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is not normal to stare at the walls at night and wish the sun never rises again; to seethe with a sense of worthlessness at the slightest jilt from the one you love, or to believe that you will be better valued dead. However, these and other such psychologically overwhelming feelings are increasingly homing in on vast sections of our people, threatening to bring them psycho-social harm, and daring the public health system to halt, if it can, the march of an advancing mental health epidemic.
Preliminary data from a recent multicentre study on India’s mental health scenario paints a dark picture. It shows 9.6 per cent prevalence of mental disorders. It states that at any given point of time, India has nearly 15 million people suffering from serious psychiatric illnesses and another 30 to 50 million experiencing mild to moderate psychiatric problems.
Over 35 per cent of people seeing general practitioners in the country report some kind of psycho-social condition that demands urgent attention but gets missed to an ill-equipped system which is as misdirected, when it comes to mental health, as it is underfed. With the result, mental illness has come to account for 43 per cent of the disability in the developing world, particularly India which has miserably failed to address or even de-stigmatise the sector.
A recent WHO study of mental illness burden on health and productivity revealed that such disorders, including depression-induced suicides, ranked second (after all cardiovascular conditions put together), accounting for 15 per cent of the burden of disease even in established economies like the US. This is more than the burden of all cancers put together.
India, with its population of over one billion, figures prominently among the nations most vulnerable to mental health burden, given its insufficient infrastructure and mental health professionals. India has one bed per 40,000 mentally ill and three psychiatrists for a million people.
Top this up with a mental health programme with no budget of its own. Mental health, despite its hazards, remains part of general health services in India, never quite managing its due, considering health itself pockets barely 1 per cent of the GDP as budget.
What the country does have in the name of a mental health policy is the National Mental Health Programme (NMHP) running since 1982 and confined still to 123 districts. Expansion of the programme has been poor as the outcome, with NMHP not even having any inbuilt evaluation mechanism or space for research and community participation.
It was recently revised to address the issue of rising morbidity due to mental disorders but remains to be approved by the Planning Commission which insisted upon knowing previous outcomes before clearing the Health Ministry’s Rs 433-crore demand for extending the programme to an additional 325 districts. Strangely, the approving body once asked the Health Ministry to locate its projects only in “districts with actual burden”, not realising the extent of spread of the epidemic, which affects the rural and urban equally.
Talk about coping mechanisms and there seem none. While the US, the UK and other developed nations have psychiatry as a separate discipline under medical education, India has the stream tagged along with medicine. Enquiries reveal that of the 142-week MBBS course a student undergoes at a medical college, he/she is taught psychiatry for just two weeks, which makes 20 hours of lecture!
“For one-third of mentally disturbed patients (0.33 per cent) a medical graduate sees on an average, he just has 1/71 (0.14 per cent) exposure to the relevant discipline. This is a gross discrepancy. The need of the hour is to strengthen psychiatry education at the MBBS level and train medical graduates to identify and treat mental conditions.
“We have proposed these changes to the Health Ministry. But we also need students to take up psychiatry, which comes with its challenges of attitudes and stigma,” says Dr Rajesh Sagar, Associate Professor of Psychiatry at AIIMS and Secretary to the Central Mental Health Authority, notified in 1993 after the Mental Health Act came into force.
It is another matter that this Authority never had any office in the Capital and is still clamouring for one. It barely gets to meet every six months, as mandated by the law. It last met on August 13 this year, one and a half years after the previous meeting. Virtually defunct itself, the Authority can hardly exercise powers over the states, majority of whom have not set up state mental health authorities to steer programmes in the sector.
However, as a psychiatrist, Dr Sagar does every bit he can to help people over the hump. He is among the few experts who did not leave for the UK. Emphasising the need for enhanced focus on psychiatry at the MBBS level, the expert says, “Only one per cent of all mentally ill require in-house treatment at a psychiatric facility. The rest can be managed with adequate and timely access to care.”
However, care remains elusive and the sector stigmatised, with society still mentioning mental health issues in whispers. Currently, India has about 3,000 psychiatrists, all in urban areas. Rural heartlands are in complete neglect even when epidemiological surveys have shown the prevalence of mental morbidity in both urban and rural areas. In villages, magico-religious healing is still the norm, with tantriks running riot and playing havoc with the dignity of the ailing.
Yet budgets for IEC (information, education and communication) in mental health remain poor. All attempts on the part of the Health Ministry to muster enhanced outlays for awareness generation in the sector have gone in vain. A proposal of Rs 100 crore sent last year for the approval of the Finance Ministry and the Planning Commission came back with a note to reduce the budget by half!
If that was less, the UPA government’s flagship National Rural Health Mission, with massive allocations in its kitty, makes no mention at all of psycho-social disorders. “We are still concentrating on communicable disease burden under the NRHM, not the non-communicable burden,” says Union Health Secretary Naresh Dayal.
Contrarily, the logic extended for linking mental health with general health services in the country is its “near-equal prevalence” in rural and urban India. In reality, however, there is no linkage. Ground reports suggest that psychiatric social workers deployed in rural areas are being forced now to train villagers to administer medicines to the mentally ill.
“There is no option. People come to us by the hordes. We prescribe them medicines but there is no one to administer. We need to train people or else the patient will relapse, bringing our efforts to a naught,” says a ground worker.
There is in fact a rising clamour in the community to abandon overemphasis on psychiatrists and promote alternative service models that are community-based and integrated into social and healthcare networks. The Mental Health Act is severely limiting as it mandates all in-house facilities for mentally ill to either have a psychiatrist in-charge or as an associate.
This remains impossible given the dearth of psychiatrists in India (the gap is 74 per cent). A case in point is Arunachal Pradesh which, in 2006, sought the Supreme Court’s permission to set up a mental health facility in the state. The facility hasn’t come up because there is no psychiatrist available.
“All we are seeking is a shift from the policy of unnecessary dependence on psychiatrists for everything. A lot of the mentally ill can be treated through timely counselling and support. We need a new mental health programme which recognises the need for trauma counsellors, rehabilitation professionals, caregivers and people trained in basic mental healthcare delivery. It’s time we understood that mental health is not a property of the Health Ministry. We must empower the community to handle the rising burden of disease on account of mental disorders. We must also ask ourselves why Erwadi happened in the first place?” questions Roma Bhagat, the lawyer who recently got the Medical Council of India to increase 125 seats in PG psychiatry for the first time in 47 years.
At Erwadi in Tamil Nadu, where 28 chained mentally retarded people charred to death in August 2001, the saga of pain continues. Enquiries conducted post August 2001 revealed that relatives of those who had died in the fire at a private mental facility had come there only as the last resort.
Some had changed eight residences and had been tired of neighbours’ complaints; some faced a choice between caring for the ward and making a living; some just could not cope with the back-breaking responsibility of care-giving.
“Had there been any form of institutional support, why would people leave their wards anywhere like that? In the developed world, the mentally ill are trained by government facilities to identify factors that trigger their condition, to accomplish basic tasks like making phone calls or reaching out for help. Here, we brush everything under the carpet and pretend everything is fine. But the reality is different. Erwadi still has its share of mentally ill. Only they are no longer sheltered and fed,” says Bhagat, citing mental healthcare delivery as the single largest challenge before the government.
However, that won’t come easy, with India still managing with just 36 government mental hospitals, their average age being 84.7 years; the oldest in Chennai is 204 years old. About living conditions in these places, the less said the better. A National Human Rights Commission survey on their quality concluded, “These are not hospitals. These are dumping grounds where relatives leave their wards to die.”
Some time back, a mentally retarded boy, on the verge of death, had to be pulled out of the Amritsar mental hospital. In two months of his stay there, he had lost 15 kg. That’s not all. The Gwalior hospital was found to be keeping the mentally ill in nakedness. The alibi? The inmates tear at their clothes. Recently, Ranchi’s Central Institute of Psychiatry, one of the better managed mental hospitals in India , published a list of 98 inmates who were fit to return home but had no home to go to.
Their relatives abandoned them for good while the government never cared to strengthen halfway homes that need to be linked to every mental hospital as per existing laws. But the issue is stuck between two Union ministries – whereas the Health Ministry is supposed to treat the mentally disabled, the Social Justice Ministry is supposed to ensure their rehabilitation. The two have been unable to resolve the matter, while thousands of treated patients wait for a chance to get some place where they can be identified as “normal”.
Those that do have homes endure other kinds of problems. A fortnight ago, the mentally-ill brother of a once-successful woman executive (she left her job to care for her brother) in Delhi tried to strangulate her. Nowhere to go, the woman struggled to let go of her brother, who gets manic strength every time he is in a fit.
“I got no help,” she says, baring the rot in the system. Shockingly, India does not have a single ambulance to take care of a psychiatric emergency. When caregivers call for one, ambulances hardly turn up. Even if they do, they never have the paramedical staff trained to handle the mentally ill.
As for psychiatrists, currently India has 211 recognised medical colleges offering PG courses. Of these, only 101 are offering PG in psychiatry. Recently, the MCI agreed to add 125 seats by relaxing teaching norms which earlier required a unit of three — professor, assistant professor and lecturer — to coach two PG and one diploma student in psychiatry. Now on, one such unit can teach three PG psychiatry students and four if the college has no diploma course on offer.
However, activists term the gesture as tokenism, shown to escape the larger question of manpower shortage in a sector that’s also impacting children now. WHO’s reports on global disease burden indicate that by 2020, childhood neuropsychiatric disorders will rise by 50 per cent, internationally, to become one of the five most common causes of morbidity, mortality and disability among children.
One-fifth of teenagers will suffer from developmental or emotional problems while one in eight will have a mental disorder (the rate being one in five among the disadvantaged). “We are seeing a lot of children now. Most of them are victims of bullying and come with severe depression,” says Dr Sagar.
With dangers so pronounced and stark, it won’t any longer suffice to have laws and no political will at all. The government can’t excuse itself by saying that it has after all recognised mental illness as a disability under the Persons with Disabilities Act, 1995. The fact remains that laws don’t guarantee rights unless honestly implemented. To date, a mentally ill person in the national capital has to still invest, on an average, 30 visits to a government office to get his disability certificate, showed a recent study.
Another tragedy is the reigning lack of understanding about the difference between mental illness and mental retardation. While the latter is a congenital condition characterised by low IQ, the former can manifest at any age and is curable if diagnosed in time.
But that does not happen due to dearth of facilities. On top of this, India is yet to figure out ways of ending the trauma of caregivers of the mentally ill. As per the Mental Health Act, a mentally ill person must present himself in the court to get himself a guardian.
“The mentally retarded on the other hand are spared this trauma. Covered under the National Trust formed to sort out guardianship issues for patients of mental retardation, cerebral palsy, autism and multiple disabilities, they can have their parents apply to a local authority for appointment of a guardian of choice,” says Ajay Mehdiratta, a parent, ruing the discrimination.
No wonder, caregivers of the mentally ill are now dumping the existing laws for easier options. Many of them are learnt to be paying off government officials to get the less-harassing “mentally retarded” tag for their ward, whose dark world, they hope, will some day shine bright. But for the system which remains dull and disabling as ever.
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