Targeting the Mental Health through Indian Roots: Fighting the stigmatised beliefs with the Idiosyncrasy of the Millennials
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the seasons of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way—in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only”.
Charles Dickens: A Tale of Two Cities
The mental health scene in India at the dawn of the twenty-first century is a bewildering mosaic of immense impoverishment, asymmetrical distribution of scarce resources, islands of relative prosperity intermixed with vast areas of deprivation, conflicting interests and the apparent apathy of governments and the governed alike. In the context of the huge and perhaps unsustainable levels of over-population, the problems appear to be insoluble. Yet, a solution must be found if we are to survive. This calls for courage, vision and a vibrant spirit of innovation, unburdened with the obsolescent shibboleths of psychiatric mythology. We will have to get off the beaten track, and embark upon this journey without a road map to help us along. We will have to invent solutions. Do we have the technical skills required to achieve this goal? Do we have the wisdom to choose the right path? Can we now consider the importance of Mental Health? Can we step out of own shackles of stigmatised beliefs and understand that the essence of Mental health is as pivotal as physiological well-being of an individual?
Burden of mental disorders had risen over last few decades. With the recent survey of WHO claiming that every 5th person in India is suffering from a mental illness caught under the cobwebs where they are not aware about it’s existence or suffer under the shed of stigma associated with Mental illness.
Mental health is a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. WHO estimated that globally over 450 million people suffer from mental disorders. Currently, mental and behavioural disorders account for about 12 percent of the global burden of diseases. This is likely to increase to 15 percent by 2020. Major proportions of mental disorders come from low and middle income countries. There are lacunae in psychiatric epidemiology due to intricacy related to defining a case, sampling methodology, under reporting, stigma, lack of adequate funding and trained manpower and low priority of mental health in the health policy.
A study conducted in Pune in 2012 reported the overall life time prevalence of mental disorders to be nearly 5 percent. Males were reported to be at higher risk. Major cause was depression followed by substance abuse and panic disorders.
These findings were similar to results of the meta-analysis, which estimated the prevalence of mental disorders to be 5.8 percent among the Indian population.
In 2010, a study conducted in NIMHANS, Bangalore reported that the burden of mental and behavioural disorders ranged from 9.5 to 102 per 1000 population. Reason behind such a wide range of prevalence could be that few studies had focused on isolated settings.
Another study among elderly done in South India in 2009 found the prevalence of depression to be 12.7 percent. On the contrary, the prevalence of mental disorders was reported to be as high as 26.7 percent by a study in elderly with predominant depressive disorders, dementia, generalised anxiety disorder, alcohol dependence and bipolar disorder. The prevalence of dementia was found to be 33.6 per 1000 by a study done in urban population of Kerala in 2005. Alzheimer’s disease was the most common cause (54%) followed by vascular dementia (39%). In 2000, a review of epidemiological studies estimated that the prevalence of mental disorders in India was 70.5 per 1000 in rural and 73 per 1000 in the urban population.
All these studies represent figures and facts that are objective in nature. But one can recognise the social hardships of Mental illness too. As the prevalence rates have been significantly growing each year, the share that Mental illness has in government health policies have been stagnant, the possibility of awareness has just been given to a single day celebrated as Mental health day. Campaigns might be running on an organisational levels but the stigma still runs through the lanes of Indian settlements where Spiritual healers are recognised to heal the demons found in minds of the people who need help. As many sectors fail to realise it’s importance, the share of Mental health is by far the only thing encountered in books, in number of organisations working through with motivation but scarcity of resources and with the sufferers coming out in open to talk about their tales of suffering as the only hope that others one can by far achieve through social media.
In this modern technological age, mental health is not only seen under the diagnostic categories of ICD and DSM but has been a path which each individual seeks in their lifetime. As 21st century could see many doors getting opened for the people who talk about the issues from their walks of life. One could see that the definition of Mental illness accommodates a dimension of Self-peace which each of us strives to find. And it is not surprising that we millennials are realising that a diagnostic label is not mandatory to consult psychiatric sector. Mental health is increasing it’s horizons with little steps in it’s growth. One can also see how it effects each strata of population.
In 1999, a study stated that the prevalence of mental disorders in child and adolescent population was 9.4 percent. Similarly, another study from Bangalore in 2005 documented the burden of mental disorders to be 12.5 percent. The study also showed that there were no significant differences among prevalence rates of mental disorders in urban middle class, slum and rural areas with annual incidence of 18 per 1000 population. The prevalence of mental disorders among 0-3 yr old children was 13.8 percent, most commonly due to breath holding spells, pica, behavior disorder NOS, expressive language disorder and mental retardation. The prevalence rate in the 4-16 yr old children was 12.0 percent mainly due to enuresis, specific phobia, hyperkinetic disorders, stuttering and oppositional defiant disorder.
Compared with the general population, industrial workers were more predisposed to mental disorders. In 2002, the prevalence rate of mental disorders in the Indian industrial population was estimated to be 14 to 37 percent. On the contrary, western world reported it to be nearly 75 percent. Another study among industrial workers mentioned the lifetime prevalence of mental disorder to be more than 50 percent. Most common associated factor in industrial workers was substance abuse (12.3%).
Besides substance abuse, suicide among young people has emerged as a major public health issue. National crime record bureau, India reported, 27.7 percent increase in recorded number of suicides between 1995 and 2005 with suicide rate of 10.5 per million. Also a study from Hyderabad stated that nearly 35 percent of suicides occur amongst youth (15–29 years) with rate of 152 per lakh for girls and 69 per lakh for boys. Compared with the suicide rates from high income countries, these rates were four times higher for boys. In 2009, a study revealed that overall 3.9 percent youth reported suicidal behavior. A study conducted in rural areas of south India, in 2010 reported 37% of those who died by suicide had a mental disorder. The two most common reasons were alcohol dependence (16%) and adjustment disorders (15%).
The prevalence rates of mental disorders reported in India are very low compared to studies done in the western world. This is may be due to that Indian epidemiological studies were not able to measure mental disorders adequately. Reasons could vary from the stigmatised beliefs to the lack of support at each level. The reasons could be found within each of us who think it’s all in the mind.
Burden of mental disorders seen by the world is only a tip of iceberg. To promote mental health, there is a need to create such living conditions and environment that support mental health and allow people to adopt and maintain healthy lifestyle. A society that respects and protects basic, civil, political, and cultural rights is needed to be built to promote mental health. National mental health policies should not be solely concerned with mental disorders, but should also recognise and address the broader issues which promote mental health. This includes education, labour, justice, transport, environment, housing, and health sector. For attaining this, intersect-oral coordination is a mainstream.
It is increasingly recognised that the prodromes of many mental disorders start at such an early age. India needs to aim at improving child development by early childhood interventions like preschool psychosocial activities, nutritional and psycho- social help to give roots for a healthy community. Presently the community is also demanding the skills building programme and child and youth development programme.
To reduce the burden of mental disorders in women, there is need to do socioeconomic empowerment of women by improving access to education and employment opportunities. Women should be involved in group activities like farmer’s clubs, mahila mandal and adolescent girls' groups. These group activities will bring people together for social, health and educational reasons as well as income generation activities. Society needs to be free of discrimination and violence. Reducing discrimination against sex, caste, disability and socioeconomic status is an important aspect to reduce mental disorders.
Social support for elderly people needs to be strengthened. More community and day centres for the aged should be developed. Programmes targeting towards indigenous people, migrants and people affected by disasters need to be established.
Programme could be implemented through school like programmes supporting ecological changes in schools or at work place like stress prevention programmes. Various organisations across the globe are now largely focusing on mental health. World Health Organization mental health Gap Action Programme aims at scaling up services for mental, neurological and substance use disorders. Since its launch, over millions of people across the world are treated for depression, schizophrenia and epilepsy, prevented from suicides and begin to live a normal life. This was especially efficient in low and middle income countries having scarce resources.
Another key to reduce mental morbidity is to strengthen the treatment of mental disorders at the level of primary health care. There are multiple interventions needed to prevent the progression of mental disorders from early manifestations to more serious and chronic cases. There is an urgent need of simple, easily available diagnostic test and low cost treatment to provide better primary health care. Psychiatric epidemiologists need to reorient their research in such a way that true burden of mental disorders are estimated at community level. This would provide true situation of the mental health problem. Secondary prevention must focus on strengthening the ability of primary care services to provide effective treatment.
With regard to the primary prevention of mental disorders, though there are no identifiable methods of preventing major psychoses and psychoneuroses, there is a consensus that the absence of emotional security in childhood may lead to behaviour problems and adjustment difficulties in adulthood. A significant proportion of people who are at high risk of becoming psychiatrically ill is constituted by those exposed to moderate or severe psycho-social stress. A good percentage of people exposed to civilian disasters or earthquakes succumb to post-traumatic stress disorders and the rest to major depression, panic disorders or paranoid disorders. Psychiatrists and Psychologists should therefore be active participants in disaster management teams.
Strategies need to be worked on to prevent the current loss to India of highly trained professionals through migration and misplacement. A significant reason for seeking opportunities elsewhere may be the reduced availability of professional posts in the public sector. As the expansion of such jobs is not without its constraints within a developing economy, clinical psychologists may look to private entrepreneurship. However, the hiatus in the legal and administrative framework needs to be rectified so as to make the necessary provision for registration and licensing and for insurance coverage.
As the inclusion of a clinical psychologist as a non-official member of the central and state mental health authorities is mentioned in the Mental Health Act 1987, the Government of India can lay down the relevant qualifications and experience for professional classification. Centres for the training of such professionals can also be notified. Additionally, the professional body of clinical psychologists can introduce a set of ethical principles and a code of conduct for its members. Procedures for disciplining erring members would be another step towards increased professional responsibility.
Rao and Mehrotra point out that clinical psychologists in India do not like to involve themselves in administrative responsibilities. International literature confirms the diminished appeal that managerial responsibilities hold for clinical psychologists. Contributions to policy formulations, programme development and implementation, training initiatives, etc., are possible within a profession only if there are individuals with sound managerial experience. In the absence of such expertise, there may be a risk for the profession to be deprived of a sense of direction and of appropriate goals for development. Managerial vision and skills usually evolve over a period of time through a process of training and participation in such tasks. Clinical psychologists need to consider giving priority to managerial and administrative duties, in order to maintain the leadership function within the profession.
Positive changes occurring at a fairly fast pace lead to the development of a profession. During the second half of the previous century, the pace at which changes occurred in the field of clinical psychology were rather slow. If the issues raised herein bring about changes within the next 15–20 years, it would be in the interest of the field of health in general and that of clinical psychology in particular.
Mainstreaming Mental Health:
Mental health services must become more relevant for Indian cultural needs.
Medicine and psychiatry do not develop in a vacuum, but they develop in a historical social context. Modern science, medicine and psychiatry have all developed during the last few centuries, in a European setting. In the case of psychiatry, the influence of European philosophy is particularly striking. Various psychiatric terms, systems of diagnosis and classifications, and approaches to management, are all based on European philosophical thoughts. This is not a very comfortable situation for a country like India, with its own rich philosophical heritage. Perhaps, no other civilisation has considered understanding the functions of the human mind, psychopathology and the management of various mental disorders, the way we have in India. Yet, we continue to blindly follow alien concepts and methods, even though these are often inappropriate in our socio-cultural context. We need to deliberate on these issues and evolve a truly indigenous approach to mental health. Operational strategies derived from such an approach will accord more closely with ground realties, particularly in respect of psycho-social therapeutic interventions.
As one realises the importance of mental health, it is crucial to place those learnings in the India root. As one takes learning from the therapeutic practices placed in the West, one could reap it’s benefits by making the practice more indigenous to fight the stigma of mental illness as an abnormal outsider. As one realises the role of Psychologist or a Therapist, one realises that it is the hurt that ir running through veins and it is the clot that is felt in the throat. As one soothes it each day, one can find peace in a home now newly found in a clinic. As one loosely deconstructs the illness as merely a robotic white coat machinery which gives medicines and to see the essence of mental illness submerged in calmness. One would be ready to fight with the stigma. As Indians would embrace mental health as something which should be individual right, as we would join hands together to fight for the wellness of each mind. That day is not far away, where India would call itself mentally developing country. As one will recognise the psychological dimension of their health, each one of us will take a step ahead for the sufferers who are living under the roofs of abnormality. As we will accept them as one of us and see mental health as only more care to the normalcy. The day is not far away when these so called demons would be treated with the utmost care and Psychiatric practices would be seen under the lens of normality. The question is, Are we all ready to bring the modern era revolution?