Coming Out Of The Closet
The World Health Organisation, in a recent study, marks India as the most depressed nation in the world and one of the highest-ranking countries for several other mental disorders. Unless the plummeting mental health quotient of the country is addressed urgently, we might soon have a new kind of debilitating epidemic catching us unpreparedBy Aatika H Jain
One in four people, like me, have a mental health problem. Many more people have a problem with that. I want to speak out to fight the public stigma and to give a clearer picture of mental illness most people know little about. Once the understanding is there, we can all stand up and not be ashamed of ourselves, then it makes the rest of the population realize we are just like them but with something extra,” said popular British comedian, actor and writer Stephen Fry, who has struggled with bipolar disorder for a long time, and has been a major supporter of mental health awareness. He opened up about his own mental health problems to help spread awareness to reduce the stigma that surrounds them. Mental health problems are as old as humankind. We realize Aristotle might have been right when he said, “No great genius has existed without a strain of madness.” Take a look at the historical figures who could have possibly suffered from mental health problems, right from Beethoven with bipolar disorder, Tolstoy with clinical depression, Gogh with bipolar disorder and/or schizophrenia, Hitler and Stalin with clinical narcissism, and so on. Mental health problems have affected millions and millions of people, irrespective of class, color or status, across the globe throughout history. Yet, even in the 21st century, there is still an all-pervasive stigma attached to them. We might have made technological advances by leaps and bounds in the field of innumerable physical ailments, made their treatments easily accessible to the masses, and removed the taboo around them. However, mental disorders remain the runt of the litter.
World, how deep is your mental struggle?
One in four people in the world will have some form of mental/ neurological disorder at some point in their lives, says a recent report by WHO, titled ‘New Understanding, New Hope’. Mental disorders are one of the most important reasons for disability and sickness in the world, with roughly 45 million people suffering from them presently. What is worse is that almost two-thirds of the people suffering from mental disorders never seek professional help even though treatments are available. WHO states that stigma, discrimination, and neglect prevent care and treatment from reaching people with mental disorders. The fourth main factor of the global disease burden is depressive disorders; this is expected to jump to the second position by 2020. WHO emphasizes that the responsibility for positive action lies with governments.
Right now, more than 30 percent of countries have no mental health programs, and about 25 percent have no mental health legislation. mental health policy exists in over 40 percent of countries. Depression is one of the principal factors of the global disease burden in low and middle-income countries (LMICs), including India. According to WHO, India is one of the three countries, along with China and the US, with the highest rate of depression, schizophrenia, and bipolar disorder. No less than 6.5 percent of the country’s population is fighting some kind of severe mental problem. Around 57 million people in India, 18 percent of the global burden, suffer from depression, which is expected to rise with the swiftly changing socio-demographic scene, migration, globalization, and urbanization. Approximately 38 million Indians suffer from anxiety disorders; Indian women are 25 percent more prone to mental illnesses, such as depression and anxiety, than men.
By 2020, 20 percent of Indians will suffer from some kind of mental disorder, WHO predicts. “We also have the National Mental Health Survey of India, which estimates that 1 in 10 Indians suffers, or will suffer, from some mental disorder. At The Health Collective, we did a very powerful interview with noted psychiatrist Dr. Vikram Patel, who pointed out that statistic, and added that it doesn’t necessarily mean that the other 90 percent are enjoying good mental health, that we may have no mental disorder and yet have poor mental health,” says Amrita Tripathi, founder-editor of The Health Collective, a website dedicated to raising awareness about mental health and mental illness in India.
“A LARGE NUMBER OF PERSONS WITH MENTAL HEALTH PROBLEMS IN OUR COUNTRY DO NOT HAVE ACCESS TO MENTAL HEALTHCARE AND SOCIAL CARE SUPPORT, PRIMARILY BECAUSE THE GOVERNMENT HAS NOT PRIORITISED MENTAL HEALTHCARE.”Dr Soumitra Pathare, Director, Centre for Mental Health Law and Policy
Mental disorder and mortality?
Mental disorders are often the trigger for suicides. Every 40 seconds, somebody commits suicide in the world. Suicide is the second most common cause of death in the age group of 15-29 years. Although suicide rates have decreased worldwide, it is disconcerting to note that it has increased in India in the last two years. Most of the people who commit suicide are less than 44 years of age while the average suicide rate in the country is 10.9/lakh people. A new Lancet study revealed that suicide is the ninth major reason for death in India with 2,30,314 deaths in 2016, which could potentially be underreported as suicide was decriminalized only two years later. Suicide is the main reason for death in India in the age group of 15-39 years.
The leading reasons were found to be unreported mental illnesses. An increasingly individualistic society has left the adolescents alone to deal with their stress, depression, and anxiety caused due to unrealistic expectations and fear of failure. In 2016, 37 percent of the women who took their lives across the world were Indian while in men a high suicide death rate (SDR) of 21.2 per one lakh was found. The rise in farmers’ suicides in the country has been because of deteriorated mental health due to the severe financial crisis which has drastically increased the SDR amongst the men. Better access to mental healthcare services and increased awareness about mental health problems are essential along with any monetary help extended by the government or society, in the case of the farmers.
Morbidity and mental health
Way back in 1954, Dr. Brock Chisholm, the first WHO Director-General, said, “Without mental health, there can be no true physical health.” The strong relationship between mental illness and chronic diseases has been mostly overlooked. People with severe mental disorders are more likely to develop a broad variety of physical illnesses. Conversely, those with the chronic physical disease are two times more prone to suffer from anxiety and depression than the general population. For some particular diseases, the rate is even greater. When mental and physical ailments occur simultaneously, the illness lasts longer and the health outcomes are poorer. It costs society economically too due to the lost productivity and greater use of health services.
Around 57 million people in India, 18 percent of the global burden, suffer from depression, which is expected to rise with the swiftly changing socio-demographic scene, migration, globalization, and urbanization. Approximately 38 million Indians suffer from anxiety disorders; Indian women are 25 percent more prone to mental illnesses, such as depression and anxiety, than men.
People with mental illnesses often suffer more from poverty, lack of permanent housing and employment, and societal isolation. These conditions increase their chances of developing chronic physical ailments. On the other hand, constant physical pain and distress often lead to depression and anxiety in the patients. Post-traumatic stress disorder (PTSD) often occurs in patients with serious physical ailments. One in five cancer patients develop PTSD after their diagnosis; the same rate was found in people with chronic pain. “I lost my father in a harrowing 6-7 month period after he was diagnosed with stage IV cancer,” says Tripathi. “Despite the best treatment available and a truly empathetic oncologist and medical team, I can’t say that there was an emphasis put on counseling or addressing the trauma of the diagnosis. There were a few conversations with us as a family about the importance of staying positive, and the importance of the patient’s outlook, but no attempt to introduce counseling as part of the care.
Sting of stigma
In August 2001, 28 people died due to a fire accident, because they were chained, at Moideen Badusha Mental Hospital, a supposedly religious place in Erwadi, Tamil Nadu. The Erwadi tragedy happened due to the belief of supernatural causes of the illnesses resulting in the family of the mentally-ill seeking interventions from religious/non-professional/traditional healers. More than 50 percent of patients and their families believe in supernatural/religious etiology and that offering prayer could cure mental illness. However, in some cases, it could partly be due to the lack of availability of alternative treatments from mental healthcare providers. The mental illness burden has largely been neglected due to several factors including the social stigma around it along with lack of awareness. The stigma attached to mental disorders leads to prejudice, which prevents people from speaking up about their mental and emotional struggles and seeking professional help.
Retard, crazy, mad and stupid are just some of the words that people use for those struggling with mental conditions. Ostracism of the people not fitting the norm of the community is common. These people might consist of the mentally ill too. The paucity of resources, ignorance, and belief in supernatural causes, lack of healthcare services… irrespective of the factors, the people struggling with mental illnesses fail to get the right healthcare and need to rely on traditional and non-scientific ways. “A large number of persons with mental health problems in our country do not have access to mental healthcare and social care support, primarily because the government has not prioritized mental healthcare,” says Dr Soumitra Pathare, Director, Centre for Mental Health Law and Policy, Indian Law Society, Pune, who has contributed to the Mental Healthcare Act 2017.
“THERE’S A RISE IN ANXIETY DISORDERS, IN DEPRESSION, THAT OFTEN GOES UNNOTICED, OR UNREMARKED UPON, UNTIL WE HEAR OF A SPATE OF YOUNG SUICIDES. PSYCHOLOGISTS SAY THERE’S ALSO NO GUARANTEE ON THE QUALITY OF CARE.”Amrita Tripathi, Founder, The Health Collective
The Mental Healthcare Act 2017 came into force on May 29, 2018, and it states that every person has the right to accessible, affordable, good quality, impartial mental healthcare services. The Act also aims to protect such individuals from inhuman treatment, to help them access free legal help and their medical records, and to grant them the right to complain in case of deficiencies in provisions. The Act also empowers a person to nominate a representative and make advance directives towards their preferred treatment for the illness. An important high point of the Act was decriminalizing suicide. It represents a more sensitized approach towards mental disorders and ensures that people who have attempted suicide are not penalized or punished for it and instead, are provided a chance at rehabilitation by the state. It recognizes the agency of the patients of mental illnesses, empowering them to make informed decisions regarding their condition.
The legislation has made it mandatory that “every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for the treatment of physical illness”. Mental health covers are common in many countries but none of the 33 insurers in India offered any such products which covered disorders such as schizophrenia, depression, and bipolar disorders. In August 2018, IRDAI, the insurance regulator, issued circular directing insurers to provide health insurance for mental disorders and comply with the provisions of the Act with immediate effect. The companies that wish to cover mental.ailments will have to file a fresh product with the IRDAI. This move was welcomed as a step towards the destigmatization of mental illnesses by recognizing that they were not any different from physical ailments. This would also help in spreading awareness about mental disorders. However, the circular fails to outline any guidelines for the insurers on how to implement the directive. The insurance companies seem ill-prepared to offer insurance cover to mental disorders.
Now that the insurance sector has become one of the stakeholders in the mental healthcare scenario, the problems beleaguering the implementation and the delivery of mental healthcare services have come under the spotlight. Currently, many of the mental health paraprofessionals are not covered under licensure by the Rehabilitation Council of India, which provides registration to clinical psychologists. The sector will have to work towards professional recognition, regulation, and registration of mental health professionals in the country. Once the insurers formulate their mental health cover plans, they will try to bring in new as well as previous clients already insured for physical ailments. For this, they will have to share the responsibility with the mental health professionals to advocate mental health issues and their acceptance in the country. This will give a thrust to the discourse on national mental health in the policy and insurance spaces which will, in turn, improve the mental healthcare infrastructure in the country. “It will spur the development of mental health services. Because this is now a justifiable right. Mental health services are not ‘infrastructure’ heavy, but human resource-heavy. There are provisions in the act for the government to increase the number of mental health professionals in the country,” says Dr. Pathare.
There is an urgent need to improve the mental healthcare infrastructure and boost the number of mental healthcare professionals in the country to realize the right to affordable, good quality mental healthcare services which also requires more funding from governmental agencies.
The rising instances of mental illnesses among the Indian population would soon turn into an epidemic if measures are not taken to alleviate the mental disorder burden of the country. The Mental Healthcare Act 2017 mandates that state governments provide affordable mental healthcare for all, but the treatment remains expensive in all states, making it hard for the common man to avail it. The development of mental health services in the country has been slow. Some of the important reasons are the current public health priorities and how they affect funding, a low number of trained professionals in mental healthcare, the problems in delivering mental healthcare in primary care set-up and the lack of appreciation of mental health as a crucial concern in the healthcare sector. Although there are efficacious methods and treatments in place, there is a severe scarcity of trained mental health workers, doctors, psychologists and psychiatrists in the country. As per the reported data in 2014, it was as dismally low as 1 in 1,00,000 people. India has only 5,000 psychiatrists and less than 2,000 clinical psychologists. The availability of mental healthcare services might have improved since then but the reality is that there still exists a wide chasm between current morbidity and the services available. “The government can increase the budgetary allocation to mental health. There is a fantastic initiative called Bridge the Gap, which advocates for access to mental healthcare and support in India. It aims to have politicians recognize the need to make mental healthcare a priority,” says Tripathi.
Although there are efficacious methods and treatments in place, there is a severe scarcity of trained mental health workers, doctors, psychologists and psychiatrists in the country. As per the reported data in 2014, it was as dismally low as 1 in 1,00,000 people. India has only 5,000 psychiatrists and less than 2,000 clinical psychologists.
There are very few important institutes in the country such as NIMHANS in Bengaluru and Central Institute of Psychiatry at Ranchi which are largely accessible only to the urban and semi-urban population while the huge part of the nation which resides in villages, towns and remote areas remain deprived of the basic mental healthcare services which are their right. One of the burning issues is the lack of awareness about mental health conditions and available treatments. The awareness can begin at the level of the community health workers who are directly involved at the micro-level of the daily healthcare services. They need to be trained to carry on mental health awareness programs. Mental health issues need to be openly discussed to reduce the stigma attached to them. The importance of optimal mental health needs to be emphasized in the public domain and should be given as much priority as physical health. Educating children and adolescents, and sensitizing them towards these issues will go a long way in moving towards a more empathetic society in the future.
“We need to talk more about it, we need to advocate for it, we need to address the discrimination faced by persons with mental health problems, and we need policymakers to give mental health the importance it deserves. We need action on the ground and not just platitudes. This means increasing the availability of services, tackling discrimination in law and policy, and correcting the severe underfunding of mental health in our country,” states Dr. Pathare. The Mental Healthcare Act 2017 requires revising its guidelines about primary prevention and rehabilitation/reintegration, without which it would be an imperfect implementation and the struggles of the mental health patients will remain. There is an urgent need to improve the mental healthcare infrastructure and boost the number of mental healthcare professionals in the country to realize the right to affordable, good quality mental healthcare services. This also requires more funding from governmental agencies. “Everything and everyone involved in the mental health sector will have to become an agent of change as well as be affected by the change. It’s going to be an incremental process and change will not happen overnight. But the Act has put in place a framework for change of mental health services in the country,” says Dr. Pathare. We just need to tirelessly keep working towards it as an individual, a society and a nation. “Mental illness is not a personal failure. In fact, if there is a failure, it is to be found in the way we have responded to people with mental and brain disorders,” says Dr. Gro Harlem Brundtland, Director-General of WHO. We are them. And they are us. Ubuntu. I am because we are.
“We need to talk more about it, we need to advocate for it, we need to address the discrimination faced by persons with mental health problems, and we need policymakers to give mental health the importance it deserves. We need action on the ground and not just platitudes”Dr Soumitra Pathare, Director, Centre for Mental Health Law and Policy
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