Making Mental Health a Global Priority: Because it is Everyone’s Business

   

“A sick thought can devour the body’s flesh more than fever or consumption.”
—  Guy de Maupassant

Every year October 10th is commemorated worldwide as World Mental Health Day, to spread awareness about mental health issues, dispel myths and misconceptions, and combat stigma and shame surrounding mental illnesses. This global initiative started in 1992 under the aegis of the World Federation of Mental Health. Over the last three decades, this annual activity has served to shed light on mental illnesses globally. Mental disorders are most often relegated to obscurity and have endured societal shame and stigma across cultures and generations. This day has helped to motivate individuals and agencies to initiate conversations and campaigns and spearhead advocacy efforts. The popularity of the campaign within two years of its inception was unprecedented, and in 1994 for the first time, a theme for the day was used to bring to focus, a specific issue each year. The theme of World Mental Health Day 2022 is: make mental health for all a global priority.

Why must we talk about mental health?

In the last two years, the world has witnessed and endured the COVID-19 Pandemic, which within a short span, transformed a global public health emergency into a full-blown humanitarian crisis. While the mortality and physical morbidity of this novel disease has been staggering, it also opened a pandora’s box of psychosocial stressors — quarantine, isolation, social alienation, changing work-life structure, financial instability, and academic stress related to online schooling, to name a few. It also directed the harsh light of scrutiny to the glaring inequities entrenched in our society, especially for vulnerable populations (Mahapatra & Sharma, 2022).¹

Data from across the globe reported an unprecedented increase in women’s experiences of domestic and intimate partner violence during the COVID-19 Pandemic, termed a “shadow pandemic” by the Executive Director of UN Women to draw greater attention and focus on the issue. In India, a 2.5 rise since the lockdown in rates of intimate partner violence has been reported by the National Commission of Women. Around 72% of the domestic workers around the world lost their jobs during the pandemic, 80% of whom were women (UN Women, 2020).²

A 10% rise in suicides was reported in India, in the pandemic year of 2020, to an all-time high of 1,53,052, according to the latest data from the National Crime Records Bureau (NCRB 2020)³. Amongst all, student suicides showed the highest percentage increase at 21.20 per cent. The maximum number of suicides in 2021 was recorded among daily-wage workers, self-employed, unemployed, and homemakers.

A culmination of various social and economic stressors precipitated by the pandemic has resulted in, what experts call a “second pandemic” of a mental health crisis in health and professional systems, as well as communities across the globe. The second pandemic is silent but no less pernicious. Its effects while not apparent initially, have the potential for far-reaching health, social and economic consequences.

Even before the pandemic, mental disorders have been among the leading causes of the non-communicable disease burden in India.

The first study (Sagar et al., 2020)⁴ to provide comprehensive estimates of the prevalence and disease burden due to all mental disorders for every State of India from 1990 to 2017, reported that one in seven Indians were affected by mental disorders of varying severity in 2017. Also, the proportional contribution of mental disorders to the total disease burden in India had almost doubled since 1990.

Depressive and anxiety disorders constitute the major bulk of mental disorders affecting the general population. Besides these, sleep disorders, and substance use disorders such as alcohol, and tobacco addiction are also highly prevalent, with serious physical and mental health consequences. Substances of abuse such as cannabis (bhang, charas, ganja, etc.) have been deemed as a “gateway drug” which increases the risk of progressing to harder drugs such as heroin, cocaine, etc. Addiction to narcotic substances not only leads to severe physical health consequences but also pushes a person into a complex spiral of crime, incarceration, and social ostracism, with ramifications for the individual, their families, and the community at large.

Understanding the mind-body connection: Decoding myths around mental illness

The mind is a function of the brain. It is a product of electrochemical circuitry produced by a plethora of neurochemicals pulsing signals across neural circuits which criss-cross the brain matter, much like a web of electric cables. While the human brain, a three-pound organ, looks almost identical in us all, its product — the mind — is uniquely constituted in every one of us. The mind as a concept appears esoteric and abstract since it cannot be visualised in the same way as one can look at a pair of tonsils with a pen-torch or palpate a liver. It is no wonder therefore, the maladies of the mind have been shrouded in mystery and fear and their causation has been attributed to occult origins, ranging from past sins to possession by evil spirits. Even now, when medical science, with its exponential progress in the field of functional neuroimaging and electrophysiology, has been successful in studying to a great extent our “minds in action”, the age-old rhetoric of supernatural causation is still deeply embedded in our cultural consciousness. This leads to a delay in seeking medical treatment, which is still very often the last stop in their pathway of care. This translates not only as a delayed treatment, which is known to worsen prognosis and clinical outcomes but often leads to travesties of human rights for people with chronic mental illness — one of the most vulnerable sections of society.

In 2001, a fire incident in Erwadi, Tamil Nadu caused 28 inmates of a faith-based mental asylum to burn to death. All of them were bound by chains, because of which they could not escape when the fire broke out. This prompted an inquiry directed by the Supreme Court, following which the N. Ramdas Commission made multiple recommendations for an organised mental health care system in the State. While such reactive efforts have been an important step forward in improving mental health services in the country, there is also the need for proactive measures, to increase the acceptability and accessibility of medical services for the treatment of mental illness.

Another stereotype surrounding mental illnesses is that it is a product of “weak character” or “poor coping”. A diagnosis of any kind of mental illness is laced with value judgments by peers, co-workers, and often family and friends. People suffering from mental illness are deemed as “weaklings” or incapable of fulfilling roles of high responsibility. They are advised to “get over it” or “deal with it”. Such myths are occasionally challenged.

Michel Phelps suffered from depression for the first time after winning six gold and two bronze medals in the Athens, Olympics. A highly vocal advocate of mental health, he has often shared his experience of living with depression and anxiety, his long road to treatment, and the importance of therapy in making that journey.

“It is honestly petrifying trying to do a skill but not having your mind and body in sync,” said Simone Biles. One of the star gymnasts of the US, Biles withdrew from the Tokyo Olympics to prioritise her mental health issues.

Such disclosures help in shifting focus to the fundamental fact that: “Anybody can suffer from a mental illness. It is okay, to be not okay. And it is important to get help.”

But greater efforts at a societal level are required to humanise psychological stress and the distress of mental disorders. It is essential to upend the artificial hierarchies of suffering, wherein the pain and distress of mental disorders are often not given the same understanding or dignity as the pain of physical disorders which can be “seen” or calibrated in concrete ways.

Occupational mental health: Need of the hour

While it is largely recognised that marginalised and vulnerable populations are at risk of developing mental illness in reaction to their life stressors, one of the major sections of the society whose mental health issues are often brushed under the carpet is of working professionals and students — the most “functional” section of the society. During the pandemic, a significant number of frontline workers including health care workers (HCWs) were reported to suffer from diagnosable mental health disorders including depression, anxiety, Post-traumatic stress disorder (PTSD), and sleep disorders.

Occupational stress has been reported to be a major risk factor for the development of fatigue and burnout which can lead to mental distress. A study conducted by Associated Chambers of Commerce and Industry of India (ASSOCHAM) in 2015 reported that approximately 42.5% of employees in the private sector suffered from depression or general anxiety disorder. A survey conducted amongst medical professionals in a tertiary hospital in India revealed that up to two-thirds reported moderate levels of stress, 16% reported high levels of stress, and up to one-third reported symptoms of depression (Grover et al., 2018)⁵. In the United States, a 2014 survey (Survey of Law Student Well-being) conducted amongst 3300 law students from 15 law schools, revealed that 17% suffered from depression, 25% were at risk for alcoholism, 37% had moderate to severe anxiety, and 6% had suicidal thoughts. A repeat survey conducted in 2021 reported again significant percentages of them dealing with mental health issues and/or alcohol/drug issues but are often reluctant to seek help. Reasons provided for this reluctance included concerns about potential threats to bar admission, potential threats to job or academic status, financial burdens, and/or social stigma.

There is a dearth of large-scale empirical studies exploring mental stress in legal professionals and law students in India. However, it is encouraging to note that institutions such as the National Law School of India University, Bengaluru have incorporated counselling services, clinical therapy, and app-based services, in their policy for student wellness and health services. Similar student wellness centers are coming up in a big way in premier government and private academic institutions. Academic stress is one of the major psychological stressors in children, adolescents, and young adults and the last few years have seen an unprecedented rise in student suicide rates. Integration of mental health services in the wellness programs of professional and academic institutions will help to reduce barriers to seeking treatment and facilitate early intervention.

Mental health legislation in India

The Charaka Samhita, compiled around the first century CE and considered a founding ayurvedic text, described general symptoms of insanity as well as prescribed its treatment. Before British colonial rule in India, the mentally ill were possibly treated in a community setting.

In the 18th century, with the advent of British rule, the lunatic asylum became the means to contain the mentally ill. Their role initially, was less to provide treatment to people with “insanity”, and more to protect society from them. By the mid-nineteenth century, with progress in medical understanding of mental illness, these asylums transformed from being custodial institutions to the seat of intervention and rehabilitation.

The Lunacy Act of 1912 was essentially the first step towards mental health legislation. It governed the management of asylums which gradually were renamed mental hospitals. However, the Act was primarily custodial in nature and had a minimal focus on the rights of mentally ill patients.

The Indian Psychiatric Society advocated for reforms in the existing Act, which subsequently led to the drafting of a Mental Health Bill in 1950. However, it took more than three decades for this Bill to transform into the Mental Health Act (MHA), 1987, which was implemented in 1993. The MHA, 1987 was a significant improvement from the previous Act, but it also was concerned mainly with issues related to admission, guardianship, registration, and maintenance of mental hospitals. The human rights, autonomy, and dignity of the patients did not find adequate focus in this Act. The MHA also did not adequately deal with the issues of treatment, rehabilitation, and community integration of the patient.

Also, since the 1930s, general hospitals in the country gradually established separate services for the treatment of psychiatric illnesses, which came to be known as general hospital psychiatric units (GHPU). Gradually, the GHPUS, became the primary locus of treatment, due to less stigma, better accessibility, and improved care. They also helped in the integration of mental health care in a general medical setting. The GHPUs did not come under the purview of MHA, 1987.

In 2007, India signed and subsequently ratified the United Nations Convention on Rights of Persons with Disability (UNCRPD) which mandates the signatories to uphold and protect the rights of persons with disability, including the right to live independently, inclusion in the community, provision for equal opportunity, and right to accessibility and information technology. In keeping with the principles of UNCRPD, efforts to amend the existing MHA led to the Mental Health Care Bill, 2013. The Bill gave way to the Mental Health Care Act (MHCA), 2017 which lays down guidelines for mental health establishments (MHEs) to provide care in keeping with the individual autonomy and dignity of persons with mental illness (PMI). While this Act has been a major milestone in the journey to safeguard the rights of persons with mental illness, the true spirit of the Act can only be realised by upscaling of mental health infrastructure which is imperative to implement its provisions fully.

One of the greatest steps forward attained through MHCA, 2017, has been the decriminalisation of suicide wherein a person who attempts suicide is presumed to be suffering from mental stress and would not be punished under the Penal Code, 1860 (IPC).

Relooking is the way forward

It is heartening to note that mental health is being recognised as one of the priority areas in health policies around the world and has also been included in the sustainable development goals. In 2014, India got its own National Mental Health Policy which outlines a roadmap to promote mental health, prevent mental illness, reduce stigma and provide affordable, inclusive, medical and social care.

The need of the hour is to reframe the mental health question; the answer can only be reached when we look at it through an interdisciplinary lens and work towards it with the spirit of intersectoral collaboration.

Mental and behavioural disorders are intimately and intricately connected to the psychosocial issues prevalent in society. Thus, a nation’s mental health indicators become not just a matter of public health legislation, but also an index of social welfare and empowerment.

The preservation and promotion of mental health need to be reconstructed on a larger framework—to become a joint medico-socio-legal and humanistic enterprise.

The varied stakeholders need to carve out a common space wherein concerted efforts to generate ideas, innovations, dialogues, and actionable plans can be envisioned and carried forward. This will go a long way in building sustainable and equitable systems to address not just the medical needs of persons suffering from mental illness, but also safeguard their rights and interests, affirm their liberty and dignity, as well as promote positive mental health for the general population.

“What mental health needs is more sunlight, more candor, and more unashamed conversation.”
— Glenn Close

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