In recent years, the impact of mental illness on the social and economic health of nations has been well understood, placing mental ill health as one of the leading causes of disability adjusted life years (DALY) worldwide. There has been much focus on early intervention, integration of mental health into primary care, stigma reduction and access to affordable health care, all very relevant and essential policy recommendations. However, we may not be addressing a related and critical area, sufficiently aggressively, if we are to respond comprehensively to what may well emerge as a health crisis, costing nations productivity and resources. Our responses thus far are on a tertiary, crisis resolution mode with negligible focus on prevention — a necessity, if we are to improve society’s collective quality of life and plan for mental health gains.
The World Health Organisation (WHO) has drawn our attention to the close interplay between poverty and mental ill health by documenting evidence that those affected by poverty, hunger, unemployment, debt or are living in poor, overcrowded housing are far more susceptible to common mental disorders. It also reports that 75 per cent of the global burden of Neuro Psychiatric Disorders occurs in low and middle-income countries. In a somewhat similar vein, Anandi Mani and Sendhil Mullainathan recently probed the impact of scarcity on peoples’ lives. The results of their trial show diminished cognitive functioning among those experiencing the strain of poverty, causing them to often make bad decisions, ignoring long-term benefits because of their more immediate preoccupation with money. This could result in poor mental health outcomes, as well.
The cyclical impact of poverty on ill health and stress and vice versa can be a trap that one struggles to crawl out of. I have seen families opt out of treatment and, sometimes, resort to suicide experiencing utter hopelessness; elderly caregivers give up, unable to bear the brunt of a devastating combination of mental illness and poverty. This interplay leaves workers such as me powerless and disillusioned, often sapping motivation and encouraging exit, leaving the sector scarcer in resources.
So, what can we do differently? While the medicalisation of sadness and unusual behaviour has been much criticised, pharmacotherapy has indeed yielded results and its importance cannot be trivialised or dismissed. But have we tried all else to address the multi-dimensional factors that impact one’s well-being? This is why the concept of Social Prescribing as a response to mental health issues may work well in a low-resource setting such as India, where the ecosystem could often precipitate stressful living conditions.
Social Prescribing is often used for vulnerable groups such as homeless persons, persons affected with mental health issues, single parents and people living in poverty and experiencing deprivation. The idea is to prescribe access to benefits, information, exercise, spirituality, social contact, employment, volunteering for a cause, peer support and participation in self help groups, social enterprises and so on to ensure that those who are preoccupied with the ‘here and now’ overwhelming issues of abject poverty and ill health have fresh insights and options to live life differently.
The facilitator, who helps access these options, offers a structured introduction to a new way of life that includes some of the finer aspects of living that contrast with the everyday monotony of distress and struggle. For those who are poor, the access to benefits including housing schemes, pensions and social care could help effectively combat other non-medical crises that build stress and accentuate depressive moods. Engagement in diverse activities and being occupied could also lend a sense of purpose or meaning to a person’s life — an empirically established way to stay happy and contented.
So, who makes this work? Besides the primary care practitioner and the specialist psychiatrist and psychologist, this would legitimise and open up the role of yet another specialist, the psychiatric social worker, who by training is equipped with skills to address and respond to the multiple needs of a person with a mental health issue. If positioned within the government-owned system, the health and the social welfare departments will have to converge to ensure that the consumer finally benefits from both types of care — a form of convergence that the 65th World Health Assembly advocates as an essential attribute of a robust mental health system.
Political will needed
While the administrative systems could respond, a measure such as this calls for strong political will and action. Besides ensuring that schemes reach the poor, an important construct of social care in mental health is yet to be managed — the disability allowance. The Persons with Disabilities Act ensures an allowance for those affected by mental illness based on compliance with certain set criteria. This benefit will ensure that the poor user and caregiver have access to some reprieve and help address socio economic challenges that we now know influence the people’s behaviour and their health. This may well encourage treatment commitment; a common and critical challenge one faces in the mental health sector. Despite being an entitlement, accessing this advantage has been a close to impossible task for many in India. During this period of economic downturn, one may debate the wisdom behind what seemingly is an indirect investment to improve health and yet a significant revenue allocation, keeping in mind large numbers affected by mental disorders. However, like Stuckler and Basu (and indeed many others) eloquently argue in The Body Economic , on why austerity kills, reviewing the response of nations from the times of the Great Depression to newer global economic crises, almost always establishing a link between better quality of life, improved health outcomes and effective social protection schemes; I would also caution governments and societies from falling into the trap of the notions of scarcity discussed earlier. Trading off long-term benefits for immediate relief could have detrimental effects on the social health of this very vulnerable group.
The good news is that India has launched a progressive attempt to both introduce a Mental Health Care Bill (that will encourage the common man to view mental health care as a right, making services mandatory) and a Mental Health Policy that will focus on precisely this — the diverse needs that promote well-being. Meanwhile, if Social Prescriptions and Protection can be tested anywhere in India, it has to be in Tamil Nadu, a leader in social innovation and health and development indicators. With the Amma kitchen and neer , basic amenities such as food and water have been made available to many at a reasonable price — an approach that can soon be sustainable, make economic sense and along the way result in social merging or mixing, blurring the lines between classes.
Now, imagine this as a mental health response — a person with depression walks into a clinic, receives medical attention and is then guided to a social worker who would refer the client to multiple other services including a social protection scheme that works. We would then truly be addressing the needs of those who according the World Disability Report (2010) are the poorest-persons with disabilities. In the process, we would build non pathological responses to healing the mind and construct holistic services that will eventually promote social capital, have an impact on progress and development and help promote equity.
(Vandana Gopikumar is founder of The Banyan.)