This morning I felt chirpy and on top of things. I fitted in a cycle-ride early morning, had a great conversation over chai mid-morning, and I could re-schedule events so I could collect my daughter staying late at soccer practice. I have skills to deal with stressful events and know where to get help if I am mentally distressed and largely because of this, mental health is mostly within my reach. For many people though, things rarely go their way and they have high stress and limited skills and knowledge to respond. This week we celebrate World Mental Health day, and we remind ourselves, there is no health without mental health.
Mental ill-health is the leading cause of years lived with disability and those affected are socially excluded, have reduced quality of life and a lower life expectancy. Building on my practice and research in community mental health in rural and urban settings in North India (and I haven’t worked in mental health in any other setting) I outline here some of the key obstacles and beacons to improving mental health in North India.
Global mental health which started as a concept/ movement in 2007, has importantly drawn attention and resources to people with mental health problems. It has described how there are many people impacted by mental health problems and the majority of these do not have access to resources for treatment (i.e. there is a huge treatment gap in low and middle- income countries). The key response worldwide has been to seek to increase diagnosis using Western biomedical frameworks, and increase access to individualised care through initiatives like the World Health Organisation’s mental health gap action programme (mhGAP), which involves training more doctors in primary mental health care and ensuring supply of psycho-tropic medicines. There is lots to like about improved access to good quality primary and secondary mental health care but from where I sit, we have not paid enough attention to the importance of local contexts in mental health or to the broader social determinants of mental illness.
A few weeks ago, I accompanied one of our community mental health workers and together we sat with Abdul, a young man who had experienced symptoms of bipolar disorder since 2017. Abdul and his family believed his symptoms were caused by a curse on their family, and like many people who have mental health problems, they had first consulted a religious healer and had never made it to a biomedical practitioner at all. mhGAP is unlikely to help Abdul and his family. Ultimately mental health is complexly tangled and tied to childhood adversity, cultural explanatory frameworks of illness, religion, colonialism, history, geography, politics, capitalism and economics, yet too often solutions to mental ill-health show a narrow and individualised response of more doctors and medicines. To improve mental health we need broader and more nuanced policy responses than those we have seen to date.
Abdul’s parents have only completed primary schooling and their family of eight lives in two window-less rooms on the edges of a polluted stream in Dehradun city, Uttarakhand. Social factors are a key determinant of mental ill-health and globally, huge and growing inequalities lead to greater mental illness. Young men in Abdul’s informal urban community are surrounded by substance abuse, violence, chaotic parenting, little education, unemployment, few positive adult mentors and entrenched hegemonic masculinity. Evidence clearly demonstrates that risks for developing mental illness are three to six times higher for those who have experienced childhood adversity such as domestic violence, or parental unemployment. Our research has showed that people in Dehradun who hadn’t completed primary school were nearly four times more likely to be depressed than people who were well educated even when other social factors were controlled for.
Abdul and his family experience social exclusion due to their Muslim identity and also because of Abdul’s mental illness. Stigma is another critical social determinant of ill-health, and in North India people with mental health problems face deep and multi-faceted social exclusion. Social determinants impact health at multiple points: people with poorer socio-economic status have greater exposure and vulnerability to risk factors, poorer health care access and poorer health outcomes. Social determinants as complex causes of mental ill-health require broad policy solutions including a focus on increasing equity, and coherent action across sectors like education, housing, and disability using a health in all policies approach. Other requisite actions include changing the mega economic structures that increase inequalities e.g. can we abandon capitalism This is easier to talk about than do but there are some new alternatives to growth economics such as doughnut economics that may be much more important for mental health than new formulations of anti-depressants. There are exciting possibilities to increase global mental health when we move beyond individual interventions and focus on the political economy. When India more effectively addresses housing, public education, livelihood, disability rights and caste exclusion and increases taxes to provide more public services, mental health will also improve.
Until recently, Abdul had never made it to a biomedical doctor, yet part of the solution to mental ill-health has to lie within the health system. Mental health services in North India are very limited. The whole health system is allocated 1.3% of the GDP, much lower than the global average of 6%. Although India has improved many key health indicators, huge disparities continue to exist between (and within) Indian states. Out of pocket expenditure in India makes up nearly 70% of the total expenditure on health, one of the highest in the world. There is very little regulation of private or public providers, and systems of kick-backs for diagnostic procedures exist which financially reward doctors and private mental health providers to practice irrationally. High out-of-pocket costs lead to catastrophic health expenditure and impoverishment for families affected by mental ill-health. The hopes of some rest in Ayushman Bharat, the new Indian flagship programme, which proposes rolling out 150,000 Health and wellness centres, as one of its pillars. These centres could potentially locate resources and skills for mental health within communities.
India’s national mental health programme (NMHP) has showed small steps of progress in the past five years, with increased roll-out of the programme in less-developed northern states, but the challenges of rolling this out are significant. The NMHP is under-resourced with excessive focus on biomedicine and is allocated a small budget. The unregulated and lucrative private medical sector attracts profit-focused psychiatrists while on the demand side, public services are not available or are inaccessible (long distances to travel, long queues or poor- quality care). In our recently published research on the impact of predatory and irrational private care for people with mental health problems in Uttar Pradesh, we describe that people with mental health problems are stuck between the devil and the deep blue sea: i.e. poor quality and barely accessible public health care, or private care that is largely unregulated, irrational and even predatory.
Given these enormous barriers to good mental health for Abdul and others like him, where are the beacons of hope? An innovative group in Mumbai, Mariwala Health initiative is framing the problems more broadly, describing the “Mental health care gap”, comprising the treatment gap, physical health care gap and the psycho-social care gap. Community mental health competence is a model that builds on the importance of safe social spaces, knowledge built in dialogue and partnerships for action that has been effective as a framework for effective community mental health programmes in North India and South Africa. Rather than arguing about the primacy of evidence based medicine, many North Indian mental health professionals promote Dua aur Dawa (prayers and medicines) as a pragmatic approach to the pluralist help-seeking that prevails across South Asia.
Task shifting, where trained community based workers complete many of the tasks traditionally performed by health professionals, has been shown to be an effective way to increase resources for mental health, and improve mental health outcomes. Communities and pro-poor social movements can support and strengthen health determinants that increase mental health and many communities offer social support and inclusion. Communities can also develop their skills through facilitated interventions such as psychosocial support groups. Then there are many other new innovations and interventions including user-led movements, peer-support, locally developed recovery frameworks, South -North initiatives such as the Friendship bench, and coproduced resources and policies. The Mental health innovation website is bristling with many more inspiring examples of contextually relevant ways forward for mental health.
Although the causes of mental ill-health are a tangled and complex web, advancing mental health may be simple but not simplistic. We need to use locally available resources, such as those in Abdul’s lively urban community with existing groups, norms of reciprocal social support and somewhat functional primary care systems. We should find locally valid ways forward (coproduced, participatory and culturally acceptable) and build knowledge in dialogue rather than monologue. Policies should support this with health systems that are accessible, acceptable, resourced and regulated. And we need to keep working on economic and social policies that are inclusive and support equity.
On October 10th 2019 I will celebrate World Mental Health day in Government schools and Community Health Centres in the Yamuna valley, a remote corner of Uttarakhand state, North India. Supported by Burans, a partnership project working with communities for mental health, community-members will perform street plays to underline the value of actively listening to a neighbour with mental distress. And we will advocate to Government decision-makers for increased access to knowledge, medicines, skills for mental health and psycho-social support for people like Abdul, not just on World Mental health day, but the whole year through.
Community psychosocial support group meeting – Dehradun led by community mental health worker (Burans project, Emmanuel Hospital Association). (Photo credit – Kaaren Mathias, permission for public use given by all people in the photo)