A State of Mind: Decades of mismanagement have hobbled India's mental health programme
An event commemorating World Mental Health week opened at the WHO in Geneva this week. At a key session, the Disease Control Priorities project released its recommendations to governments to address the burden of mental disorders. This was timely for India, for few countries have witnessed so many high-profile debates related to mental health while ignoring the centrality of mental health in any of them. Consider just three examples of long-standing, repeated tragedies that evoke media outrage and endless political mudslinging: The impoverishment of families, domestic violence and deaths related to alcoholism; the continuing tragedies of suicides, the leading cause of death in young Indians; and the acts of terrible violence by adolescent boys who have faced terrible deprivations in their own childhood. For those of us who have been documenting the science of how these problems could be addressed effectively and how other countries have successfully addressed them, it’s not surprising we have achieved so little.
The Disease Control Priorities project has documented several findings relevant to India. The burden of mental disorders is large and growing, and their impact on mortality, families and society has been greatly underestimated. A wide variety of effective interventions, including medicines, psychological treatments and social interventions, can prevent and treat many disorders. Some interventions can be delivered through legislative and regulatory measures — for example laws that restrict access to means of suicide (notably pesticides) and that reduce the demand for alcohol (by, say, combating surrogate advertising of alcoholic beverages to youth). Some effective interventions are delivered through a variety of community-based sectors, such as parenting programmes from infancy through adolescence, and life-skills training in schools to build social and emotional competencies in children and adolescents. At the level of health services, there is evidence to support the delivery of frontline interventions by community health workers with appropriate training and supervision, in partnership with primary care doctors and mental health professionals. In addition, there is the need for specialist care, such as in district hospital-based inpatient units, and continuing care, for instance through supported housing, for a relatively small proportion of people affected by severe disorders like psychosis, intellectual disability and dementia.
Tragically, the vast majority of our population has no access to the benefits of this knowledge. Those who are affected by mental disorders must rely entirely on their own resources to recover. Many incur heavy costs as they seek cures from a variety of sources, including religious, traditional and private medical practitioners. Stigma and discrimination lead many to endure the worst forms of human rights abuses, including torture, in their homes, communities and even in the hospitals set up to care for them.
While India has the distinction of being one of the first countries in the developing world to establish a national mental health programme, decades of mismanagement have led to pitifully small gains. If the government has any desire to change this abysmal status quo, it would need to look no further than to implement, in letter and spirit, its own National Mental Health Policy and District Mental Health Programme. To do so, it would need to address the abject lack of technical capacity in most states and districts to implement the public health approach to mental health these documents espouse. It will need to free mental health programmes from the narrow confines of medical school departments of psychiatry, embracing other public health institutions, sectors of government (such as education) and a broad range of civil society groups. It will need to create a new cadre, or empower existing ones, of community health workers who address mental disorders alongside other chronic diseases, working through primary healthcare. It will need to adopt the draft Mental Health Care Bill, which has been languishing in Parliament. It will need to aggressively reform the country’s 40-odd mental hospitals to transform them into institutions that are seamlessly linked to the community. It will need to actively empower networks and groups of persons affected by mental disorders and their families to enable their voices to be heard and hold services accountable. Without these steps, both the mental health policy and programme will meet the same fate as two decades of government programmes to address mental health in India.
By Vikram Patel
The writer is professor, international mental health, at the Public Health Foundation of India and the London School of Hygiene and Tropical Medicine