CB BureauWith a population that is slowly becoming aware of the importance of physical health (blame it on the air pollution), there’s another aspect of a person’s overall health that hasn’t received the same attention in India. Mental health is as important as physical health and in many ways, even more critical for a person’s well-being. After all, even the most physically fit person can struggle with mental-health issues. Unfortunately, in this country, mental health is something that’s swept under the rug, much like sex or child abuse.
Some facts about mental health
The World Health Organization (WHO) defines mental health as ‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.’ In the same definition, the ‘positive dimension’ of health is stressed upon – ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ Essentially, mental health is about one’s well-being, not illness, marked by presence and not absence.
The widespread stigma against people with mental disorders – who are dehumanised as unintelligent, incapable, and difficult – and misconceptions regarding the cause, treatment and prevalence of such health issues prevent people from seeking or providing help, affecting existing discourse around mental health. For instance, around 20 per cent children and adolescents around the world have mental problems and about 800,000 people commit suicide every year, with 75 per cent occurring in low- and middle-income countries.
Mental health is shaped and influenced by a range of socioeconomic, biological and environmental factors. Poverty, violence and deprivation are strongly correlated with mental disorders. For example, sexual violence severely affects mental health. It is also related to factors such as work conditions, gender discrimination, social exclusion, and unhealthy lifestyle. Industrial workers are more predisposed to mental issues than the general population. In 2002, one study found the rate of mental disorders among them to be 14 to 37 per cent.
However, prevalent ideas about mental health paint a sordid picture wherein a person suffering from mental problems is seen in isolation and their disorder is perceived as something that is just ‘there’, that somehow it’s a part of their intrinsic nature or their personal failures, rather than a consequence of factors that are beyond their control.
The Live Love Laugh Foundation (TLLLF) conducted a survey, How India Perceives Mental Health, in 2018. The study had 3,556 participants from eight cities in the country. Of the respondents who showed awareness about mental illness (87 per cent), around 71 per cent displayed stigma towards it through ableist terms (cr*zy, ret*rded, etc). As many as 40 per cent of respondents felt that it was frightening to have people with mental illness in their neighbourhoods, while 57 per cent were of the opinion that no one had the right to exclude them. Almost 68 per cent also stated that people with mental disorders should not be given any responsibility.
State of mental health in India
In India, the percentage of population with depressive disorders is 4.5 as per a 2015 WHO study. Another study by WHO, conducted for the NCMH (National Care for Medical Health), points out that at least 6.5 per cent of the population suffers from some form of mental disorder and over 5 crore are depressed. The suicide rate in India in 2015 was 15.7 per 100,000 people, which is higher than the regional average of 12.9 and the global average of 10.6. Of extreme concern is the fact that almost 80 per cent people diagnosed with mental problems do not seek or have access to any treatment. Just about 1″2 per cent of India’s health budget is directed towards mental health compared to 10″12 per cent in other countries.
A 2015″16 survey by NIMHANS (National Institute of Mental Health and Neuro Sciences) in partnership with the ministry of health and family welfare found that the prevalence of mental-health morbidity was 10.6 per cent. Those with lower income had a greater prevalence of one or more mental disorders, while the risk of suicide was observed to be highest in the 40″49 years age group, it being greater amongst females and those from urban metros.
While the National Mental Health Program envisioned a District Mental Health Program for each of India’s 630 districts by 2025, only 27 per cent of districts were covered till 2015. And even the existing ones have been plagued by funding, governance, training and staff issues. As per WHO, between 2012 and 2030, the economic loss in India due to mental-health conditions is 1.03 trillions of 2010 dollars. Mental-health workforce in India (per 100,000 population) include psychiatrists (0.3), nurses (0.12), psychologists (0.07) and social workers (0.07). The numbers speak for themselves.
Mental-health organisations
While there’s much cause for concern about the state of mental health in this country, let’s look at a few organisations working to correct some of these wrongs.
The Minds Foundation
Focusing on delivering mental healthcare in rural areas, Minds Foundation believes in a grassroots approach and community engagement. Service delivery of healthcare is free and is done through local clinics, with the Foundation’s team providing initial counselling and helping patients get proper care, including linking them with government schemes. Community members and CMHWs (community mental-health workers) are trained by the Foundation. There are intermittent follow-up sessions and mental-health camps.
To educate communities on mental health, evidence-based workshops are organised in rural villages, in collaboration with CMHWs and local village leaders. Workshops can take the form of discussions, Q&As, visual aids, street plays, interaction with mental-health professionals, and video documentaries.
The organisation consults key stakeholders from the community while designing and implementing the programmes, which are based upon research and data collection including needs assessment. They also claim to continuously monitor and evaluate their programmes. Research is another key focus area where they have several academic partnerships, and many research papers have been published internationally. Between 2014 and 2017, they completed 12 academic research projects.
To date, Minds Foundation has educated over 35,000 rural citizens in 84 villages, 19,500 students, and 1,150 teachers on mental health; directly screened 15,500 people; and provided direct treatment to 580 beneficiaries. They have so far trained over 60 CMHWs. The Foundation currently operates in Gujarat, Mumbai and Delhi.
Samadhan
Founded in 1981, Samadhan focuses on children with intellectual disability (autism, cerebral palsy, Down syndrome, learning disabilities, etc.), from poor and marginalised backgrounds in Delhi. They work with communities that fall in the low socioeconomic category. Community outreach takes the form of raising awareness on intellectual disability, advocacy in local mainstream schools, therapy, special education, and early intervention. They currently have two centres, in Dakshinpuri and Dwarka.
The organisation’s outreach programmes are awareness sessions through puppet shows, street plays, slides, talks and informal discussions, health camps, and training of trainers. Rehabilitation services include bringing children with intellectual disability to rehabilitation clinics by trained community workers for assessment and screening by health professionals. Depending on the assessment, therapy and specific interventions are identified. When possible they are admitted into the organisation’s own services or referred to other agencies.
Early intervention is provided to children in the 0″6 age group through paediatric clinical programme, special education, home-intervention programme, and specific therapy sessions. Other programmes are capacity building of local women and mothers of identified children, drama therapy, collaboration with local MCD schools, and an online facility offering information on issues related to intellectual disability (called the Communication Network on Disability).
As per the 2017″18 annual report, the numbers of new beneficiaries (children) enrolled in early intervention and special education were 17 and 16 respectively. Both numbers were an improvement over the preceding years.
The Live Love Laugh Foundation (TLLLF)
A relatively new organisation, they focus on stress, anxiety and depression. TLLLF’s mission is to reduce stigma and spread awareness on mental health. The platform provides information and helps people connect with professionals.
The organisation’s objectives are to implement school programmes that educate young students, train general practitioners, create a national database of mental-health professionals, and develop helplines. As part of the flagship school programme, You Are Not Alone, they have covered 84,949 students and 13,145 teachers across 427 schools.
They have also partnered with The Association of People with Disability (APD) to provide psychiatric treatment to people with mental illness through treatment camps and surveys. This is an effort to aid the Karnataka government’s District Mental Health Programme. The initiative covered more than 800 patients across 4 taluks in 2017. TLLLF has also collaborated with NIMHANS.
On awareness, they conducted what is termed as India’s first-ever nationwide public awareness campaign on depression, Dobara Poocho. While there seems to be an uptick in press and social-media coverage post the campaign, it is not clear if there’s actual impact on its target population. A separate study will have to be conducted to assess that.
Banyan
Established in 1993, Banyan enables access to mental healthcare for those living in poverty, through clinical and social care approaches that are designed to be replicable and sustainable. They provide emergency care and recovery services (ECRS) as well as a reintegration and aftercare programme to help beneficiaries move back and settle into their homes. Those who are unable to do so are provided inclusive living options, ranging from cottage-styled supportive living accommodation called Clustered Group Homes to a model of care in a homelike environment which are shared spaces, providing housing to about 250 individuals in 45 homes across 3 states. Some choose independent living as well.
The NALAM project is a multi-interventional, community mental-health programme that focuses on the wellness side of mental health. NALAM clinics work alongside other governmental organisations such as the Department of Health and panchayats as well as NGOs. For example, NALAM Urban operates in low-income areas in Chennai, offering clinical and social care through outpatient clinics and mobilisers, while NALAM Rural offers services in outreach clinics that are co-located in government spaces. NALAM mobilisers are trained to help community members with counselling and facilitate access to their rights and entitlements. The NALAM approach will soon be replicated in collaboration with the Tamil Nadu government to strengthen the existing District Mental Health Programme (DMHP). Until 2016″17, NALAM was operating out of 11 clinic locations, servicing 9 urban wards and 91 rural panchayats, and benefiting 10,000 people since inception.
The organisation also offers skill development and work placement options including small- and medium-scale grants and linkages to external employment agencies. They currently operate through 16 centres and clinics in Tamil Nadu, Kerala and Maharashtra, and claim to have reached a population of over 100,000. Apparently, 1,950 homeless people with mental disorders have accessed their ECRS until 2016″17.
The yawning awareness gap
While many organisations working on the issue of mental health have tie-ups, linkages and partnerships with various government agencies, corporates and other non-profits, these mostly take the form of donations or collaborations on specific projects. There are fewer partnerships on awareness-raising campaigns on this ubiquitous issue.
Awareness about mental health and its treatment is extremely important because, as mentioned earlier, existing attitudes towards such disorders are extremely discriminatory and predicated on harmful stereotypes and dangerous misconceptions. And such problematic behaviour towards those suffering from mental illness is not limited to rural areas.
As stated here, mental-health awareness needs a multipronged approach utilising conventional media, social media and internet, government programmes, industry, educational system, and crowd-sourcing (through communities).
Some of the existing awareness campaigns are directed at young students, such as You Are Not Alone by TLLLF and Semicolon (;) by Medical Students’ Association India. Then there are websites that disseminate information and provide a safe space for young people to talk about mental health, such as Public Health Foundation of India’s (PHFI) portal called www.itsoktotalk.in.
A few are harnessing the power of social media platforms such as TLLLF’s partnership with Facebook and PHFI’s youth-focused ‘It’s Ok To Talk’ campaign with Instagram. Others like SCARF (Schizophrenia Research Foundation) organise awareness programmes in rural areas using indigenous modes of communication. Video films and audio-visual materials along with old-school pamphlets are also used.
Mpower, an organisation under Aditya Birla Education Trust and that works on mental health, claimed in 2018 that it had impacted 17 million people through awareness sessions and therapy in the previous three years. Its three main programmes are: The Movement, which spreads awareness through events and digital campaigns; The Centre, which offers diagnostics, counselling and treatment for psychological and psychiatric problems; and The Foundation, which provides the same services as The Centre at a subsidised cost to people from economically backward sections.
It is understandable why most NGOs in this field don’t have sustained campaigns on mental-health awareness; such projects are costly and time-consuming. And helping people with mental disorders is in itself a costly and time-consuming process. However, there is no reason why the internet and especially social media cannot be used as a cheap but effective medium to spread useful information and provide a platform for people to come together on this important issue. Merely having a semi-active presence isn’t enough; with some good content, smart promotion, and innovative engagement methods, one can influence enough people to make a tangible difference and even save lives.
Corporates can easily step in and make mental-health awareness a focal part of their CSR, not just in terms of funding but also implementation. After all, there are plenty of causes, including healthcare, for which they routinely run awareness programmes. Minds Foundation has identified long-term, regular, and sustainable partnerships with donors and interested organisations as one of the challenges that they often face. Clearly, there is a huge divide between potential delivery and available resources.
Starting with the low-hanging fruits that are their own employees and the communities around their operational areas, they can partner with several organisations working in this domain to educate people on this extremely critical health issue. Their reach, manpower, and deep CSR pockets can bridge the gap between intention and implementation for many NGOs. However, care must be taken that such initiatives do not get relegated to an annual phenomenon that mysteriously crops up only during World Mental Health Day or some such.
Some thoughts
Mental health in India is still seen as a taboo, something that happens to ‘weak’, ‘unintelligent’ people. Though the private sector and NGOs have much to offer, the government needs to take the lead and give it the priority that it deserves. Most of the state- and centre-sponsored programmes are woefully short of funding and attention – that has to change if we are to truly help the millions of Indians suffering from such illnesses and the millions more who will, at some point in their lives, experience such debilitation. If the government can almost eradicate polio and come up with innovative campaigns for diseases such as AIDS, there’s no reason why it cannot do so for mental health, which affects not only individuals and communities but also the nation’s progress and productivity. As per WHO, to increase the availability of mental-health services, key barriers need to be addressed: absence of mental health from the public health agenda and the implications for funding, current organisation of mental-health services, lack of integration within primary care, inadequate human resources for mental health, and lack of public mental-health leadership. Suffice it to say, India is a classic case of all five problems happily co-existing without any concerted attempt to mitigate them.
As pointed out by Minds Foundation (the only organisation to respond to CB’s questions), better awareness efforts from the government, aided by a well-informed mental-health policy, and higher budget allocation (currently 0.06 per cent of the total health budget) are imperative to improving the conditions of those suffering from mental-health problems. Resources also need to be diverted towards this issue. For instance, in rural India, lack of resources and infrastructure is a serious impediment in raising awareness.
Mental health is a global and national issue, whether one admits it or not. It can happen to anyone and for those without the privileges of class, location and identity, accessing appropriate care and remedies is often not a viable option. It is time that we recognise and address the quiet sufferings of the millions of our fellow Indians. The blueprint already exists – it’s now a matter of will and implementation.