareness and provide “psychological first-aid.” The programme also includes counselors who are imparted mental health literacy. The third line of workers consists of expert psychiatrists, who are qualified to provide medications for more serious mental health disorders.
The programme uses Primary Health Centres for screening and feeding people with mental illnesses. Such programmes aim to provide more counseling and other services, the way some urban-based programmes do. But time is limited for both outreach workers and the patients they serve. People are more receptive to these community workers than they might be to a licensed doctor from the city, especially when discussing sensitive subjects. “In some families, we get attached,” says one of them. “People talk to me like family.” They share a lot of personal stories with me.”
The organisations run by Patel and those by others with similar objectives are filling the Indian “treatment gap” in psychiatry not with more doctors, but with new technology and community training. Telepsychiatry connects hard-to-reach patients with psychiatrists and medicines delivered through mobile units of voluntary organizations. By reimagining what it means to provide mental health care, advocates like Patel may end up creating a model for the rest of the world to follow.
Training for health workers to enable them to detect and manage mental health disorders can be put in place, improved, or expanded. Such programmes should also cover peers, parents, and teachers so that they know how to support their friends, children, and students in overcoming mental stress and neurotic problems. There is a need for more open discussion and dialogue on this subject with the public and not just experts. This can help create a more inclusive environment for people with mental illness.
India’s community programmes can enable the country to ‘scale up’ its delivery of mental health care. With its formal mental health system and its certified mental health specialists overburdened, these programmes can develop ‘community capacity in treatment and counseling fostering rich, bottom-up cadres of community-based counselors for more systematized approaches with deeper and better outreach. However, promising they may look, community mental health programmes’ success will hinge on India’s approach across the board.
At the same, there is enough hope that with simple yet effective steps, we can turn the situation around and build a more accommodating environment for those struggling with mental distress and expand access to mental health and psychosocial services.