World Mental Health Day
[ Dr Tame Kena ]
The World Mental Health Day was observed for the first time by the World Federation of Mental Health, led by Richard Hunter, on 10 October, 1992. Since then, it has been observed every year the world over to create awareness on mental health issues and advocate for people and families suffering from mental illness.
The theme for this year couldn’t have been more relevant, given the stage we are going through during this Covid-19 pandemic, ‘Mental health for all: Greater investment and greater access’.
The importance of mental health and wellbeing cannot be emphasized more as the mental stress and its consequences are felt more heavily during this prolonged period of pandemic. In many ways, it has highlighted the stark realities of human frailties and helplessness we face across the globe, leading to more awareness about mental health and wellbeing as never before. Hence, there is more need to work towards greater investment and greater access towards mental health for all.
However, the big question is, are we prepared and ready to invest? What is the burden of mental illness, and is there any treatment gap for those suffering from the illness?
When we look at the policy level, there were major landmark steps taken by the government of India. In 2014, the National Mental Health Policy was drafted and released. A national mental health survey was conducted across the country in the same year by the National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, and commissioned by the ministryh of health & family welfare, New Delhi.
Burden of illness
The survey results were quite mind-boggling, as it suggested that 10 percent of the population (13.8 crore) suffered from mental illness of the 138 crore national population. Of these, 0.8 percent (1 crore) was suffering from severe mental disorder, which amounts to say that one crore families were going through the ordeal of the consequences of a severe mental illness. When we look at the illness, unlike other physical illnesses, it’s not only the individual but the whole family goes through stages of denial, anger, frustration of restraining and ensuring compliance to treatment, stigma from the society and loss of economy and productive time while caring for the person with severe mental illness.
The study also found a huge treatment gap of about 70-86 percent; so only about 15-30 percent of the population was able to access treatment at the time of survey. There were many reasons enumerated, the prominent ones being not having access to mental health care, not aware of being mentally ill, not having regular supply of medicines, lack of counsellors and therapists, stigma, discrimination, etc.
When we talk of a country like India, the numbers are huge in terms of the treatment gap; hence, there is greater need for investment in mental health to have greater access for all.
The other landmark study in the field of mental health was concluded a year ago, in 2019: the national survey on extent and pattern of substance use in India, by the ministry of social justice & empowerment, in collaboration with the National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi.
Every state and union territory was surveyed and the results are quite alarming. Four districts of Arunachal were included in the survey: Papum Pare, West Siang, Tawang and Tirap.
At the national level, the survey showed that 16 crore population were using alcohol, 5.7 crore are problematic users and 2.9 crore are dependent or addicted on alcohol. Again, when we look closely, we are talking about 2.9 crore families being affected. So it’s not just the individual but the whole family going through the burden of alcoholism and its consequences.
For cannabis, the survey showed 3.1 crore users with 72 lakh problematic users and 25 lakh dependent or addicted to cannabis. Opiate users amounted to 2.6 crore with 77 lakhs problematic users and 28 lakhs dependent users. The survey also showed 10 lakhs for cocaine, 18 lakhs for amphetamines, 12 lakhs for hallucinogens and 7 lakhs for inhalants in children. These are reported numbers from all around the country, but the actual numbers may be higher.
Among all the 36 states and union territories, Arunachal ranked among the top five in almost all categories, including cocaine, inhalants, opioids, amphetamines, alcohol and cannabis.
As far as suicide is concerned, the National Crime Records Bureau in 2019 reported that 1,39,123 persons committed suicide, which equates to 381 completed suicides every day, and 16 suicides every hour. However, for every completed suicide there are approximately 20 attempted suicides, which amounts to 28 lakh people attempting suicide in India.
We had a spurt of suicides in our state in the past few months, including in the adolescent age group, which is quite worrying. Given the time of social isolation, the actual figures could be higher as many family and friends remain cut off from one another for a prolonged period of time. There is also the stigma of possible labelling as death from Covid-19 and further isolation by the society.
Mental Health Care Act, 2017
The Mental Health Care Act was enacted with the aim of ‘Right to access mental health for everyone, not only for people with mental health disorder’ in 2017.
Under the act, a person with mental illness has the right to outpatient and inpatient mental health services; support to families of persons with mental illness; rehabilitation services and child and geriatric mental health services; and provision for free/affordable essential medicines.
The above should be made available from community health centres and upwards in the public health systems. Every district should have a mental health programme as per the act and people should have access to mental health services. Under this act, there is also a provision for advance directive, wherein a person who is not a minor can specify in writing the way he/she wishes to be cared for and treated for a mental illness, and also appoint or nominate a representative in order of precedence.
There is another major change in the Mental Health Care Act Section 115 (1) regarding the attempted suicides, which states that “Notwithstanding anything contained in Section 309 of the Indian Penal Code any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said code.”
This is a significant change, given that those who attempted suicide could be booked in the past and could even be sentenced to imprisonment or fined, which was a big deterrent for people with severe stress or mental health issues to seek help.
Although the exact figures are not available, there has been an increase in the number of anxiety and depressive disorders presenting in the psychiatry department of the TRIHMS OPD. An average of 15-30 patients are catered to in the OPD on a daily basis, with a sizeable number managed over as part of tele-consultation, especially for those who need follow-up and cannot travel to the hospital. There is an increased shift of patients suffering from anxiety and panic disorder and depression. Many of them suffer from psychosis, mood disorder, acute stress reactions, multiple somatic symptoms, relapse of seizures, and insomnia. A significant number presents with substance use disorder – predominantly opiate and alcohol use disorder.
What has been observed is the increased number of relapses from previous mental illnesses whilst on treatment, which is termed ‘breakthrough illness’. It is also significant to note that, despite the stigma and fear of contracting the virus, there is an increase in the number of people seeking help for mental health issues. This shows the seriousness and the need for greater access to treatment of mental illness.
As part of mental health initiative, the department of psychiatry, TRIHMS, in collaboration with the DHS had conducted various webinars for the doctors, nurses and counsellors in the districts. Topics covering identification and treatment of various mental illnesses and substance abuse and dealing with substance abuse in the districts were imparted through webinars to the districts.
Treatment protocols for emergency situation due to substance abuse, especially in Covid care centres and quarantine facilities were educated. TV programmes and panel discussions were conducted through All India Radio and Doordarshan in Itanagar on the impact of Covid-19 pandemic on those with persons and families with mental illness and substance use disorders.
As we become fatigued and weary from the long war with Covid-19 pandemic, we are yet to feel the full impact of stress and its consequences with the rise in numbers of positive cases and death. The effect is likely to extend not only to the general population but also to health workers, law enforcing agents and others who are mandated to keep the wheel moving while we remain uncertain of a definitive treatment for the illness.
We are also uncertain of the impact on our children who are made to remain indoors, take online classes and miss out on their playtime and social bonding with peers. The risk of mobile and internet addiction among young children, impact on their sleep pattern, mood swings, etc, will only emerge in the days to come.
As highlighted earlier, the lockdown was also one of the factors for which people in stress during this pandemic couldn’t reach out for help, given the paucity of services available in the districts. Still, many are stranded in far-flung areas with limited transport services, road blocks and fear of contracting Covid-19.
The recent advent of tele-medicine initiated by the department of health & family welfare through the TRIHMS is a welcome step and would go a long way to address the above issue.
As we can see, the burden of mental illness is huge and the treatment gap is large. There is a need for greater investment and greater access as never before.
As we pause and ponder today on this day of World Mental Health Day, let us pledge to at least help one person with mental illness – it could be your work colleague struggling to cope with work, your distant cousin in depression, your neighbour next door struggling with the loss of business, or your old parent unable to sleep. Let us join hands to advocate ‘greater investment’, so as to have ‘greater access to mental health’ for everyone, everywhere! (Dr Tame Kena is Assistant Professor, Department of Psychiatry, TRIHMS, Naharlagun.)
There is an increased shift of patients suffering from anxiety and panic disorder and depression. Many of them suffer from psychosis, mood disorder, acute stress reactions, multiple somatic symptoms, relapse of seizures, and insomnia. A significant number presents with substance use disorder – predominantly opiate and alcohol use disorder.