Mental Health

While delivering a speech at NIMHANS in 2017, the former President of India, Sri Ramnath Kovind, warned India about the imminent mental health epidemic that India is staring at. But the nation hasn’t paid much heed to his early warning. It took the suicide of Bollywood celebrity Sushant Singh Rajput allegedly triggered by depression for the nation to come to terms with what the former president had warned us about. Unfortunately, in our country, mental health isn’t often talked about. It’s a kind of taboo. But, over the years, it has spread under the carpet like wildfire, and the pandemic added fuel to the fire. As a result, India has bagged a notorious distinction of being the world’s most depressed country in terms of sheer numbers. To know the reasons, let’s dig deeper.

What is Mental Illness?

According to the World Health Organisation, “A mental disorder is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour which is usually associated with distress or impairment in important areas of functioning”. Many people develop mental health concerns from time to time. But concern becomes an illness when the symptoms cause severe stress and affects the normal functioning of the person mentally. Mental health issues affect our thinking, feeling, mood, cognition, and behaviour.

Types of Mental Disorders

• Anxiety disorders: These are a group of mental illnesses that includes generalised anxiety disorders, social phobias, specific phobias (for example, hydrophobia and claustrophobia), panic disorders, OCD, etc.
• Behavioural and emotional disorders in children: These include oppositional defiant disorder (ODD), conduct disorder (CD), and attention deficit hyperactivity disorder (ADHD).
• Bipolar affective disorder: It is one of the most common types of mood swing disorder, previously regarded as ‘manic depression’. A person with bipolar disorder experiences bouts of elation and depression. Both extremes keep on shuffling.
• Depression: It is a mood disorder characterised by symptoms like lowering of mood, loss of interest and vigour, and diminished energy. It is not merely a sad feeling. There are different types of depression. Many times, depression leads to suicidal thoughts. The recent suicide of Sushant Singh Rajput belongs to this category.
• Obsessive compulsive disorder: It is basically an anxiety disorder. Obsessions are recurrent thoughts, images, or impulses that are intrusive and undesirable.
• Paranoia: It is an irrational and persistent feeling that people are there to harm you.
• Schizophrenia: It is a complex psychotic disorder generally characterised by disruptions to thinking and emotions and leads to a distorted perception of reality.

State of Mental Health Crisis in India

Mental disorders are now constituting the top leading causes of health burden worldwide, and India is no exception. According to the National Mental Health Survey 2016, 14% of the Indian population suffers from one or the other form of mental disorder. In 2017, an assessment of mental illnesses across all the states in India revealed that as many as 19.73 crores of Indians are in need of mental health care. Among them, 5.57 crores of people are suffering from depressive disorders, and another 4.49 crores are suffering from anxiety disorders. These numbers have further swelled during the Pandemic, which has triggered unprecedented levels of mental illnesses; WHO says that people with mental disorders in India would have reached 20% during the pandemic. Mental health issues are taking a serious toll on Indian human resources to the extent that, according to WHO, they are going to cost India around $1.03 trillion between2012-2030.

 A study conducted across various states in India by the Lancet has reported that states like Maharashtra, Kerala, Karnataka, Telangana, Tamil Nadu, Himachal Pradesh, Maharashtra, Andhra Pradesh, Manipur, and West Bengal have the highest prevalence of anxiety disorders. An analysis based on gender revealed that more women have suffered from mental health issues than men.

Reasons Behind

Mental illness is a result of cumulative effect of biological, social, psychological, hereditary, and environmental stressors. Interplay between different factors results in different disorders.

• Biological: There are many biological reasons in play. A few of those are;
  • Genetics (heredity): Scientific evidence has proved that many mental disorders have their genesis in genetics, i.e., they are inherited from their parental generations. However, it isn’t as simple as we speak. Alongside the genes, there are many other factors that work in tandem. That is the reason that even among the twins, who have inherited the same genes, we may not observe the same mental disorder in both. It may be present in only one of them and this is due to the fact that both of them may have been exposed to different environments.
  • Infections: Certain infections directly damages the brain cells, ultimately leading to the culmination in mental disorders. For example, Streptococcus bacteria produces an illness called Paediatric autoimmune neuropsychiatric disorder (PANDAS) which is linked to obsessive compulsive disorder.
  • Pre-natal damage: Recent evidences throw spotlight on disruption of early foetal brain development due to the physical, chemical or biological damages. For example, shortage of oxygen to the foetal brain during development results in autism spectrum disorder.

Other biological causes include Brain injuries, diseases, poor nutrition, etc.

• Psychological factors:
  • Psychological traumas: People accumulate various traumas during the course of life. But the ones that are experienced during the early ages would get imprinted much stronger in the minds. These would leave a lasting impact. Some of those could be childhood abuse, emotional neglect, sexual abuse, etc. It’s hard to break out of the traumas and many times people carry these all along their lives.
  • Loss of loved ones: Losing someone like parents, siblings, pets, etc would have a destabilising effect.
  • Feeling isolated and unwanted: It creates a kind of inferiority complex. This would cause many mental disorders like depression. This could often be seen in schools and work places.
• Environmental factors:
  • Dysfunctional family: A family that’s replete with fights, lack of love, lack of warmth, etc takes a toll on mental peace.
  • Divorce: Divorceand separation would often result in increased anxiety and depression, and increased risk of substance abuse.
  • Changing jobs or schools: Leads to cultural shocks. Our minds may not adjust to the frequent changes in social environments around us. That is the reason elders find it hard to travel along with their children for settling in new places. Many Indian parents who have travelled abroad along with their children are reported to have developed psychological depression.
  • Socio-cultural expectations: Society places serious expectations upon each of us, like to earn more, to look fashionable, to buy a car, etc. When these aren’t met, the individual may develop an inferiority complex and may slip into the abyss of depression.
• Changing lifestyles: Globalisation, modernity, and increasing incomes have made a mess of healthy lifestyles. Most people today lead a sedentary lifestyle without adequate physical activity. This has a negative correlation with mental health. Also, the increasing consumption of alcohol, drugs, smoking, addiction to mobile phones and gadgets, isolated existence, divorces, corporate jobs, increasing consumerism, etc, have been taking an irreparable toll on mental health.

Impact of Pandemic

The once-in-a-generation crisis i.e., Covid-19 has left a devastating effect on the mental health of a huge swathe of people, especially in developing nations like ours. Death of a countless number of people, loss of livelihoods, loss of family members, running from pillar to post for medical aid, lockdowns, isolations, separations from families, etc, have a long-lasting debilitating impact on the public’s mental health. A health care company, ‘Practo’ has reported a jump of 665% in the number of mental health consultations with them, and most of the consultations are for anxiety, stress, and panic attacks. Some of the ways in which the pandemic has taken a toll on mental health in India are;

• Faced with extended closures of academic institutions, students felt socially isolated and disconnected from the world which fuelled anxiety, loneliness & uncertainty.
• Indian women bore the brunt of lockdown as the domestic violence was on rise during the lockdowns as was evident from the rise in cases reported by the NCRB. Complaints filed at National Commission for women have jumped by 2.5 times during the lockdown. This could be traumatic to both the victim women and the children exposed to this.
• Loss of livelihood drove many into anxiety, depression, trauma, etc. It led many to suicidal thoughts as well.
• While mental health crisis worsened during the pandemic, lockdown forced the closure of mental health services. This is a double blow.
• WhatsApp and other digital media provided a platform for the fake news peddlers, which had triggered mass hysteria among the Indian public.
• The mental distress of losing beloved members gasping for breath may leave a life-long trauma.
• The frontline workers were severely over-burdened and we have seen news of many of them breaking down while on duty.

Effect of Mental Illnesses

Mental illnesses impact people at different levels i.e., on individual, families and on society/country at large.

1. Effect on patients: Individuals suffering from mental ailments are prone to decreased quality of life, issues with cognitive abilities, educational difficulties, depreciated productivity, and other social issues like discrimination and abuse. Education takes a hit if mental disorders creep in early childhood. It adversely affects their cognition and ability to learn, leaving them academically crippled forever. This could jeopardize their employability. Even at the workplace, their productivity may be relatively lower, leaving them behind in the race. A study conducted by ‘The Mental Health Charity’ of the United Kingdom revealed that 2/3rd of the people who suffer from mental ailments face prejudice in the workplace in India. Further compounding the woes, they are subjected to social stigma, discrimination, human rights violations, exploitation, and often being looked down upon. This further aggravates their existing mental ailments. It’s a never-ending spiral. What is worrisome is the fact that people with mental disorders are less willing to be treated. They develop an aversion toward medical interventions which makes the cure a daunting task.
2. Effect on Patient’s family: Generally, the burden of tending to a mentally ill person is shouldered by the immediate family or relatives. These caregivers, usually, cannot work at their full potential due to the additional burden of having to care for a mentally ill patient. Having a patient at home reduces the mobility of the family for livelihood activities. This hampers their livelihood opportunities. This leads to retarded income generation which along with the burden of medical expenses of the patient, slides the family into poverty. Alongside the patient, even their family might suffer from psychological impacts due to their family member suffering from mental illnesses. Not to forget the stigma associated with the family that endures a mentally ill person.
3. Effect on society/country: Mentally ill individuals can pose a significant financial and social burden on their respective nations. The World Health Organisation reckons that mental health crisis would cost developed nations between three and four percent of their respective GNP (gross national product). The WHO estimates that India copes an economic loss of about US$ 1.03 trillion between 2012 and 2030 owing to a mental health crisis. The National mental health survey (NMHS) revealed that mental health takes a disproportionate toll on less privileged sections. These costs predominantly emanate due to the less productivity of the mentally ill patients and the expenditure incurred on their treatment.

Challenges in Tackling Mental Health in India

1. Lack of resources: Mental ailments cannot be cured with the traditional health care infrastructure. We need a specialised & sophisticated mental health care network that includes doctors, counsellors, post-treatment follow-ups, rehab centres, etc. Even In India, there is a treatment gap of 90% for those suffering from mental illness. As per WHO, India faces a massive shortage of psychiatrists and psychologists compared to the size of the crisis. According to the ‘International organisation’s data, there are only three psychiatrists and psychologists for every one lakh people in India. Globally, mental illness constitutes 31% of the disease burden, but only receives 1% of the health budgets of the nations on average. India is faring even worse in terms of budgetary allocation, with a meagre allocation of 0.5% of the health budget. The government has allocated only 40 crores to the ‘National Mental Health programme’ out of the total health sector allocation of 2.23 lakh crores for the year 2020-21.
2. Lack of awareness and sensitivity: Unfortunately, in India, the majority of the population doesn’t even understand the concept of mental illness. And those who understand would often look down upon the mentally disordered persons. They lack the basic awareness as to what causes the mental ailments and lack the sensitivity to empathise with the patient. And in most cases, the lack of knowledge about the symptoms of the mental ailments would prevent parents, relatives, or associates from taking the person for timely medical intervention. Lack of awareness leads to overlooking, misjudging, and dismissing the early signs of imminent illness.
3. Social Stigma: As we have discussed above, mental disorders are either looked down upon or mocked by people. This would cast a dissuasive effect on the person to disclose her mental illness. Even the families in India usually try to shove the issue under the carpet as they fear stigmatisation by the neighbourhood. They are branded as lunatics. This is the primary reason behind the poor reporting in India. As per the National Institute of Mental health and Neuroscience (NIMHANS) data, more than 80 percent of people in India do not avail the services for a plethora of reasons, ranging from lack of knowledge, stigma, and high cost of care.
4. High out of pocket expenditure: Due to the lack of adequate State efforts and enough penetration of health insurance, people have to resort to consulting private mental health professionals. This incurs the huge out-of-pocket expenditure. The average cost of a counselling session in any Indian metro city amounts to around ₹1,500 an hour. Some professionals charge as high as 3000-4000 rupees an hour. As one needs weekly therapy, it amounts to around 6000-1000 rupees per month. The cost of medicines would be a further addition.
5. Under reportage: As we have discussed earlier, mental health issues carry a huge amount of stigma and social discrimination. Adding insult to the injury, persons with mental disorders not only find it hard to get employed full-time, but they are also prone to get paid less and fare dismally on their performance appraisals. So reporting is highly disincentivising, and dissuades the patients from disclosing it. Also, the lack of enough zeal from the government resulted in inefficient reporting.
6. Patriarchy: In a society where patriarchy is deeply entrenched, women are more prone to mental disorders as they are subjected to gender discrimination, social exclusion, marrying at younger age against their will, sexual abuse, domestic violence, etc.
7. Post-treatment gap: Patients with mental disorders, need to be followed up after the treatment. Patients, post the treatment need a proper rehabilitation to restore to normalcy. But India lacks this ecosystem.
8. Ceaseless modernity: No matter what efforts the governments put in to contain the mental health crisis, as long as people keep on embracing the so-called modernity blindly without judging it on its merits, these efforts would always remain inadequate. The deleterious change in life-styles and modern habits is posing a serious challenge in the fight against the mental health crisis.

What has the Government done?

1. National mental health program: Launched in 1982, this program has three sub-components;

• • Treat the mentally ill persons
  • Provide rehabilitation
  • Prevent the mental illnesses

2. The mental health care act, 2017: The various provisions under the Mental Healthcare Act are as follows;

• • Central and State Mental Health Authorities: Establishes these authorities for regulation & coordination of mental health services in India.
  • Rights of Persons with Mental Illness: Every person is endowed with the right to access mental healthcare services.
  • Advance Directive: This empowers a mentally ill person to have the right to make an advance directive about the way she/ he wants to be treated for the requisite illness in future.
  • Decriminalizing Suicide: It decriminalizes suicide attempts by a mentally ill person.
  • Insurance: Act requires insurance companies not to discriminate the mentally ill persons and treat them on equal pedestal as the rest.
  • Right to appoint a Nominated Representative: Every person also has the right to appoint a nominee to take decisions regarding his/her health on his/her behalf.

3. KIRAN helpline: It is a 24/7 toll-free helpline provided by the Ministry of Social Justice and Empowerment. This help-line provides an online help for people in mental distresses.
4. Mano Darpan Initiative: It is an initiative launched by the Ministry of Education under the umbrella of Atmanirbhar Bharat Abhiyan. It provides psychosocial aid to students, family members, and teachers for their mental well-being during the times of pandemic.
5. RAAH app: NIMHANS has made a one-stop source app for all the information related to mental health care resources in India.

Need of the Hour

• Increasing the budgetary allocation must be the foremost focus of the government. In tune with the other developed nations, our allocations should constitute at least 5% of the total medical budget. This increase in allocations should be channelised to improve the resources like increased mental health professionals, setting up mental health centres in rural areas, setting up rehabilitation centres, etc.
• Another important recommendation is to strengthen the mental health care at the grass root levels, i.e., at the Primary health centres. Timely intervention at the local level right after early manifestation of symptoms would help preventing the illness from degenerating further.
• Government should diversify its focus solely from the infectious diseases to non-communicable diseases that include Mental health disorders.
• Empowerment of women through education, skill development, legal aid, cooperative movement would shield them from mental disorders emanating from the clutches of patriarchy.
• Government should engage with civil society to disseminate proper information to people and sensitize them about the way to treat the persons with mental ailments. This requires a socio-cultural change.
• Social care for the elderly community needs to be enlarged and strengthened.

Acknowledging the extent of the issue would be the first step towards addressing the mental health crisis in the country. For that we need to create an ecosystem of care and empathy which demands the participation of all the sections, from governments, to civil society to general public. Only then we can change the public’s perspective on the mental health. India cannot afford to ignore and sweep the imploding crisis under the carpet anymore.

 

References

• Introduction to Global Mental Health: Effects of Mental Health on Individuals and Populations (uniteforsight.org)
• Mental health may hurt India to tune of $1.03 trillion; here’s a dose for cos – The Economic Times (indiatimes.com)
• Causes of Mental Illness (webmd.com)
• India is world’s most depressed country with most numbers of anxiety, bipolar disorder cases | Lifestyle News,The Indian Express

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