The biggest problem that we have in understanding and addressing an issue like mental health in Mumbai is that we actually have very little idea of the size of the problem; the data is so scarce that any kind of nuanced understanding becomes extremely hard.
In recent years, the Census has had a provision to list family members with serious mental disorders, because they are eligible for disability benefits. The numbers give us an idea of how many serious cases of mental illness there are: mental illnesses that require hospitalisation and/or care in mental health facilities. Our medical system has for long focussed only on these. But on general mental health, and what we refer to as distress — people who suffer from stress, anxiety and depression — we have no numbers that we can publish.
But make no mistake, the problem is huge and only getting bigger. According to the World Health Organisation (WHO), one in four adults across the world suffers from some form of mental illness and it will almost certainly become one of the leading causes of ill health globally.
Our government can help, but not enough has been done
Way back in 1982, India had formulated a national mental health programme, recognising the high burden and incidences of such illnesses. The programme speaks of ensuring availability of and accessibility to minimum mental health care for all, encouraging application of mental health knowledge in general health care, in social development and to promote community participation in the development of mental health services. More than three decades later, no headway seems to have been made. At an event in September 2015 in Delhi, the chairman of the National Human Rights Commission pulled up health secretaries of various states for not utilising the funds made available to them under the programme. State-funded mental health clinics are the need of the hour, but when there is a lack of basic implementation, it seems far-fetched to talk about the need for setting up more.
The recent passage of the Mental Health Care Bill by the Rajya Sabha has sparked a broader discussion on the subject. As such moments are few, and fleeting, this is a good time to lay out some of the most critical issues and see how far we have to go to deal with this problem.
From the discussion around the passage of the Bill, we do have some important numbers: India allocates just over 1 per cent of the Centre’s health budget to mental health, and the states make comparable allocations. The situation today is a far cry from what was initially promised in the Mental Health Act, 1987, which spoke of state- and central- level authorities dealing with the problem of mental health.
A lot should change with the new legislation, especially in terms of allocation of funds, but it is important to point out that this is but the tip of the iceberg in terms of true reform. Crucially, the Bill only recognises the role of psychiatrists — i.e., those qualified to prescribe medicine in the treatment of a mental illness — but still does not acknowledge the roles of counsellors and psychologists, who also work with patients suffering from mental and emotional distress.
A related problem: the Bill largely addresses the requirements of people in mental health care facilities. The reality today, however, is that not every person diagnosed with a mental illness needs institutionalisation.
And while the bill has a line about mandating insurance companies to provide medical insurance to the mentally ill on the same grounds as other illnesses, counselling services are unlikely to come under its purview. This is a crucial gap and one I will discuss in more detail later.
The less visible mental illnesses need to be recognised
Having worked as a mental health professional in Mumbai for close to two decades, I can report that the situation on the ground is rapidly changing. We have come a long way from the time when we treated only serious mental disorders. A large chunk of patients we see today suffer from non-serious disorders such as stress or anxiety.
I think this is because we are changing as a society.
Mumbai has always been a city where you came to realise your dreams, and people here have therefore always been more hardworking and possibly lead very stressful lives. A few years after the economic reforms of the early 1990s, the fabric of our society began changing slowly. We have become more consumerist, and ambitions around lifestyle have become a major trend. Which is not to say that we were laidback before; we were a driven society anyway, and the vast array of choices we now have has just added to the complexity. But no one had really looked hard at the these factors, and so no one could quite estimate the quantum of people with mental illnesses that we could be dealing with, now and in the future.
Once upon a time, across socio-economic strata, people would seek help for mental illnesses only if there was a severe disorder. For example, if a family member started muttering to himself, or abusing people without any reason, then they would send him to hospital. This perhaps explains why government machinery was largely focused on those kinds of cases and, to some extent, still is.
If you go to a regular municipal hospital today, what they will mostly give you is medication. If you go to a mental health outpatient department, there will be more psychiatrists than social workers and psychologists, whose job it is to provide counselling. In many cases, given the sheer volume of patients who come in, they are mostly involved in simply assessing patients at the first step.
In a city like Mumbai, though, there are people who have mild symptoms of stress, anxiety, frustration who could benefit from both psychology and psychiatry. Are we looking at addressing them? Probably not enough.
We need to change the way we think about mental health
Until last year, there used to be government-prepared adverts on TV that had messages about how people with mental illnesses should not be discriminated against. But even these messages were focused on severe mental conditions.
The reality is that the large chunk of people who have conditions like stress and anxiety are ticking time bombs: if stress and anxiety keep increasing, they could lead to serious illnesses. Extreme anxiety can lead to physical symptoms like blood pressure and cardio-vascular illnesses. Depression, if not treated in time, leads to extreme forms of the illness, including feeling suicidal. The problem is that there is no one to tell this large chunk of people how to handle these problems. How do we get the message out about this?
To a certain extent, government messaging about mental health does work. I had a patient come in once for counselling for Obsessive Compulsive Disorder (OCD). I asked him, how did you happen to come to me, and he said he had gone to a doctor who had treated him and had sent him to me. He explained that he used to panic in many situations, and he thought it was a physical thing since it would come out in symptoms like sweating or anxiety. Then, one day, when he was buying a train ticket he turned around and saw a poster, government-sponsored, that explained that if you have such and such symptoms, you need to consult a medical health professional.
Would these kinds of campaigns work in a city like Mumbai? I’m not so sure. It’s like the anti-smoking ads you see in multiplexes, which audiences either ignore or cringe at; they may get the attention of people in the middle to lower socio-economic strata — that audience possibly regards such messaging with more respect — but it is not on the right wavelength for the general middle class. We are not doing enough to reach out to people who come into this category.
When we talk about reluctance to come in for treatment, we are actually talking about a phenomenon that cuts across social classes. It shows us that the messaging hasn’t gone out in equal ways.
The stigma associated with mental illness and the need for mental healthcare is still there, but I don’t really know what kind of person has it; there are people from poorer sections who don’t have that prejudice, and people from more prosperous backgrounds who still think it is taboo. And then we have over-awareness: people coming in with issues which are actually not so serious.
A big factor with the middle class is what I like to call the He-Man Syndrome: it seems to be part of our culture to say we should be strong about our issues. You’ll hear people saying things like “I don’t have stress, I only give stress to others.” This is unfortunate; you may want to deal with the problem, but no one has taught you how to do it.
Mental healthcare shouldn’t be just for the affluent
A significant cause for the general reluctance to treat mental illness is the cost. Which brings me back to my earlier point about insurance.
As I have said, the government focus is largely on more severe illnesses, so if you have one of those you can access good care reasonably cheaply. But what happens, say, when you experience work stress and it becomes uncontrollable? You know you should see a psychologist, or a counsellor, but maybe you can’t afford it. Largely, non-medical help for mental illnesses exists only in private set-ups — you visit a psychologist in his consulting rooms — or in NGOs, like the Institute for Psychological Health (IPH) in Thane, where I work. And the fees charged are more than that in government hospitals.
In practice, unless people reach a certain tipping point, they don’t come to us. And the tipping point can be affected by economic status: if they’re unsure about the money, they won’t come. It is important, therefore, that insurance companies address this.
Let’s take a simple example. Suppose I have clinical depression. Therapy and counselling are not services you can get in a government hospital easily, so I go to a place like IPH which, as an NGO, is somewhere between a government hospital and a private practice in terms of cost. The psychiatrist feels I need medication, so I’m charged for consultation, and I have to buy medicines. These medicines take time to work, so you’re looking at about two to three weeks of medication, after which you go back for another consultation. The psychiatrist may then send you for another assessment, and decide you need counselling. So you’re paying for consultation, medication, counselling, and all them are recurring costs. It’s not as simple as getting physically ill, going to a doctor, getting some medication, getting well, and then you don’t have to go back and see that person again.
In other words, making mental healthcare affordable is crucial.
In European countries like Sweden, and in the U.S., your medical insurance covers visits to mental health professionals. We are still a long way from there.
Taking away the stigma
A big part of helping people get over the reluctance to visit centres that treat mental health is to tell them to go once and see how it is. In IPH, for instance, we get many children who come in for treatment for conditions like hyperactivity. So, if an adult patient comes and sees children there, sees people who seem normal, then maybe the stigma will go. They will realise that this is not a place where there are only people muttering to themselves, people who have to be restrained.
I think a lot of this kind of communication is effective if it is by word of mouth. People should encourage their friends who they know are having problems to go to a place where they can be treated. They could perhaps go with them.
Creating awareness around mental health has not been an organised effort. Generally, if you run a mental health centre, then you have to do some kind of publicity, whether it’s writing columns like this one in the media or giving talks at events. It may serve to get you more clients but it also serves the broader purpose of publicising the issue. They are not organised efforts, but everyone is doing their bit.
Beyond this, there needs to be some organised effort to communicate with people who are slightly higher up the social ladder. I’m not sure yet about the kind of shape such an effort could take, but an advertising campaign that appeals to all sections of society, that is more attuned to the middle class, could help. Some kind of message to say, these are genuine mental health concerns that can become bigger, please take care of them.
As told to Jayant Sriram
About the author
Kuldeep Datay has a Master’s degree in Clinical Psychology from Mumbai University. He has a private practice in the city, and has also been working with the Institute for Psychological Health since 1997. IPH is a NGO focused on helping people with psychological problems and also those who wish to improve their mental health. He thinks of his work as being for both people with problems as well as those who wish to improve themselves. He has worked with several government organisations as a trainer and has worked with Special Police Forces to psychologically assess candidates and provide counselling and therapy support to members of the force. At IPH, he has been involved in planning and organising community programmes designed to improve awareness around mental health and as a coordinator for large community events.
Points to ponder
* Largely, only mental health issues with some visible manifestations get noticed, treated. This needs to change.
* Seemingly everyday issues like work stress can, over time, have serious effects on our health.
* Awareness is one issue that needs solving. Removing the stigma around needing mental healthcare is another.
* Mental health treatment should be covered under health insurance, as it is in more advanced economies; this ensures that more people can get this kind of help.
