The World Federation for Mental Health (WFMH) themed this year’s Mental Health Day as “Mental health in an unequal world”. Inequalities pertaining to global mental health are being discussed in comfortable armchairs of well-ventilated conference rooms, while at the grassroots level, another adolescent suffocates himself sniffing whitener fluid. A correction is indeed needed. The preamble of mental health needs to be rewritten for the welfare of the people, for the people, by the people.
The inequalities are manifold. Mental health is almost like the Cinderella of health, given step-sisterly treatment, abused and neglected. The glass slipper is unique and not equal to the rough trekking boots of physical health. The delicate curation of issues associated with mental health highlights the first inequality. Mental health is an invisible disability, absent to the naive observer, further compounded by its dynamic nature and impairing abstract domains of social and cognitive capacity.
The second inequality lies in the systematic stigma faced by mental health compared to other non-communicable diseases (NCDs). Mental health is the frog prince of NCDs; even though India was the first country with a dedicated National Mental Health Programme (NMHP), it has always been gauged through the lens of other NCDs like diabetes, cardiovascular diseases, etc., and was in fact deemed unsuccessful, without giving it enough time. The need to understand the complexities of mental health while also including it in primary healthcare packages at par with other NCDs is a delicate balance that will be the kiss of a princess to realise its full potential.
It is not just the identity of mental health that is at stake; the causative models of mental health and their disproportionately higher prevalence in vulnerable groups highlights the third inequality. The three little pigs of mental health—biological, psychological and social factors—are dynamically interacting, which provides the scaffold for mental health. However, the wolf of adversities differentially dismantles the people living in houses of straw and sticks. The bidirectional relationship between poverty and mental health has been well-recognised and evidenced. Poverty brings with it stress, debt and a struggle to sustain; existence is equal to surviving another day. The social causation theory talks about impoverishment as an important determinant of mental illness whilst people living with such problems are often unable to work and thus get stuck in the vicious loop of disease, disadvantage and disability. These vulnerabilities are exponentially enhanced in religious and sexual minorities, which have been further intensified by the ensuing Covid-19 pandemic. These inequalities are existent in terms of visible (poor infrastructure, etc.) and invisible factors (stigma, etc.). Ways of improving access from both the demand and supply side and stressing on the felt needs of individuals despite various barriers is the reinforcement needed for the flailing infrastructure. The Mental Healthcare Act of 2017 is a rights-based model that, under Section 18, guarantees every person the right to access to mental healthcare (free essential psychotropics, ambulance services, etc.) and qualifies an individual for compensation from the state in the absence of the same. It is a step in the right direction.
Not only recovery but also treatment needs to be viewed with a spectral perspective; both should not necessarily aim at an absence of disease as this may increase inequalities between ill and normal when the entire construct of mental illness is itself lying on a spectrum. To mitigate this, we need to focus on universal, selected and indicated prevention. “Prevention is better than cure” is an adage that has stood the test of time, place and person. Increasing health expenditure in general and mental health costs in particular, training community mental health workers in basic counselling skills, imparting awareness and inculcating protective lifestyle habits like yoga, correct nutrition, etc., are the way forward rather than focusing on just those with diagnosed mental illness and reconceptualising it as a family diagnosis rather than an individual one.
The final inequality is in terms of available mental health infrastructure. It is a sad reality that the number of mental health professionals available in the country is far below the required international standards. A majority of these limited professionals are concentrated in urban settings whereas a major chunk of the Indian population resides in rural areas. There is also a clear North-South divide. Many early-career psychiatrists drift to Western countries due to a multitude of reasons. As psychiatry is still not a golden egg speciality like radiology and dermatology, better inclusion in the medical curriculum, more hands-on experiences with psychiatric patients and adopting a community integration model for people with mental illness rather than institutionalisation may open new vistas for medical graduates and reduce inequalities in mental health from a service provider’s stance.
Thus, mental health in the current scenario is not a fairy tale. However, we all can strive to be the fairy godmother and provide the necessary mental health infrastructure to promote mental well-being. We must be the change we want to see and help write the next chapter in the book of mental health in an ideal world.
Thus, a lot needs to be done to turn this grim tale into a Grimm’s fairy tale.
Dr Prateek Varshney, Psychiatrist, NIMHANS, Bengaluru
Dr Debanjan Banerjee, Consultant geriatric psychiatrist, Kolkata