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Thursday, July 09, 2020

This is a historic opportunity to transform India’s mental healthcare system

Mental health problems were already a major contributor to the burden of illness in India before the pandemic, with a third of all female and a quarter of all male suicide deaths in the world occurring in this country.

Written by Vikram Patel | Updated: June 20, 2020 2:04:52 pm
mental health, depression, anxiety Mental health care must embrace the diversity of experiences and strategies which work, well beyond the narrow confines of traditional biomedicine with its emphasis on “doctors, diagnoses and drugs”. (Illustration: CR Sasikumar)

The suicide of the actor Sushant Singh Rajput, days after that of his manager, which in turn precipitated a public acknowledgement by Milind Deora, a prominent politician, of his own tryst with depression, has once more thrust mental health into the spotlight. The open and thoughtful manner with which this subject, usually invisible even though it is at the core of our personhood, is being discussed, is very welcome. The imperative now is to understand the nature of mental health distress and what we must do to address it in these troubled times.

I think of the mental health consequences of the pandemic as playing out in two overlapping acts. The first act, which began in March, is characterised by a “pandemic of fear”, largely as a consequence of the profound uncertainties which have overwhelmed all our lives. If one considers the sheer breadth of these uncertainties, from our personal risk to be infected, to why the country is facing a surging epidemic despite the most stringent lockdown in the world, or when life will return to a semblance of what it used to be, or what news we should believe in, to what our economic prospects might look like, it is not at all surprising that experiences of anxiety, fearfulness, sleep problems, irritability and hopelessness have become widespread. These are mostly rational responses of our minds to the extraordinary realities we are facing. That said, for those who were already facing mental health difficulties before the pandemic, these experiences might be the straw that breaks the camel’s back.

But it is the second act which threatens to morph into a more sinister pandemic in the months ahead. “Deaths of despair”, a term coined by the Nobel prize winning economist, Angus Deaton, have been documented as the reason for the reduction in the life expectancy of working-age Americans following the economic recession in 2008. Suicide and substance use related mortality accounted for most of these deaths, driven by growing inequality, the weakening position of labour, deep polarisation of society and the lack of prospects for the future. By all accounts, the economic recession facing India will be incomparably greater. India not only shares many of the ills of American society, but has to, additionally, contend with colossal numbers of people who are absolutely impoverished and a fragmented mental healthcare system which, even before the pandemic, failed to reach more than 10 per cent of the population. This makes for a perfect storm.

Mental health problems were already a major contributor to the burden of illness in India before the pandemic, with a third of all female and a quarter of all male suicide deaths in the world occurring in this country. Most of this illness and death goes unnoticed. Celebrity suicides and testimonies attract our attention to mental health because it is the only explanation we can invoke for people who are so privileged. Of course, it is the poor, dispossessed and marginalised who bear the greatest burden of mental health problems, but we have historically dismissed their suffering as a natural extension of their social and economic conditions. And it is this vast section of our population which will be disproportionately affected by the economic recession.

Editorial | It is imperative that the battle on the mental health front is integrated into the war against COVID-19

So, what’s the solution? While there has been a flourishing of initiatives to address the rising tide of mental health problems, most notably through telemedicine platforms, they rely heavily on mental health specialist providers who are very scarce in number and often unaffordable. This is compounded by the digital divide: Digital literacy and adequate internet connectivity remains a distant goal for large swathes of our people. Still, these initiatives are welcome for their demonstration of the feasibility of remote delivery and the value of psychological therapies, which have historically played a poor cousin to medication.

But what holds the greatest promise for a country of our size, diversity and resources, are the frugal innovations which Indian scientists and practitioners have ingeniously pioneered, at the vanguard of which is the deployment of community health workers who, with appropriate training and supervision, effectively deliver psychosocial interventions for conditions ranging from autism and depression to drinking problems and psychoses. A brief psychological treatment for depression developed by Sangath, one of the leading innovators in the country, has the unique distinction of now being implemented in wealthy nations like the US and Canada. Sangath is forging partnerships with several state governments to scale up its psychosocial interventions through community health workers and, in doing so, reimagining how mental health care can be delivered even in the most under-resourced communities of the country.

For readers who are wondering how to manage their own mental health, there is no one-size-fits-all prescription for experiences which are intimately intertwined with our unique, personal life stories. Yet, there are some general principles I might suggest. First, be aware of and acknowledge your mental health, as much as you do your physical health. Feeling irritable for no reason should be as important to you as feeling pain in your chest. Second, this should lead you to talk to someone, anyone you feel comfortable with, for “It’s Ok to Talk”, a slogan coined by Sangath to promote the idea that sharing one’s story about mental health is not only a powerful way to feel better, but is also the most effective strategy to reduce stigma.

Explained | The cost of COVID-19 on mental health, and what experts recommend for dealing with it

Third, do something for others, for science has shown that care-giving and community service not only makes your life more rewarding, but also longer. Fourth, remind yourself that all of humanity is being buffeted by the same rough seas and, even if some of us travel in yachts, the overwhelming majority of us will safely reach the shore. This epochal event will pass, as every pandemic has in history. Finally, if your distress is persistent and coming in the way of getting things done, seek help from a professional.

In closing, a plea for those who finance and provide health care: This is a historic opportunity to invest in and transform India’s mental health care system. While we certainly need more money, we also need to spend it wisely, guided by the best science. Mental health care must embrace the diversity of experiences and strategies which work, well beyond the narrow confines of traditional biomedicine with its emphasis on “doctors, diagnoses and drugs”. I cannot imagine a more valuable investment in response to the most serious crisis facing the country since our independence.

Also read | ‘Sushant was trying to make it on his own in a world structured around nepotism and cronyism’

This article appeared in the print edition on June 20, 2020 under the title ‘A perfect storm’. The writer is the Pershing Square Professor of Global Health at Harvard Medical School and co-founder and member of managing committee, Sangath.

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