- It is more than two years since Akila*, in her early 50s, had a visitor from home. She remembers being unwell and uncared for, going without food, sleep and a bath for days, and developing a fear of water. As her symptoms worsened, her son left her at the Institute of Mental Health (IMH) in Chennai where she was diagnosed with Bipolar Affective Disorder. He has not returned since, and her daughter, whom she remembers seeing two years ago, expressed her inability to take her back home. The campus is her home now, and Akila, who has improved with treatment, is no longer keen on going back either
- Almost a decade ago, the death of her husband sent Bairavi*, now aged 38, into depression. Upset and sleepless is how she could explain her state then. But she knew she needed help. Diagnosed with Major Depressive Disorder, she spent the next few years in treatment and rehabilitation at The Banyan. After spending nearly five years away from her daughter, Bairavi is back home, managing the NGO’s office in a district in Tamil Nadu, enthusiastically reaching out to people like her.
- Jency* was in her early twenties when her mother was diagnosed with mental illness. Her mother’s death by suicide left a permanent scar. Years later, Jency found herself in the midst of a sea of emotions precipitated by the death of her husband’s friend. She feared losing her husband. That marked the beginning of her long struggle with bipolar disorder. A six-month-long stint in a health care institution enabled her to put the pieces of her life back together. Tackling relapses, she knew advocacy was her strength and embarked on a new journey
Mental illness changed the lives of these three women. Like hundreds of people in the same situation, Akila, Bairavi and Jency are still not understood by the vast majority. The reasons: lack of awareness and stigma attached to mental disorders.
The problem partly lies in differentiating mental health from physical health. From there on, it takes a different path; a path in which availability and access to mental health services, adequate mental health professionals, affordable treatment leading to rehabilitation and integration into society become issues.
Disease burden
The recently-published ‘The burden of mental disorders across the States of India: the Global Burden of Disease Study 1990-2017’ (Lancet Psychiatry, 2019) says mental disorders are among the leading causes of the non-fatal disease burden in India. Giving the prevalence and disease burden of each mental disorder for the States, it finds that the proportional contribution of mental disorders to the total disease burden in India has almost doubled since 1990.
The prevalence of mental disorders that predominantly manifest during adulthood – depressive and anxiety disorders, schizophrenia and bipolar disorder – was generally higher in the more developed southern States than in the less developed northern States, it says.
Tamil Nadu, being one of the States in the high socio-demographic index group, accounted for a high prevalence of depressive disorders, anxiety disorders and schizophrenia.
The crude Disability Adjusted Life Years (a summary measure of total health loss) rate of depressive disorders was highest in T.N. in this group.
Commenting on the study, R. Thara, vice-chairperson of Schizophrenia Research Foundation, says that there has been no country-wide look at the burden of mental disorders so far.
“The Global Burden of Disease study is not prevalence or an epidemiological study. The data was collated from experts. Nevertheless, it gives us an overview of the prevalence of mental disorders,” she says.
With better literacy rates and mental healthcare services, southern States such as T.N. and Kerala have accounted for higher rates of depressive and anxiety disorders and schizophrenia.
“We need to see if this is due to better reporting or a true reflection of prevalence rates. How are we going to handle this? We need to think about increasing awareness on mental health, early diagnosis and treatment, and reduction of stigma,” she adds.
Modernisation and urbanisation are among the likely causes for this high prevalence. Vandana Gopikumar, co-founder, The Banyan, feels that urbanisation has resulted in migration, cultural disaffiliation, identity crisis and certainly overcrowding, all of which may have an impact on mental health. “Nuclearisation of families has many gains, but it has also resulted in decreased support networks,” she adds.
C. Ramasubramanian, former State Nodal Officer for Mental Health Programme, attributes the rise in the numbers of depressive and anxiety disorder to the isolation caused by urbanisation. Even in tier-2 cities such as Madurai, joint families have disintegrated to form nuclear families which make individuals ‘islands’, he says.
Access to services
Dr. Thara says: “Our research has shown that in rural areas, 80-85% persons do not access mental health services and remain untreated for 10-12 years. Despite a fairly good District Mental Health Programme in the State, the distance to the nearest medical facility is still huge.
When treatments are not accessible, disease burden increases, observes Anna Tharyan, retired professor of psychiatry, Christian Medical College, Vellore. “Psychological treatment is even less accessible than medical treatment, especially to low and middle socio-economic populations in rural areas. Non-availability of psychiatric treatment at primary and secondary level government hospitals means that the financially deprived cannot access care.”
It is here that primary health care should play a larger role.
“Today, we have technology to address most of the problems of mental health at the primary and secondary care level but its implementation is ineffective. The emphasis is on starting invention as early as possible. The primary health care system, which comprises the first contact care, should identify persons with mental illness and bring them to care,” says K.V. Kishore Kumar, director, The Banyan.
Less-recognised areas
Certain areas continue to be less recognised — post-partum depression, substance/alcohol abuse and domestic violence.
The study observed sex differentials in the distribution of mental disorders; higher prevalence of both depressive and anxiety disorders in women than in men could be related to gender discrimination, violence, sexual abuse, antenatal and postnatal stress and adverse socio-cultural norms.
Mental health is not without newer challenges, especially involving the young. The rapidity of social changes is a huge factor. Social networking, gadget addiction and having virtual friends than real friends, experts add.
Sapna Bangar, psychiatrist and head, Mpower-The Centre, Mumbai, says children are not taught to take ‘no’ for an answer and are given more privileges; as a result, they, as a generation, have poor resilience and poor coping strategies.
Are there strong links between mental disorders and suicides? Lakshmi Vijayakumar, psychiatrist and founder of SNEHA, says depression is an important factor associated with suicide but not the only factor. One-third of persons who die by suicide are addicted to alcohol or are under the influence of alcohol. “Here, we need to look at triad of depression-alcoholism-suicide,” she says.
Where T.N. stands
For a State that leads in a number of health indicators, T.N. has come a long way in establishing mental health services, but more needs to be done, say experts.
P. Poorna Chandrika, director of Institute of Mental Health (IMH), Chennai, says, “When compared to other States, Tamil Nadu is way ahead in providing mental health services.”
Under the District Mental Health Programme (DMHP), which was launched in 1997 and expanded to 32 districts over the years, every district has two psychiatrists, a clinical psychologist, psychiatric nurse and social worker, and 10 beds allotted for psychiatric patients in district hospitals.
IMH, one of the largest treatment facilities in T.N., is currently home to around 900 patients. A document of the Department of Health and Family Welfare shows that IMH catered to an average of 341 out-patients per day during 2017-2018 and 352 during 2018-2019. Its in-patient figures were 861 per day during 2017-2018 and 833 during 2018-2019. But it is the average length of stay of each patient that makes IMH different from other institutions – 97 days in 2017-2018 and 102 in 2018-2019.
‘Mindset must change’
“The mindset of people should change. Institutions such as IMH are hospitals and not asylums. Integrating persons, who improve with treatment, back in society is crucial, and we are taking steps towards it by providing training, and creating job opportunities for many of them,” Dr. Chandrika adds.
Implementation of DMHP varies from place to place.
A 10-bedded psychiatric ward at Usilampatti’s Government Hospital is occupied by patients with reported fever cases. “It is common for us to utilise the psychiatric ward because there are only a few people who ever get admitted. Some visit the doctor at the out-patient wing if there is a necessity but it is not used much,” says a nurse.
Usilampatti Government Hospital is a telling sign of the ground-level execution of the mental health programme in Madurai. Although several institutional arrangements are made for the effective implementation of the mental health programme here, the work on the ground does not measure up.
There are districts that are trend-setters. Take Pudukottai for instance. Its DMHP programme officer, R. Karthik Deivanayagam, says a special helpline for people to contact in case of emergencies was launched, and it receives at least five such calls a day. Among other initiatives, Mental Health Clubs at various government schools and colleges, and village mental health committees at the panchayat level are being formed.
He says that interdepartmental dependence is required across all medical domains, not just in mental health.
"If a patient has a cardiac problem, is he/she not referred to the cardiologist? Similarly, a psychiatric referral must also be resorted to," he says. The biomedical approach to medicine, wherein medicines are prescribed for all illnesses, must be discouraged, he adds.
At the school level, the city corporation and M. S. Chellamuthu Trust have begun ‘Happy Schooling’ at 24 schools in Madurai city. The programme is aimed at promoting emotional well-being among the students.
Revathi Mohan, a psychologist from Thiruchengode, says that though counsellors are appointed in many schools, they are not utilised well.
Need of the moment
Long-term care is one of the many challenges. Ms. Gopikumar, points out, “In keeping with the Mental Healthcare Act, Mental Health Policy and Rights of Persons with Disabilities Act, it is essential that inclusive living options be provided for such persons when they seek it.”
Dr. Bangar says the immediate need is to improve the healthcare budget as the government spends less than one per cent on mental healthcare, when the need is four to five per cent.
There is a need for more number of mental health professionals.
Social workers dedicated to mental health at the block primary health centres and creating posts of deputy director for mental health at the district-level are important, say officials. A senior psychiatrist says a line listing of all cases is essential.
“Attitudes change by contact and experience. Therefore, we need to have more people with mental health issues in the workforce and greater diversity in communities. Challenging prejudice and stigma requires determination, persistence and radical empathy. That alone will ensure lasting change and better help-seeking patterns,” Ms. Gopikumar sums up.
*Names have been changed to protect identity
(With inputs from Sanjana Ganesh in Madurai, Kathelene Antony in Tiruchi and Vignesh Vijayakumar in Salem)
