Navigating through the issue, one realizes that Karnataka has a long way to go when it comes to mental health service accessibility for the people in the rural areas.
Bengaluru: Mental health continues to remain an alien concept in the rural parts of the country, especially the villages. Muniyamma uncomfortably smiled when she was asked about what mental health or suicidal thought is. The local flower vendor, in a green saree seemed reluctant and clueless about it.
As per World Health Organization (WHO) statistics , one person dies every second leading to 8, 00,000 deaths per annum globally due to mental health illness. Mental health issues related to anxiety, depression are increasing across the states of India.
The people in the rural area are unable to access the mental health services as only 0.2 psychiatrists, 0.05 psychiatric nurses, 0.26 mental health beds per 10,000 population, 0.2 in mental hospitals, and 0.05 in general hospitals are available in the country.
People are unaware of what mental health is in the rural areas of Karnataka. Amrutha, who runs a medical store in the Kumbalgudu village seemed lost when asked about mental health. Suicide and depression seemed like jargon that one ought to avoid.
Mental Health in Urban Areas
India is home to an estimated 56 million people suffering from depression and 38 million people suffer from anxiety disorders, according to the World Health Organization (WHO). However, of the 20 percent of the population that have mental disorders, only 12 percent of them are able to seek treatment.
Due to a lack of psychologists, psychiatrists, or counsellors in rural areas, people are unaware of a lot of things when it comes to mental health disorders. The country also lacks resources and infrastructure for providing proper treatment to the patients.
Deiptimaan was diagnosed with depression by a psychiatrist in 2016 after a mental breakdown. However, the psychiatrist just gave medicines and no therapy. In 2017, he went to a psychiatrist who then diagnosed him with Borderline Personality Disorder and acute depression. He then started going for therapy which brought about a significant change. He said, “I was able to stop self-hate, increase my self-worth and my mood swings decreased.”
Lockdown created a wider gap in providing mental health services. Deiptimaan said, “I haven’t been able to go for therapy since the first lockdown. It has been difficult to encourage myself to do it online. I ran out of medicines for a few days but was then able to get hold of some through prescription.” “During the time of Covid, I almost took my life due to how emotionally stressed I was,” added Deiptimaan.
Furthermore, he said that mental health is still not included in a lot of school curriculums. Including mental health as a subject for everybody would pave a way for better understanding of the issue among students. Empathy should be inculcated from a young age. Mental health issues can be taken care of at an early stage.
A tenth grade student from Sacred Heart High School, Bangalore, said that mental health is not included in the school curriculum. They do not teach anything regarding mental health and said that it should be included in the curriculum.
Undergraduate Psychology student, Zainab from the Indian Institute of Psychology and Research, Bangalore, said that mental health services have come a long way. People are vouching for therapy and counselling. “Media has played a hugely instrumental role. But again the services are limited only to the privileged. Not everybody can access them as not everybody is exposed to them. It is beginning to come into the light. It is too soon to say that the services are not available to everyone. Counsellors in schools have increased and the importance for a need for one is improving,” added Zainab.
Joseph* has been going through therapy because he had a tough few years and he no longer felt like himself. He said, “I was depressed since 2017 and felt that some professional help and effort from my side could improve my lifestyle and good mental health might help me get back on my feet.” He added, “India is yet to make good strides in the field of mental health services. While there are online resources available and frankly more therapists than I was expecting, the services are expensive and not easily accessible in places outside of major cities.”
Tanya Malik, a psychologist said “Mental health services are not accessible in rural areas. Research is still going on regarding this. The government is trying to make the services accessible. A lot of psychologists and other counsellors are being trained to make people aware of the mental health issues.”
There is a lot of stigma that exists in the society. A lot of traumatic incidents do take place in the society but they are attached with a stigma. Mental health is something that has been normalized and normalized does not mean that it is okay to not talk about it, she added.
There are national and district mental health policies and programs but the outreach of these is still questionable. People refuse to come to a primary healthcare centre due to the stigma built around issues related to mental healthcare. People often prefer going to the faith-healer or the durgahs or temples stating that they can pray and make the illness go away. Such myths and beliefs still, unfortunately, exist in our society when it comes to mental health.
Lockdown in India exacerbated mental health issues
The pandemic has aggravated pre-existing issues. It has adversely affected individuals when it comes to mental health. Kala Balasubramanian, Counselling Psychologist at Inner Dawn Counselling and Training said “During the lockdown, a lot of couples have approached with distressed issues as there is no alternate outlet available during the lockdown for them to let out. Two people are stuck in the house and frustration does build up. So relationship issues did increase.”
Children and adolescents are the other group of effected people who have approached with mental health issues. Issues like self-harm have gone up. Aggression and anger issues have also cropped up during the pandemic, added Kala.
Even though Deiptimaan was emotionally stressed, he managed to find a way around the lockdown to keep himself busy. Deiptimaan said, “ I met a director who lived in my building and I started meeting him every day. We discussed movies, philosophy, politics, etc. It kept me occupied. I started working for him. This way I found a purpose. As a person with BPD, it’s really hard finding and maintaining relationships.”
Looking beyond mental health in the rural area
Mental health issues are not just limited to psychiatric issues but also include social and lifestyle problems. Nowadays people are reaching out for help as people have realized that it is okay to do so but it is more prevalent in urban area and less in the rural.
People who face sexual assault or domestic violence in the rural areas are not able to access services for mental health as they are not aware about such services. They are told not to talk about it and thus do not attempt to approach. The trauma that they go through becomes secondary for them to seek support for.
Kala Balasubramanian said, “Now, most of the services are available online due to the proliferation of technology. During the pandemic too, online services have helped people both in a rural and urban areas as everybody can access it via smartphone. We can increase the reach of services via smartphones through which one can get online counselling.”
Begin from the grass root level
Kala said that a lot of schools are talking about physical health. But a good way to go about mental health being included in the school curriculum would be that of talking about signs and symptoms of mental disorders. Important is to give them tools to deal with while handling mental health and identifying them. In urban areas too there is a gap when it comes to accessibility to mental health. As it is not subsidized by the government.
“Awareness should start from as early as school. Not just have a school counsellor but going beyond it and educating children about mental health is needed. This would be a proactive way of dealing with challenges. Basic life skills like how to deal with a failure should also be given importance. Teaching empathy and being there for others can help an individual,” said Kala Balasubramanian.
“There is a lack of mental health professionals,” added Kala. More than a million people sought mental healthcare in public health institutions across Karnataka during 2018-19, and depression and general anxiety disorders constituted 34 percent of the cases. This is according to the Karnataka Mental Health Report-2019, brought out by CHD Group, a public health organization based out of Mangalore.
Sudha, Principal of Swami Vivekananda School in Kumbalgudu village said, “Our school conducts seminars for the students to make them aware about mental health. It is not really included in the curriculum.”
Parents and caregivers play a major role
Deiptimaan said, “For me, throughout my childhood, my parents were unaware of how much trauma was inflicted on my sibling and me. However, when I sought therapy, they were supportive as I had become self-destructive during that time. I think people should be encouraged to seek help if they need to. Sometimes they don’t want it themselves which makes it difficult.”
Families should be equipped with ways to encourage such an individual in a positive manner rather than getting frustrated with them, added Deiptimaan.
“For people in rural areas, although not as isolated as people in cities due to community relations, it can also have the opposite effect where the society becomes a culture issue. Families should be equipped with ways to encourage an individual in such a situation in a positive manner rather than getting frustrated with them,” added Deiptimaan.
Sudha, the principal said that parents’ mentality towards punishment should change. The punishments given to their children by them are harsh which leaves the children thinking about why the punishments are given. Children are unable to channel their anxiety and stress properly as they get suppressed. They are not able to navigate such feelings and thoughts.
Mental health policies in India
The Mental Health Care Act 2017 was passed in 2017 and came into force from July 7, 2018. The Government of India launched the National Mental Health Programme (NMHP) in 1982, keeping in view the heavy burden of mental illness in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it.
In 2018, the Government also initiated the Ayushman Bharat, a medical insurance scheme for economically deprived people. Ayushman Bharat allows for insurance for medical treatment of the mentally unwell and allows financial protection in the form of allowances.
Presently, the Government of India is providing mental health services in 125 districts out of 626 districts through District Mental Health Programme (DMHP) under NMHP.
What Can Be Done?
Mental health services need strong implementation and proper allocation of resources. An efficient and effective mental healthcare system will help in increasing the accessibility of such services. A lot of times people in the rural area find it difficult to even identify signs or symptoms of mental disorders. In that case, it’s essential to improve the awareness campaigns on mental health. Awareness and sensitivity towards the topic is the need of the hour.
Even though there are helplines available, they need to be made publicized in order to make it more accessible. People are aware that 100 is the helpline for police but nobody really knows the helpline number for mental health services.
The number of psychiatrists in India currently is about 9000 and counting. About 700 psychiatrists graduate every year. India has 0.75 Psychiatrists per 100,000 populations, while the desirable number is anything above 3 Psychiatrists per 100,000. This is a very conservative estimate going by the figures of 6 Psychiatrists per 100,000 population in the high-income countries. Taking three Psychiatrists (per 100,000 population) as the desirable number, 36,000 is the number of psychiatrists required to reach that goal. India is currently short of 27,000 doctors based on the current population of country.
Dr. Santosh K Chaturvedi, Consultant Psychiatrist and Former Dean of Behavioral Sciences and Head, Department of Psychiatry, Mental Health Education and Psychiatric Rehabilitation Services, NIMHANS said, “Looking at the shortage of mental healthcare professionals it is difficult to say so if we do have a shortage. There are barely any vacancies in psychiatric jobs. If we look at the Indian Psychiatric Society directory then there is a listing of around 10,000 psychiatrists.”
*indicates name change