Mental health has come a long way from stigma, fear of ostracisation and dreaded admissions to mental asylums and sanatoriums, with people, especially the young, seeking professional help for prognosis and treatment of mental health issues at early stages. Celebrities have played a crucial role in bringing mental health to the public domain and into family conversations. One of the positive outcomes of the Covid pandemic has been an increased awareness on health, including mental health, says Prof of Psychiatry Prabha S Chandra, Dean, Behavioural Science, National Institute of Mental Health & Neuro Sciences (Nimhans) in an exclusive interaction with the editors and staff of TNSE. Excerpts:
What is the level of mental health understanding now?
It is no longer that people call a person ‘mad’ if he/she has a mental health problem. There is a certain level of acceptance of mental health problems, at least in urban India, if not everywhere. The general level of understanding about mental health, especially after the Covid pandemic, has increased. More people, especially the young, are aware of mental health and are seeking help.
What are the common mental health problems which young people are seeking help for?
There is a wide range of mental health issues. The anxiety levels of the youth seeking help are high. They are worried about their future. It ranges from education to workplace stress, academic performance, interpersonal relationships, handling grief etc. Many people lost their loved ones during the pandemic and they have not been able to come out of grief. The pandemic has also resulted in other losses, like that of a whole year of being without peers, not having regular routines or access to sport or recreation -- all of which impact a person’s mental health.
With it there has been a heightened sense of health related anxiety and vulnerability. Also, the present generation is facing a different set of challenges/pressures unlike the previous generations. While earlier, parents would compare their child with a neighbour’s or relative’s child, who is doing well and force their child to perform better. Today, the youth are not only aware, they also compare their performance with people from across the world and feel the pressure. They try to excel in many things at the same time, which is not possible and can lead to stress and feelings of low self-worth, depression.
Is social media and Internet addiction on the rise? What are the reasons for this?
Yes, addiction is on the rise as people are using technology more than they should and are seeking help to come out of it. The average age of people coming to our Services for Healthy Use of Technology (SHUT) clinic at Nimhans for treatment is 14-25 years. When other factors that helped people relieve stress came down during the pandemic, they began using mobile phones for not just entertainment, but also for social networking and gaming, leading to addiction. Sports, theatre, literature and art are excellent ways to relieve stress. However, a lot of these came down after the pandemic and are only gradually being resurrected. When people lose their social connections or face interpersonal problems, they often use the phone and Internet as solace leading to overuse and addiction. It is important for people to be able to voluntarily control their phone usage. If phone addiction is impacting your work and relationship, if you are losing sleep over it and if not being connected to your phone or Internet even for a short while makes you irritable and unhappy, then it is time to seek help. People should differentiate between “use, overuse and addiction.”
What about the problems faced by the elderly?
Loneliness is one of the biggest mental health issues among the elderly in India. Countries like the United Kingdom and Japan have appointed ministers to tackle loneliness. In India, we find many elderly people who are used to “meaningful connections,” now living on their own. Our population is also ageing and this problem of loneliness should be handled effectively as the elderly cannot reach mental health care providers easily like the younger ones. The elderly are used to being stoic and not using terms like depression and anxiety. They would say that they are tired and sleepless, but would never mention depression. Elderly abuse has also gone up. The present urban set-up, roads and public spaces are not conducive for the elderly to move around, go for a walk and meet people, making them even more lonely.
Suicide has become a worry for the country. Why do people choose to end life?
Suicide rates in India are extremely high especially in the age category of 15-29 years. Suicide is a big issue that needs to be addressed and the Indian government recently released the National Suicide Prevention Policy. Unlike in many other countries, where suicides are a result of mental illness, in India the reasons are mostly socio-cultural. Among the young, the reasons are multifactorial and complex and cannot be attributed to simple reasons that are often highlighted in the media. Academic failure is one big reason why young people attempt self-harm. We must have dignity of labour and should provide different pathways to a child besides rote education and chasing marks to explore his or her fullest potential. Suicide does not happen in a vacuum. There are many things that may lead to it. A lot of the families where suicides happen have distinct problems.
A child may not find anyone to talk to. His or her identity gets reduced to academic prowess. Developing school and professional systems will help minimise vulnerabilities. For example, remedial education for those who do not fare well, early supplementary exams, choice of subjects and support for persons with learning difficulties and career counselling to look at alternate routes of skill development should all be part of education and schooling. In the West, not many children go to university. They have other ways of getting somewhere. After academics, a lot of attention needs to be paid to bullying. It has become a big problem globally and in India.
Often the bullies go through their own issues at home. Addressing and calling out bullying in some way, either in schools or otherwise, is important. There are bullies in workplaces or we might have a partner who is a bully. Among women, domestic violence and sexual violence are the commonest factors contributing to the high rates of suicide in Indian women compared to global figures. It is a problem that needs to be addressed urgently by providing more support to mental health consequences of violence towards women and girls and also preventing violence by working with men and boys. Financial support, stimulus packages, especially in times of crisis, are a good method of preventing suicide because particularly in men, job loss and economic difficulties are very high reasons for suicide. Alcoholism is also a major factor. Suicide rates are much higher in men in most countries because of alcohol. A lot of suicides in men happen under the influence of substances, particularly alcohol. An elephant in the room is responsible media reporting of suicide and not sensationalising it and having more stories of resilience in the media.
How can suicide be prevented?
Firstly, all the factors that contribute to suicide should be addressed. We talk about universal prevention and selective prevention. Universal prevention includes broad brush interventions such as school mental health, workplace mental health, parenting programmes, substance use prevention and life skills training. Selective interventions focus on persons at high risk -- women facing violence, those who have attempted suicide earlier, persons with alcohol or substance dependence and persons with mental health problems especially depression. Helplines and gatekeeper training programmes have been found to ebe useful. It is a well-known form of training that happens around the world and in India, where you create gatekeepers in offices, schools, colleges, hostels, police, army and anywhere else. Gatekeepers are people who act as a link between a person who may be at risk for suicide and a mental health professional. So, if you find that a person is disturbed or a person is very distressed not feeling good or vulnerable, or they may be going through challenging life situations such as job loss, financial loss, domestic violence, a serious health problem or grief then the gatekeeper is able to come and help that person and sign post them to the right resources.
All of us may need to be gatekeepers at some point. Most people in distress want to talk to somebody. It’s just that no one is available to them. There are many touch points in a person’s life – like schools, libraries, workplaces, where we can prevent suicide. There are many places where touch points can be identified, like hospital emergency rooms where people are admitted after suicide attempts. On an average, there are around 10 to 12 people who have overdosed admitted to Victoria Hospital every day. We now have a programme – Brief Contact Interventions (BCIs) – under which, anybody who has attempted suicide is approached for a brief intervention and followed up with. The WHO has shown that periodic brief contacts with the high-risk person or even through phone, are effective in preventing subsequent suicide attempts. After years of advocacy, the Thayi (maternal health card) has decided to include two questions on mental health. This is because it is one of the few times in a woman’s life when she is in touch with the health system regularly and provides us a unique opportunity to address her mental health. It’s a very good opportunity to ask about any violence occurring in the family or any kind of mental health issues that she might be facing.
What are the signs that a person is at risk of ending life by suicide?
Someone who has made one suicidal attempt is a very strong candidate. Watch out when someone says that he feels like dying or appears very distressed or withdrawn. If a person is known to be impulsive in the past and is currently facing a difficult life situation, they may be at risk too. Instead of countering his feelings or labelling it as a sin, help that person process that thought and ask them what’s going on in their minds and how you can help. Encourage them to speak about their distress, validate their emotions and gently show them other alternatives. If the person still looks distressed, ensure that they meet a mental health professional.
What role do parents play in bringing up mentally balanced children?
Our research has found that conflicts, fights between parents or family fights can affect babies as young as six months old. Violence at home impacts a baby’s behaviour and sense of well-being. For older children, they understand that there can also be conflict, but what kids want to see is resolution. This is called rupture and repair. They want to see that even though their parents are fighting with each other, they are still able to resolve it in some way. Parenting is a responsible job and should be treated with intentionality and reflection. We must not become parents by default. We must think whether we have the time to devote to a child as well as the space to raise the child. Parenting isn’t just about providing things to children, it’s about spending your time with them, listening to them and helping them with issues that they may be going through. This is something that many kids are missing out now because parents are also glued to their gadgets. The parent-child time that used to happen earlier doesn’t happen anymore in many families. The early years of a child and adolescence are unique opportunities to prevent mental health problems from surfacing later and we should use the family and school spaces to address these. Teaching about expressing and labelling emotions, handling anger and disappointment, managing conflicts effectively, supporting others and altruism are areas that need to be addressed very early on.
How do people know when they should seek medical help as a lot of problems are normalised?
When one feels that they are not okay, they should first talk it out with their near and dear ones. When you are not enjoying things that you like, if you are feeling depressed without any reason or more than what is expected due to a life event, if you lack concentration, are disinterested and if all these are affecting your day-to-day activities and lasting for a longer period without relenting, say for more than two to three weeks, then you should seek professional help.
Has the disintegration of joint families led to an increase in mental health problems?
Mental health problems were present even when joint families existed, so it may not be appropriate to attribute the increase in mental health problems only to nuclear families. What has happened over time is the lack of support which a joint or extended family usually offers. Also, if people are living by themselves and facing a mental health problem, even day-to-day challenges become more overwhelming leading to escalation of the severity of the mental health problem. Families which are connected – even if not physically under the same roof – offer support. But its disintegration has led to an increase in mental health problems. The level of social connectedness in the families itself has come down.
You mentioned that social connectedness is important for mental health. How do we stay socially connected?
More than through social media, it is important for us to remain socially connected. Urban planning should include spaces that should create opportunities for social connections. Parks in localities where interaction is encouraged through ways for groups to interact can go a long way. Easy access to these parks and spaces for the elderly, mothers with young children and kids are important. Currently parks and lakes are being used only for walking and the timings are such that young mothers with infants or toddlers or older people cannot access them during the day. Having grounds where children can play (and not converting every area into a park) encourages sports and play which is essential for mental health of children and adolescents. Libraries can act as fabulous places for group chat and conversations about a recent event, a book or an article. Museums should also facilitate such activities and ideally bring different generations and diverse groups together. The important thing is to not make any of these activities only available to those who have privilege or resources but be accessible to all including people with disability. All these should be part of urban planning. Scientific evidence strongly suggests that social connectedness is a core psychological need, essential to feeling satisfied with your life.
What types of treatments are now available for persons with mental health problems or the mentally ill?
It depends upon the problem and the prognosis. There are common mental health problems, namely anxiety, depression, life situation-related stress, panic disorders or phobias. Then there are severe mental health disorders, like psychosis, schizophrenia, very severe obsessive-compulsive disorder or bipolar disorder, where the person is usually completely out of touch with reality or has difficulty managing his/her day-to-day life. These need a proper assessment by a mental health professional (psychiatrist, psychologist, psychiatric nurse or a psychiatric social worker) who will decide the line of treatment. A lot of family physicians or general practitioners are now trained and are equipped to deal with common mental disorders, so they don’t need to always approach a psychiatrist for these issues. If the problem is more of a workplace adjustment or relationship and is recent, then a counsellor can be approached. If the issue is more long-standing or deep rooted, then a psychologist will be more equipped to help you with therapy sessions.