Troubled Beautiful Minds

They are there—each residential area has its mentally disturbed people; each family has anecdotes of crazy relatives. Nobody wants to acknowledge them. As pressures of life grow, so do troubles of the mind. Governments worldwide are looking for ways to tackle mental illness that poses a major threat to global economy. India has a national programme in place to tackle the problem for more than three decades but it has failed to deliver. Now, to improve the situation the government has drafted a new mental health care bill, which will be tabled in the monsoon sesssion of parliament. It is also charting a mental health policy. Vibha Varshney and Kundan Pandey analyse whether the efforts will help improve the lot of india’s mentaly ill

By Vibha Varshney, Kundan Pandey
Published: Thursday 15 August 2013

Troubled Beautiful Minds

For the past three years, every month Jagat Ram travels from Hapur district of Uttar Pradesh to Delhi’s Institute of Human Behaviour and Allied Sciences (IHBAS) to fetch medicines for his younger sister. She suffers from depression, the most common mental illness in the country. “It all began at her in-laws’ place. She used to complain of torture,” recalls the 35-year-old. In 2007, after losing her newborn she slipped into shock. It was a crushing blow to her already shaky marriage. She became quiet, stopped doing household chores, did not care for her appearance and even stopped bathing.

Eccentric side of India
Person suffers from delusion, hallucination

Mood disorders
Include depression and bipolar disorder, marked by alternating episodes of mania and depression

Cannabis users
Those addicted to intoxicating hallucinogenic drugs

Mental retardation
A condition due to incomplete growth of brain, characterised by impaired cognitive, language, motor and social abilities

Child, adolescent disorders

Geriatric disorders
Mental illness that onsets with aging

Deterioration of an invidividual’s intellectual, emotional and judgemental abilities; can occur with aging or injury to brain

Common mental disorders
Describe a state of deeper psychological distress; includes anxiety disorders, dissociative disorders, phobia and somatoform pain or acute false pain

Neurological disorder with convulsive seizure

Alcohol dependency*
A pattern of compulsive alcohol use

Opiate users
Instead of getting her treated, her in-laws would accuse her of acting out to garner attention. Her condition continued to deteriorate. That’s when Jagat Ram forcibly brought her back home.

For almost a year, he spent money on costly private treatment in his native place. But she showed no sign of improvement. It was by chance that the family brought her to IHBAS. She is now on the road to recovery.

“We now have to keep her away from negative thoughts,” Jagat says. “Though I still spend money on travel and take frequent leaves from office, it’s worth it.”

But Jagat Ram’s sister is one of the few people who have found their way to a premier institute like IHBAS or expensive private care.

The rest—in the absence of government data, IHBS director Nimesh Desai says one in 10 people in the country could be suffering from diagnosable mental problems—depend on a nearly defunct National Mental Health Programme or find relief in faith healing.

About 900 km away, in a tribal village in Jhabua district of Madhya Pradesh, 19-year-old Sanju, too, displays symptoms of depression. His father, Ratan Singh believes he is under the spell of evil spirits. Sanju was fine till two years ago.

Then his behaviour suddenly changed. He stopped responding to calls and did not even care for himself. He would cry for no reason. In the past two years, Ratan Singh and his wife have travelled several times to the Baba Dongar temple atop a hill, hoping that god would cure Sanju.

They also promised to sacrifice cocks at the temple if Sanju showed improvement. Though the boy is yet to show any sign of improvement, the couple dared not break their promise. Baba Dongar is their only hope.

When asked why he does not take Sanju to a doctor, a bewildered Ratan Singh says Sanju does not have any health problem. And he is not the only one to believe so.

Kalu Singh Bamanai, a photographer of Samni village who earns his livelihood by taking photos of the pilgrims at the temple, says every day five to 10 families, even educated ones, visit the shrine, hoping their mentally ill relatives would be cured.

imageWhen the Centre launched National Mental Health Programme (NMHP) in 1982, one of its objectives was to allay such ignorance and integrate mental healthcare in general healthcare by introducing mental health centres in each district. These centres are headed by psychiatrists who travel to interior parts of the district and provide treatment to patients. The programme floundered.

“Very few patients visit the doctor,” says R K Bairagi, head of NMHP’s district mental health programme (DMHP) for Sehore district in Madhya Pradesh. “While some fear social stigma, the rest are superstitious. We are planning to take the help of tantriks to bring mentally ill patients to the centre. Tantriks deal with many such patients and could be helpful to bring them here. They would perform their rituals and after that ask patients to visit the centre,” he adds.

Even if it works it will be only half the solution. If people actually approach the Sehore DMHP centre it will not be able to handle the load. The Sehore DMHP centre is the only hospital, other than the Mental Hospital Indore and Gwalior Mental Hospital, to cater to the mentally ill people of Madhya Pradesh. Between 1996 and 2007, the Central government had sanctioned four other DMHP centres in Shivpuri, Dewas, Mandala and Satna districts, but all of them have become dysfunctional.

Even the Sehore centre is under-staffed. “We advertised for the posts of psychiatrists and psychologists for this centre at least four times but no one responded.

There is shortage of psychiatrists and psychologists in the state because there are no PG courses on these subjects in any of the six medical colleges of the state,” says Bairagi, who shuttles between Sehore and his hometown Bhopal, about 50 km away. He comes to the centre only twice a week.

Secretary of the Madhya Pradesh State Mental Health Authority, R N Sahu, says DMHP failed in the state because it is not a priority for the authority. The money sanctioned for Satna and Jabalpur centres was returned to the Centre because the district authorities were not interested in the programme.

“I had sent proposals to revive the defunct centres and begin DMHP in five new districts more than a year ago. But the proposals were never forwarded to the Centre,” he says. The situation is no better in other states. The programme has made little headway in the past three decades.

“Although DMHP is supposed to be active in 123 districts (of 652 districts), it is barely functional in most districts,” states the mental health policy group, established in May 2011 to create a mental health policy for the country and provide recommendations to improve DMHP in the 12th Five-Year Plan.

The group submitted its report in June 2012. “…barring islands of good performance, the DMHP is yet to achieve its objectives,” says the group.

Inconsistent fund flow, lack of trained staff, lack of coordination between departments and non-availability of psychotropic drugs and psychological treatment are plaguing the programme.

The group’s report indicates that states are reluctant to take over funding of DMHP. As per the guidelines, the Centre will fund DMHPs for five years, after which the respective state governments shall take over the programme.

Rahul Shidhaye, clinical psychiatrist working with advocacy group Public Health Foundation of India, points out another flaw in the programme design. “NMHP is the only public health programme in the country where finances are routed through the Directorate of Medical Education,” he says.

“The deans of medical colleges are busy training psychiatrists and are not concerned about public healthcare whose foundation rests on awareness and reduction of stigma.”

In the 12th Five Year Plan, the government plans to redesign the programme and expand it to all the districts in the country. But will it be effective given that India has never undertaken an official mental health survey?

Several analysts are sceptical. A similar effort in 2002 to revamp NMHP and expand it to 22 districts had significantly changed the scope of the programme.

“The new policy reduced emphasis on access to services and community participation (which were the prime aim of the 1982 policy) and moved towards provision and distribution of psychotropic medication,” say Sumeet Jain and Sushrut Jadhav from University College London, the UK, in a paper published in March 2009 issue of Transcultural Psychiatry.

The authors suggest that the authorities revamped the programme without analysing the problems that were ailing NMHP. “...there is no indication of who was involved in this (consultation) process and what resulted from it,” it notes.

The study holds lessons for Union Ministry of Health and Family Welfare, which plans to revamp its mental healthcare system. It has drafted a Mental Health Care Bill to replace the Mental Health Act of 1987.

The Cabinet cleared the Bill on June 13. In all probability, the Bill will be tabled in Parliament in the Monsoon Session, beginning on August 5, and will be cleared. To facilitate its implementation the ministry, for the first time, is charting a mental health policy.

Biological reality of mental illness
There is no single cause that triggers mental illnesses. There are several factors, right from genetic inheritance and exposure to brain-damaging chemicals to conditions that beset people, such as work pressure, death of loved ones or even romantic rejection, which can trigger dysfunction of the brain and lead to mental disorders.

Generally, it is considered that the dysfunction occurs due to problems with neurotransmitters, or chemicals that help neurons in the brain communicate. For example, the level of the neurotransmitter serotonin is lower in individuals who suffer from depression. Similarly, disruption in neurotransmitters, dopamine, glutamate and norepinephrine, is linked to schizophrenia.

Such understanding helps in the development of drugs to treat the problem. Biological psychiatry is now an established branch of psychiatry and uses imaging techniques like psychopharmacology and neuroimmunochemistry to pinpoint the problem. Using these techniques, researchers, in the past five years, have identified genes that influence susceptibility to five common psychiatric disorders, including bipolar disorder. Their finding was published in medical journal The Lancet. Using the technology, researchers at the National Institute of Mental Health in the USÔÇêare developing a classification system that would help differentiate the structure and function of a mentally ill brain from that of a healthy one. This will help researchers understand why a traumatic event leads to post-traumatic stress disorder, neurology of hallucinations and how drug addiction rewires the brain.

There is still a long way to go. Scientists are nowhere close to understanding the brain the way they understand heart, kidneys and other parts of the body.

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