The first law in pre-independence India focusing on mental illness was the ‘Lunatic Removal Act 1851’. Its main purpose was to regulate the transfer of British mental health patients back to England. Ahead, the British introduced many such acts such as The Lunacy (Supreme Courts) Act 1858, The Lunacy (District Courts) Act 1858 , The Indian Lunatic Asylum Act 1858 (with amendments passed in 1886 and 1889), The Military Lunatic Act 1877 and The Indian Lunacy Act (ILA) 1912.
However, these acts were not patient centric – as they were kept in poor living conditions and provided almost no therapy or care, which minimised any chance of recovery or cure. These shortcomings led to the Indian Lunacy Act (ILA) 1912, which became the first law to govern mental health in India. Its focus was not on the patients itself but majorly people who were in danger because of their presence. This act is believed to have completely neglected human rights and concerned only with custodial sentences.
It was in 1920s that an evolution from asylums to more humane mental health institutions really began. Significant developments internationally in terms of medicines that could affect a person’s mental state, general psychiatric units in hospitals, more specialists and surveys – which could contribute to mainstreaming psychiatry as a medical speciality in India.
In 1947, the Indian Psychiatric Society came into existence, which deemed ILA 1912 as inappropriate for the mentally ill patients. But the government still focussed mainly on psychiatric training and building hospitals rather than developing a non-mental health specialist workforce.
During the 1950s and 1960s, non-mental health specialists were used only in tertiary cities such as Madras, Amritsar and Calcutta. In that period, no formal government plans really existed for making mental health services available to the community. However, this was still a major time for the development of primary and community health worker services in general as the First Five Year Plans were executed by the Indian government. At that time, they majorly understood the importance of contribution of health programmes directly to the socio-economic growth of the country. After such plans, specific programmes were formed and institutions were built. (Sourced)
Another mental health bill was drafted in 1950 and was implemented as a Mental Health Act in 1993. It proposed a different definition of mental illness, which led the focus to shift from custody of those in distress and protection of people who might be at harm, to emphasis on care and treatment. There was an understanding on the need to protect human rights, guardianship and the management of the property of people with a mental illness. Their major objectives were a)establishing central and state authorities for licensing and supervising the psychiatric hospitals, b)providing for the custody of mentally ill persons who are unable to look after themselves, c)regulating procedures of admission and discharge of mentally ill persons to the psychiatric hospitals or nursing homes either on voluntary basis or on request, and so on. This bill seemed to express a more humane approach to problems of mentally ill persons.
From the year 1975 to 1982, many models were started to extend mental health services in the country. World Health Organisation’s study, ‘Strategies for extending mental health care, instituted primary-level health worker -delivered mental health care in seven countries. A similar model was developed in Karnataka from 1976 to 1986 through the National Institute for Mental Health and Neurosciences (NIMHANS), one of the largest mental institutions in India. (Sourced)
The National Mental Health Programme(NMHP), established by the Government of India in 1982, produced a mental healthcare delivery system utilising specialist and non-specialist workforce. This made India the first post-colonial ‘non-white’ independent country to carry mental health reforms. The NMHP was initiated to promote community mental health care through integration with Primary Care by training existing Primary Health Workers to diagnose and treat mental disorders..
While in some ways NMHP’s progress can be said to be significant, there are other factors which have led to its stunted growth. NMHP has been the guiding principle for the development of the mental health programme in India, its most important progress remains the development of models for the integration of mental health with primary healthcare. The Indian Council of Medical Research’s severe mental morbidity demonstration project examined the feasibility and effectiveness of this approach in four centres – Kolkata, Patiala, Baroda and Bangalore. However, it was found that only about 20% of people with mental disorders were being brought into care with such an integration. It was also observed that the population covered was very small in comparison to the national need. In 1984, the district model for mental health was started by NIMHANS in collaboration with the district administration and the director of health services, Karnataka. This mental health team that provided care for almost about 2 million people was an important model, because it showed the possibility for upscaling what was done at one primary health centre to over a dozen such centres. It also identified the practicability of a district mental health team initiating mental healthcare. The model with an extension of the District Mental Health Programme (DMHP) was implemented in 25 districts in 20 states between 1995 and 2000.
NIMHANS identified that their models which operated at Public Health Care level were too resource-intensive for small areas. They implemented a district-level initiative in Bellary district in Karnataka from the year 1985 to 1990. Alongside, the NMHP asked each state to operationalise a programme in at least one district in their State. The Bellary model was one of the very few operationalised and favourable programmes at that time. It was taken up by the government as a national model and has remained the model for primary mental care delivery since then.
The National Mental Health care Policy then focused on the hospitals. Between 1990-1996, the healthcare in India drifted from the 1982 pro-poor and comprehensive National Health Policy. The government started reducing the healthcare budgets of the States, which ultimately affected the mental health care. Thereon community mental health models started collapsing.
Only a small number of centres actually implemented the NMHP, and therefore the programme stagnated. NGOs were depended on more in order to address the gap in mental healthcare provision. They developed several innovative models, including rehabilitation and advocacy, using non-specialist health workers like social workers and users and bypassing government primary care centres. The most important activity that has occurred in the last 20 years is the rise of a wide variety of community care models especially from the voluntary sector. These included day care centres, half-way and long-stay homes, and also suicide prevention and school mental health programmes. This showed the need for alternative community care facilities, which would be used by the general public when they are provided in a user-friendly manner.
When NMHP was formulated, the number of psychiatrists was less than a 1,000 and in the last 20 years it has nearly tripled to 3,000. However, there is hardly any progress in the fields of clinical psychology, psychiatric social work and psychiatric nurses, who are very important to the team, but aren’t trained in adequate numbers.
From the year 1996 to 2002, Human rights violations in psychiatric and religious institutions were exposed by the media. For example : It was widely reported when 27 chained mentally ill patients were burned to death in an accidental fire in the Erwadi Dargah in 2001. The human rights movement had then criticized the terrible institutional care. This helped the District Mental Health Programme (DMHP), which was launched in 1996, to gain support for its strong advocacy for community care as a part of integration of tertiary, secondary and primary care.
Since the NMHP in the 9th Five Year Plan was focussed only on the District Mental Health Plan, the 10th plan re-strategized the NMHP to strengthen the state-level administration, mental institutions and medical colleges. The government increased its budget to about seven-fold, however these funds were subsequently under-spent. A large private mental health sector flourished because of continuing poor government provision from the year 2002 to 2007
In the last 20 years, the developments related to the legislations supporting mental health care, namely, the Narcotic Drugs and Psychotropic Substances (NDPS) Act 1985, the Mental Health Act 1987 and Persons with Disability Act 1995 changed the approach of the mental healthcare to one of promotion, prevention and rights approach. As Persons with Disability Act 1995 was launched, for the first time mental illness were included as one of the disabilities. Other developments included the recognition of human rights of the mentally ill by the NHRC. This led to a systematic, intensive and critical examination of the mental hospitals in India. An examination was held in 1999, which showed the inadequacy of the existing mental hospitals, especially in terms of services, as well as in upholding the human rights of the mentally ill. Another key development was the revision of the NHP 2002- almost till 1983, the NHP had not referred to mental health in any significant manner. The NHP 2002 clearly recognised mental health as a part of general health and specified how mental health had to definitely be included as a part of general health services and elaborated the importance of human rights of the mentally ill. The growth of the mass media in the last 20 years is another very significant factor. Television and radio stations are now available in many languages and all these address mental health issues through phone-in programmes, serials, features, panel discussions and audio participation programmes. It is gratifying to note that both professionals and non-professionals participate in discussing mental health issues through these media. The last significant development is the major contribution of professionals in mental health research. It was in 1980s when the ICMR, New Delhi, gave a big push to mental health research in India. This research has not only brought to light the importance of understanding mental disorders like schizophrenia in the cultural context, but has also shown the feasibility of developing models involving schools, primary healthcare, general practitioners and working with families. This has continuously supported the development of mental health programmes.
Barriers to reach the desired NMHP goals which were set out in 1982 were many. The first and foremost being the lack of funding. Though the NMHP came into being in 1982, the subsequent three Five Year Plans did not make adequate funding allocation. Further, even the funds allotted were not fully utilised. It was only in the Ninth Five Year Plan that a substantial amount of Rs 280 million was made available and in the Tenth Five Year Plan the amount was nearly Rs 1,900 million. Undergraduate training in psychiatry has not changed in spite of all the efforts in this direction, which continues to be a major barrier to have adequately trained medical doctors in psychiatry after their basic training. The inadequacy of human resources in mental health is an added problem. It is to be noted that most Indian districts do not have public sector psychiatrists. Some of the medical colleges do not even have departments of psychiatry, especially the government medical colleges. Not having enough facilities for training in clinical psychology, psychiatric social work and psychiatric nursing is a major limitation for other non-medical models and community-based programmes to take their roots beyond major cities. The community care models developed have not been adequately evaluated, especially the DMHP. Its implementation between 1995 and 2000 continues to be one of extension services by professionals rather than true integration of mental health with primary healthcare. It has been repeatedly pointed out that a manual is missing to guide the district mental health programme. The next major barrier is the uneven distribution of the resource across states and UTs. This uneven distribution limits the national level plan to be implemented in all the states and UTs. Though the National Mental Health Act 1987 was very progressive, its non-implementation was a major drawback. Specifically, the state mental health authorities have not functioned as they should have and the norms for licensing and maintaining standards of care were insufficient. The other drawback has been the privatisation of healthcare in the 1990s. It is to be noted that globally the amount of money available for healthcare has decreased. In addition to this, India has the least amount of public funding for healthcare, while more than 5% of its GDP is spent on health, out of which 83% comes from private, (mostly out-of-pocket expenditure) rather than from the public exchequer. This is a reverse pattern of public and private funding is similar in many developing countries. In countries such as Sri Lanka, public health expenditure is about 50% of the total health expenditure. (Sourced)
During the 11th Five Year Plan, the NMHP was renewed, following some adverse evaluations of the NMHP/DMHP. With a budget increase to 10 billion rupees (still only 2% of the public health expenditure in 2007), new elements were incorporated into the NMHP such as school and suicide prevention programmes. Also, training of general medical officers became a priority.
A Mental Health Care Bill was introduced in the Rajya Sabha on 19 August 2013, which included the right to access mental health care and treatment from services run or funded by the government. The bill also included the provision of essential psychotropic medications, insurance coverage; funding for private consultation in case a district mental health service is unavailable. The bill more or less emphasized the treatment and rehabilitation, and supported the rights and dignity of patients, including those from disadvantaged socioeconomic backgrounds.
It emphasised on establishment of central and state mental health authorities and establishments. It focused on establishment of a mental health review commissioning body for review and making of advance directives, which also advises the government. The Bill recommended decriminalization of suicide, focusing on ‘stress’ as the problem – not the individual, and banned Electroconvulsive therapy (ECT-can be used only with use of muscle relaxants and anaesthesia).
The next Mental Health Bill came out in the year 2016, which was drafted to not only address the inadequacies of the existing Mental Health Act, 1987, but also more because it felt 'necessary to align and harmonize the existing laws' with the principles of human rights as enunciated in the United Nations Convention on Persons with Disabilities (UNCRPD) to which India became a signatory since 1 October 2007.
The 2016 bill aimed to empower the right of mentally ill patients to choose or refuse certain treatments in advance, and to nominate their 'representatives' who can take decisions on their behalf when they are ill lacking the capacity to decide for themselves. However, the bill mentioned that when the patients are judged to have the capacity to understand the pros and cons of their choices, their wishes have to be respected even if they appear contrary to that of the doctor or what the family thinks is best for them. If they are 'supported' in their admission (meaning thereby detained in the hospital against their will for involuntary treatment), they were promised the right to challenge that decision in a prescribed manner. Finally, the bill assured the mentally ill patients the right to not to be prosecuted for making a suicide attempt any longer, with the presumption that any person attempting suicide was under severe stress and hence needed help instead of punishment. Along with these rights-based provisions, there are provisions mandating the government to help persons with mental illness with essential medicines and other facilities in the community, along with creating infrastructure and human resources to prevent, detect and treat mental illnesses.
Unfortunately, to solve these problems the MHCB borrows heavily from western concepts and Mental Health Acts of western countries, especially of the UK. There are several Acts, both in England and Scotland, which refer to detention of patients, capacity of patients to decide for or against a particular treatment intervention, and patient rights in general. The MHCB appears to combine all of these into one single power-packed document. In doing so, it has become quite of foreign origin with perhaps fantastic but unrealistic plans. For example, the MHCB 2016 is being implemented with the presumption that the bill will be applicable across the country irrespective of geographical, cultural and resource variations. Though MHCB relaxes some of the deadlines for the northeastern states, but still it does not seem to be enough. There are so many disparities that exist in rural and urban areas, in different states and in different terrains which definitely need to be addressed while planning a Mental Healthcare Bill.
The main problem with MHCB 2016 remains that western concepts have been incorporated without appropriate adjustments to the traditional Indian concepts of family, collectivistic society with its focus on 'mutual interdependence' as the driving value system rather than the western value of 'personal autonomy and independence'. Also, given the diversity of Indian population, the Act ignores how a ‘one side fits all’ approach is bound to miserably fail.
Also, it has been noted that many critics feel that the inclusion of General Hospital Psychiatric Units under the name of the Mental Health Establishment will defeat its purpose by discouraging general hospitals to have psychiatry units. This could push back psychiatry care extensively. Further there could be utter chaos if extensive paperwork for detention and tribunals are carried out in Psychiatric Units, given the heavy rush of patients. In India the system will collapse if such pressure mounts with hundreds of patients and inadequate infrastructure and resources. Infact, the desperation to complete the paperwork might foster less-than-ideal practices. It’s possible domino effect can cause more harm than help people with mental illness, thus further marginalizing and stigmatizing mental healthcare.
Mental health care coverage has been limited on both the specialist and the primary care fronts. There are 3600 psychiatrists in India for a population of 1.2 billion. Most are located in the private sector and in major cities. There is a 40–60 fold deficit in the number of clinical psychologists, social workers, and nurses. As for primary mental health care, still only 127 districts of the 626 districts in India have implemented the District Mental Health Programme, the district implementation of the NMHP which operationalizes mental healthcare integration into primary care. It has been found that within these districts not all primary care doctors are trained. (Sourced)
1.3.3 Identification and Review of Mental health care surveys undertaken by NIMHANs
Mental disorders can affect any individual, without a consideration of age, gender, residence and standards of living, and although some groups remain at a higher risk for certain illnesses; the impact gravely varies. Like, mental disorders among children, depression among pregnant mothers, and dementia among the elderly is well known. Mental problems are of a chronic nature, which result in a lifelong impact. It is very important to understand that the Indian society regards mental disorders as associated with a considerable amount of stigma, leading to neglect and marginalization. These affected individuals and their families face a number of challenges in daily life. In India, important social determinants of health like employment and education, living standards, environment, access and equity and few others contribute significantly to both the causation and recovery from mental illnesses. Poverty, low living standards and related factors are implicated in the increased occurrence. They also lead to the cycle of poverty and impoverishment. India was one of the first countries to have taken a vow to promote the mental health of its people. It was achieved with the initiation of its National Mental Health Programme in the early 1980s. However, mental health has often been given a lesser priority amidst other health and social priorities given the stringent stigmatisation of the disease. Hence, the progress remains far from satisfactory. A successful mental health system needs to definitely be responsible of reducing the substantial burden of untreated mental disorders, increase in human rights violations, ensure social protection and thereby aim to increase quality of life. Thinking beyond just providing care, it should also integrate and include mental health awareness and rehabilitation prospects.
Persons with mental disorders are widely associated with a range of social and societal problems if their illness isn’t recognized or managed appropriately. Well-planned mental health systems have immense scope for better delivery of services, positive outcomes and improved human rights for people suffering from mental disorders.
Nevertheless, reports state that mental health initiatives in India are growing, both in quantity and quality, even though at a slow pace. In India, a systems approach to mental health becomes crucial not only to increase the awareness of mental health, but also because of its impact on the nation’s commitment to implement Mental Health Action plans and to achieve Sustainable Development Goals ahead. Reports suggest evidence of higher prevalence of mental morbidity in Indian urban cities. The prevalence in urban metros was higher in urban cities as compared to rural and urban non-metro areas which have a population of less than 10 million people. However, differences exist across various diagnostic categories.
Reports suggest that The prevalence of schizophrenia and other psychoses (0.64%), mood disorders (5.6%) and neurotic or stress related disorders (6.93%) was nearly 2-3 times more in urban metros. The contribution of various factors such as paced lifestyle, stress, breakdown of support systems, economic instability add more to such prevalence.
With increasing urbanisation, the burden of mental illnesses is expected to rise and hence, there is a need for an urban specific mental health programme.
While the causes, risk factors and protective factors vary in urban and rural populations, availability, accessibility and affordability of mental health services as well as awareness are major drivers of service utilisation. Therefore, the need for coverage of mental health illnesses and services across India on an equitable basis is of utmost importance.
(Sourced) Many news reports suggest that Depression was higher in females, in the age-group of 40-49 years and among those residing in urban metros. Equally high rates of Depression were reported among the elderly (3.5%). The prevalence of tobacco use disorder (moderate and high dependence) and alcohol use disorder (dependence and harmful use / alcohol abuse) was 20.9% and 4.6%, respectively. The prevalence of alcohol use disorders in males was 9% as against 0.5% in females. Nearly 1% of the population reported high suicidal risk. The prevalence of higher suicide risk was more in the age group of 40-49 years (1.19%), among females (1.14%) and in those residing in urban metros (1.71%). Nearly 1.9% of the population were affected with severe mental disorders in their lifetime and 0.8% were identified to be currently affected with a severe mental disorder. Severe mental disorders such as schizophrenia, other non-affective psychoses and bipolar affective disorder were detected more among males and in those residing in urban metro areas. The current prevalence of severe mental disorders in most states was less than 1%, except in Manipur and West Bengal. Although prevalence of severe mental disorders is quite low in comparison to common mental disorders, severe mental disorders are considered to be equally important. Their manifestation, outcome and impact are drastically different from Common Mental Disorders. Furthermore, there is a significant stigma associated with these disorders as they affect all domains of life and require long term rehabilitation services. Significant gender differences exist with different mental disorders.
(Sourced) It has been noted that the overall prevalence of mental morbidity was higher among males (13.9%) than among females (7.5%). However, specific mental disorders like mood disorders (depression, neurotic disorders, phobic anxiety disorders, agarophobia, generalised anxiety disorders and obsessive compulsive disorders were higher in females. Only a small number of female alcohol users were identified as dependent users. These gender differences have been reported in earlier studies as well. Prevalence of mental disorders in the age group of 13-17 years was 7.3% and was almost equal in both genders. Reports suggest that nearly 9.8 million of young Indians aged between 13-17 years are found to be in need of active interventions. Prevalence of mental disorders was nearly twice in urban metros at 13.5% as compared to rural areas which was 6.9% . The most common prevalent problems were found to be Recurrent Depressive Disorder (2.6%), Agoraphobia (2.3%), Intellectual Disability (1.7%), Autism Spectrum Disorder (1.6%), Phobic anxiety disorder (1.3%) and Psychotic disorder (1.3%).
A study was conducted in the state of Himachal Pradesh among the age groups of 15 – 24 years. It revealed that some adolescents suffered from a wide range of mental health conditions such as depression (6.9%), anxiety (15.5%), tobacco (7.6%), alcohol (7.2%), suicidal ideation (5.5%). This interferes in their growth and development, education and everyday social interactions. Their vulnerability becomes greater due to several factors within and outside home. However, only early recognition and intervention can help in realising favorable outcomes as soon as possible. Neurosis and stress related disorders affected 3.5% of the population and was reported to be nearly twice as much in females as males. The report found that stress related disorders were quite commonly found in primary care settings where they are mostly misdiagnosed or not identified.
The study also revealed that a huge treatment gap for all types of mental health problems: ranging from 28% to 83% for mental disorders and 86% for alcohol related disorders. Except epilepsy, all the other mental disorders reported a treatment gap of more than 60% with the highest treatment gap being for alcohol use disorders.
The proportion of disability proportion was found to be relatively higher among individuals with bipolar affective disorders (63 – 59%), major depressive disorder (67%-70.0%) and psychotic disorders (53-59%).Persons with severe mental disorders reported disability, it was worth noting that a significantly large proportion of people with common mental disorders also reported suffering high levels of disability. Nearly 50% of those with major depressive disorders had difficulties in carrying out their daily activities. At any quarter of the year, family members of affected individuals had missed about 10-20 working days to take care of mentally ill persons. The report noted that disability and its disadvantage is thus not only limited to persons affected but also gravely affects the family members and caregivers. Assessment of mental illnesses and the rehabilitation of an individual to reduce the disability forms a crucial point of immediately required action.
A couple of previous surveys have recorded the extensive limited number of mental health professionals in the country, which stands at about 10,000 professionals of all categories for one billion population. These surveys have also noted the extremely limited mental health service infrastructure, which stands at about 30,000 psychiatric beds for over a billion population. Media reports mention that the limited investment in health by the government is only about 17% of the total health expenditure. However, the problems of poverty, which stands at about 30% of population live below poverty line along with low literacy and stigma for persons with mental disorders is a rising concern.
An Al Jazeera report quotes that of half a billion people worldwide currently suffering from mental illness, three quarters live in the developing world. India spends less than 1 percent of its medical budget on mental healthcare.Providing mental health in India’s cities has its own set of challenges, it is a concern that the Indian government still spends less than 1 percent of the national health budget on mental illness. The report mentions that there are fewer than 5,000 psychiatrists to care for a population of 1.2 billion. Pragya Lodha of Minds Foundation mentions of the loopholes even in the latest Mental Healthcare Bill of 2016. “Loopholes are several with regard to the Mental Health Care Act. On one hand the bill has aided growth in the definitions, rights and provisions for people with mental ailments, on the other hand, it has failed to proportionately do justice to the care department, which largely affects the quality of treatment of the people with mental illnesses. Some of the loopholes- no definition of intellectual disability which is a part of mental health issues, competence of professionals has not received attention (defining counselling psychologists), redundant concept of advance directives, insufficiency of the mental health review board,” she tells. MINDS was launched in August 2010 and first registered in the USA, where it started programs on-the-ground in December 2010. It was registered as a society NGO in India since March 2012. The NGO is focused on tackling mental health issues in a rural setting in India. “We bring key stakeholders from the community into the design and implementation of programs. Our programs are all evidence-based due to our strength in academic partnerships and research which has been widely published in international academic medical journals. We train community members to empower them to become mental health advocates and run our programs on their own. We provide continuing education for community mental health workers.
The approach of involving community members to effectively contribute to mental healthcare is now being followed in India. Dr Vikram Patel’s (considered one of the world’s foremost experts on global mental health) VISHRAM programme is an example where he was working on Vidharba’s stressed farmers. The programme works with locals to increase awareness of mental illness and provide a form of psychological first aid to rural communities. In a previous media report, Patel says that the government has a wrong approach – the need to focus on the causes of mental health suicides. He thinks it’s absurd for the government to give money to farmers families who’ve killed themselves. “Doesn’t this act as a bait?” he questions. While the discourse around farmer suicides in India has focused predominantly on economic and social issues, Dr Vikram Patel,, says the strategy to combat those suicides must include mental healthcare. In the absence of such provision by the Indian government, Dr Patel and his team had launched a pilot mental health programme in a handful of local villages, relying on community-based mental health interventions to stem the tide of suicides.
Urban challenges
Given the limited spending of the government, most people in need of care don't get any help. A local NGO called Bapu Trust has delegated community members who form a support network to help in reduction of suffering of those suffering from mental illnesses.
A recent report from Human Rights Watch documented widespread abuse in some of local mental health hospitals, where "women and girls constantly pulled lice from their hair", faced unsanitary conditions, neglect and abuse.
Dr Bhargavi Davar, founder of the Bapu Trust, was inspired to take action after seeing her own mother suffering in one such institution. A previous media report quoted that Dr Davar’s organisation was treating about 200 patients at a cost of $100 per patient per year; a small fraction of the cost to treat them in hospitals and clinics.
Bapu Trust outreach workers hold community meetings and recruit local people and counsel those living with mental illness, right from depression through to psychosis. Bapu provides anone in need with basic counselling, arts-based therapies and psychosocial interventions. The organisation like many other similar programmes, relies heavily on private donations and grants to keep it afloat.
Women are differently affected by mental health concerns as the number of such diseases rise in the country. Dr. Rangaswamy Thara of Tamil Nadu based SCARF Fondation tells that women and mental health is a big issue because of many reasons. Some of the main ones comprise of delayed treatment, underdiagnosis, stigma of mental illnesses is greater among women, burden of caregiving falls on women and majorly there are biological life events such as menarche, menopause, lactation etc which play a critical role in mental health.
“Many women seek help later than men do. The family and social pressures seem to make things worse for them. The stigma is also more,” suggests Thara.
Elaborating on this, Praga Lodha of MINDS tells that Mental illnesses affect men and women equally but differently. “For some disorders, like depression, psychosomatic illnesses and anxiety- women may be more prone to suffer. This is attributed to psychological-sociological and psychological factors. Conditions like epilepsy and substance abuse are seen more than depression and anxiety in rural parts of Gujarat- the prevalence has been reported more in men than women. Though the mental health problems prevail in both- men and women- the severity, presentation and prevalence rate differ (in any mental health problem for that matter)”.
Dr Tara Beattie , Assistant Professor in Social Epidemiology, Department of Global Health and Development, London School of Hygiene and Tropical Medicine has concentrated her fieldwork on the young adolescent girls in two districts of Karnataka, which are heavily impacted by the Devadasi system, hence prevalence of selling sex for work. Most of these girls are from the backward sections : SC/ST. The prevalence of HIV is higher among adults of the population. If the girls do not enter sex work, Tara tells that they are forced into child marriage.
She brings out an interesting point saying that even though much research is concentrated on other things, the mental health of these girls/women often remains neglected. Also, according to her very less global literature is available on the impact of child marriage on mental health.
Tara tells that since they are married early, there are high rates of school dropouts. This leads to a form of social isolation, and further mental health disorders.
Most of these mental health disorders relate to
Depression
Suicidal thoughts
Anxiety
“I feel we are seeing huge changes in India in terms of education and child marriages as well. The Beti Padhao Beti Bacahao Yojna, has been able to bring changes”.
Tara mentions about epidemic of silence. “This refers to a point where the feelings were so internalised that whenever you would talk to them in terms of depression, they’d ensure nothing is wrong by not talking about it. In fact the rate of suicide among girls is high in India and is now known as unseen epidemic.
She mentions that while there are huge gaps in India in terms of need and provisions, there is also fairly less amount of research available on mental health concerns. She mentions how interventions need : a) what drives mental health concerns?
b) how public health is addressed.
But she questions the lack of autonomy,
“There is a solid need to use interventions to support women and girls specially once they’re suffering from some kind of mental illness, which majorly accounts for depression and anxiety. But who looks after their autonomy to access a health service? Do they have to seek permission from parents, from spouse? Are they dependent on the consent of others to use a service which is crucial for their life? In India if services like these exist, are they even confidential? Will she be able to physically reach there? Will she have to sneak out of her house or probably bunk school? How can we really remove these barriers?
Also, how will she be able to access control as a minor?
Tara has also agrees to higher rate of mental health concerns among people selling sex for work. “These women have to face a huge amount of regular violence. It could be from their clients, police, landlords, community workers, men external to their lives – all of which depends where they are selling.
To tackle the issues of lack of Mental Health awareness, White Swan Foundation is a dedicated organisation providing an online platform especially to young urban minds on the prevalence of mental health diseases.Manoj Chandran of White Swan Foundation tells us that the organisation started its work understanding the importance of right knowledge on mental illnesses, so that effective decisions can be taken. “Since there is no formal knowledge culture on Mental Health, on what basis can decisions be based?,” asks Manoj. The Foundation focuses on developing awareness among the youth on mental illnesses – so that they can have an access to a platform where they unlearn and relearn”.
Manoj talks about the concerns of mental health issues among women. “Gender with itself creates unique issues. While the manifestation of the situations might be typical, when and why it may occur can be unique.”
Mental health issues among women are also driven by the biological functioning of the body. “Women face risk of mental illnesses at different phases of their lives. For example, maternal mental health is a subject in much discussion nowadays. Women face likelihood of depression during pregnancy or post pregnancy. Because of unawareness of this not only the immediate family can become unsupportive but also the workplace environment for working mothers can become very tough”.
He also mentions prenatal and perinatal mental illnesses among women. “We’ve also realised through our work that women play a much larger role in making decisions on mental illnesses. Therefore it is very necessary to make the women empowered to take these decisions for the rest of the family.