Even as the world marked Suicide Prevention Day on September 10, India seemed to have escaped the stark reality it faces when it comes to mental health.
Even as the world marked Suicide Prevention Day on September 10, India -- a country of over a billion where every one in 20 suffers from depression -- seemed to have escaped the stark reality it faces when it comes to mental health.
For Indians, fitness has always been equated with physical health. But Dr Zirak Marker, a renowned psychiatrist, says that when speaking of health or well being, one almost always ignores the spectrum of mental well being of a person.
"When one uses the word 'mental health', the first image that comes to our mind is someone committing suicide or attempting suicide or the classical cases of schizophrenia or depression. But mental health starts with well being and positive psychology," Dr Marker tells Moneycontrol.
Dr Marker is associated with Mpower, an organisation dedicated to promoting awareness about the issue and to help out individuals suffering from various mental health concerns.
How does India do on mental health parameters?
The World Health Organisation (WHO) defines health with regard to a lot of aspects which is inclusive of social, spiritual and mental health, and not merely the absence of disease or infirmity. The WHO International Classification of Disorders includes a range of mental illnesses including schizophrenia, bipolar disorder, borderline personality disorder, multiple personality disorder, depression, anxiety etc.
The National Crime Records Bureau (NCRB) documented that around 1 lakh people commit suicide in India every year from 2004-2014. Suicides have increased at 15.8 percent over the past decade. The total number of suicides recorded in NCRB also includes the high number of farmer suicides in India.
India has alarming figures for the number of Indians who suffer from mental health concerns with WHO observing that 36 percent of Indians suffer from depression at some point in their lives.
A National Institute of Mental Health and Neurosciences (NIMHANS) survey estimates that 13.7 percent of the Indian population above the age of 18 suffers from mental morbidity, requiring active intervention. It also suggests that one in every 20 Indians suffers from depression. Nearly 1 percent of Indians suffer from high suicidal risks. Almost 9.8 million children in the age group of 13-17 years are suffering from mental health concerns and requires an active intervention.
While these statistics underline the miserable situation, the country in general seems to be lacking substantial understanding in the matter.
When one has a toothache, a fever or malaria, he/she immediately consults a physician for fast recovery but what happens when one is faced with low moods or depression? Why does one hesitate to visit a psychologist to cater to mental illness concerns? Why do schools, colleges, universities and work institutions not grant leaves if one produces evidence of being mentally unhealthy?
The aforementioned questions are some of the critical queries the nation needs to address at a policy building level, according to Dr Marker.
The NIMHANS report reiterates Dr Marker's arguments, outlining the dismal treatment gap for mental illnesses and disorders across India. The study shows that the treatment gap for mental disorders range from 28 percent to 83 percent and is the highest at 86 percent for alcohol use disorders. Nearly 80 percent of mental illness patients have not received treatment despite the presence of illness for more than a year.
While the figures point towards a huge lack of awareness in Indian masses, the NCRB which records suicide data in India recognizes a list of causes for suicide, which excludes mental illness as a legitimate cause of suicide in India.
The Society and Mental Illness: The shaky relationship
Awareness through intelligent information given to suffering individuals as well as their family members is the key solution to bridge the gap of the mental health statistics in India, says Dr Marker.
The NIMHANS report states that "a good mental health system has the responsibility of reducing the substantial burden of untreated mental disorders, decreasing human rights violations, ensuring social protection and improving the quality of life especially of the most vulnerable and marginalised subgroups in a society."
It adds that moving beyond care, it should also integrate and include mental health promotion and rehabilitation components.
The report emphasises that mental health conditions have implications which are not just restricted to an individual level but impact the whole society in general. This not only results in lower productivity and earning potential of a person, it also leads to a number of antisocial behaviours, crime, homelessness, domestic violence, alcohol and drug abuse.
In light of that, the recurrent cases of farmer suicides in India, especially in the state of Maharashtra, Madhya Pradesh etc. have a direct relation with the massive ignorance of mental health. "We, as mental health professionals should visit regions showing a growing trend in farmer suicides to cater to the suicidal thoughts in such farmers," says Dr Marker.
According to trends determined by the NIMHANS report, common mental disorders (CMDs) like depression, anxiety and substance abuse and severe mental disorders (SMDs) like schizophrenia, bipolar disorders and other psychoses have specific occurrences based on gender and class.
The male working population in India aged between 30-49 years has the highest prevalence of mental disorders. Working females in the same age group also exhibit higher occurrences of mental disorders.
Yet, schools, colleges and workplaces do not recognise it as a legitimate cause for granting leave. Dr Marker in association with Mpower, has taken up various initiatives to visit schools, colleges and universities and corporate organisations to help them recognise the importance of mental health education.
"In all the schools and colleges I have visited, there were at least 7-8 people who disclosed that they were going through mental problems but unable to speak out because of the stigma. What we need is not one counsellor but mental health awareness cells in all organisations," he says.
The psychiatrist also says that schools and colleges across India are resistant to accept the importance of mental health concerns. Recalling the various challenges he faced while visiting schools, he says that there have been incidents where they were denied entry in schools.
The stigma of the 'invisible' illness
Mental health concerns are mostly stigmatised in the Indian society due to the absence of physical symptoms that are manifested if one has the flu or cancer. Physical ailments which show "visible" traits detected through blood, urine or other medical tests do not apply in these cases, apart from some illnesses like schizophrenia or bipolar disorder.
However, Dr Marker says that the so-called "invisible" disease has "clear cut symptoms which are easily diagnosed" by a psychiatrist/psychotherapist. "Making one recognize the symptoms is where the awareness should start."
When most people try expressing their conditions, friends and family inevitably respond with an "it's just a phase, it will pass", always terming it as emotionally turbulent times.
Instead, Dr Marker points to the existence of something called as the "mental health first aid" -- which is used to provide interim relief to patients before consulting a therapist.
Media portrayals also contribute greatly to the situation in India, says Dr Marker, pointing to the example of the Blue Whale Challenge which triggered two young people to commit suicide in India under the influence of the game.
He says, "Blue Whale challenge is the most media hyped thing currently. But what about the thousand other children who silently suffer every day and exhibit suicidal thoughts. Why does the media not talk about it?"
"Irritability, withdrawn behaviour, lowness of mood, lack and loss of interest in everything, sense of feeling hopeless and worthless, negative thoughts of self-harm, attempts of self-harm, changes in sleeping patterns and eating patterns are some of the most common symptoms and one must consult a therapist immediately," he says.
Sometimes, even a traumatic incident such as marriage breakup, relationship trouble, war memories, memories of violence and extortion could lead to post traumatic stress disorders (PTSD) in individuals, says Dr Marker.
"There is no specific cure for conditions which are not clinical. Cognitive behaviour therapy, family therapy, supportive psychotherapy and other methods can be used to help one cope with the situation.
The class divide: Rural vs Urban and the cost of care
The NIMHANS survey concludes that the prevalence of mental disorders is higher in urban metros than rural areas, with certain diseases like schizophrenia, psychoses and mood disorders being 2-3 times more in urban metro areas.
It also recognises an upward trend in the mental health concerns in urban areas and recognises the need for an effective urban mental health programme. In fact, the report indicates that poverty, low levels of income and unemployment lead to mental health issues.
Dr Marker says that in rural areas, where the basic necessities become the primary concern of the population, people seldom have time to indulge in mental health issues or even realise the occurrences of it in the daily toil. Nonetheless, he says that mental health concerns do exist in rural areas and stress and anxiety among children about their future and education is a growing concern in rural regions.Another worrying factor is the cost incurred for mental health care in India which definitely digs a hole in the pocket. The NIMHANS report estimates an expenditure of Rs 1000-Rs 1500 a month for treatment. Thus, better recognition and awareness would lead to acceptance of poor mental health as a legitimate health concern.