Social stigma surrounding the mental health disorders surfaced during the peak of the first and second wave of the Covid pandemic. Ahead of the World Mental Health Day, Medically Speaking discussed the social stigmas surrounding the issue, severity of the topic and initiatives being taken on the same, with a panel of mental health experts: Dr Manish Kandpal, Prof of Psychiatry, RML Hospital; Dr Aditi Rana, Chief Coordinator, MHFI; Dr Aditya Kumar, Honorary Director, MHFI; Dr Nand Kumar, Honorary President, MHFI, Prof of Psychiatry, AIIMS.
Here are a few excerpts from the interview:
As far as the pandemic is concerned, many people who did not even have COVID were anxious, and many people are still anxious even though the numbers are on the decline. Cases of mental fog, brain fog, and so on are being reported. Do you believe the COVID pandemic has taught many of us to take our mental health more seriously?
Dr Nand Kumar: Mental health is a day to-day phenomenon. You cannot separate it from the physical. For example, if you plan to do anything, it has to come first in your mind, then only you can physically execute it. So that’s mental health. Mental health is not a mental illness, just like you’re all physically healthy despite the changes in your body’s shape, size, and texture, so health has a dynamic. Unfortunately, the stigma is there because when people talk about mental health, they keep misperceiving and confusing it as a mental illness. So, mental health illness is entirely different and mental health is also different. So, health is a day-to-day phenomenon.
As far as you know, the stigma around mental health is concerning. Since you’re in communication, you also interact with us in the media on a day-to-day basis. What are the activities that you all have done to spread awareness about mental health?
Aditya Kumar: Since 2014, we have been celebrating mental health day every year on the 10th of October. As you know, this is a new mental health celebration. We started celebrating it just to initiate a conversation regarding the importance of mental health. So you know, on a day to-day basis, I am noticing more and more young people, particularly those who are engaging themselves with us and participating in the events, and this is the only way to start the conversation regarding mental health. This will help people to understand the importance of mental health. This year we are celebrating virtually from October 8th to October 10th, from 10 am to 6 pm, so all are invited and we are trying to inculcate this awareness among the people.
Mental health is a topic that is rarely talked about, of course, because it is shielded by stigma, patriarchy, and shame. When you’re talking about the participation of the youth, what type of participation are you seeing from the youth when you have the virtual program? Are you still seeing some sort of reluctance when it comes to accepting basic issues, perhaps like anxiety or panic attacks, if not a short-term mental disorder or even depression?
Dr Aditi Rana: So the Mental Health Foundation in India is basically a non-profit organisation which came into being in 2003. Since then, we have been working through different programmes to promote mental health in a very holistic manner. When we talk about mental health, it’s not only about mental disorders or diseases, but it’s also about physical wellbeing, for which we meditate, do yoga, and do pranayama in the same way. When I talk about mental wellbeing, we have to look at it in a holistic manner and that is what MHFI works towards. Other than that, we also happened to have a petition to decriminalise suicide, and when we are talking about mental health and when we are talking about stigma, then one thing that comes into picture is the language barrier that people have. When we are talking about all of this, we are coming from a place where we understand English and these languages, but the majority of the population of India is Hindi-speaking, and there has been a lack of any publication that you know addresses this audience.
When a person begins to notice signs that are alarm bells and should elicit a response from their loved ones, those around them, this does not occur; please help us understand what the alarm bells are. What are the signs one must look out for right in the beginning?
Dr Manish Kandpal: One is mental health and the second is mental illness. Health we define as not the absence of disease but a sense of mental, social, and functional wellbeing. It is a state in which a person can function to their optimum. This is the health concept and the second concept that we have is disease. Like you already said, there is a lack of awareness in our country regarding mental wellbeing. It could be because of various factors, like low education, because of low literacy rate, or because of a decrease in the number of mental health professionals. This is also one of the reasons we don’t have so many mental health professionals in our rural settings. This is one of the main causes of second stigma. One of the factors is that even if people have a disease or issue, they don’t want to talk about it because of shame. This is one of the factors. In mental health or mental illness, there are two or three broad classifications of illnesses that we generally can say are what we call anxiety disorders or neurotic illnesses. The second category is mood disorders, which include depression or bipolar disorder, the third category is psychotic disorders, which include schizophrenia-like illnesses, and the fourth category is the very important disorder of addiction. in the first group of disorders, that is anxiety disorders, we say the people are extremely worried, not able to concentrate at work, they are extremely concerned about small petty things, and they have physical symptoms like palpitations, pounding of the heart, breathlessness, either in a particular setting that we call a phobia or in a normal general setting. We call these general anxiety disorders.
When a person goes to a counsellor, are these signs considered as danger signs?
Dr. Nand Kumar: With milder signs like anxiety and insomnia, people do not go to the doctor. But once these problems start affecting one’s life and nothings seems to be helping, one should approach a medical help. When the person comes to the counsellor, he expects solution, not the medication, but when the problem is intense, medication is needed.
It totally depends on how you explain it to the patient. For example, if a patient comes to you, as a psychiatrist, counselor, or psychologist, your perception is that it is an untreatable medical condition, so you have to take medicine for a long time. Once you start saying this to the patient, he might be reluctant to take the medicine, because no one in life wants to take unnecessary medicine, no one wants to take unnecessary medicine unnecessarily, whosoever it is. So what happens is that we have to educate the patient properly.
Talking about various types of classifications of mental disorders and mental illnesses as well. You know, when this situation, of course, becomes extremely grave, then you see suicides, which is very unfortunate but very high. When we speak of India, the number of suicides in India is increasing at an alarming rate. If you look at the crime record bureau data, certainly there is an alarming rise in the same. The solution to this in layman’s in my mind is recognising the problem right in the beginning, is that true ? if yes , how much it helps you as professionals in diagnosis and treatment sir ?
Dr Manish Kandpal: Yes, as you rightly say, suicide is the leading cause of death, a lot of deaths in India. India is one of the countries where the largest number of suicide deaths occur. As we know, about 2/3 of the people who commit suicide have some sort of depression in them. One of the leading causes of suicide is depression. More than 2/3 of people have depression. So one of the things we can do is, one of the things is apprehension; we had some education or seminar on the general health physician about a week ago. So, one of the general health physician’s concerns was that if we asked the patient about suicide, we would instil this idea in his mind.
How do you refrain from that?
Dr Manish Kandpal: Every patient who comes to you with the symptoms of moderate to severe depression will be asked about the question of suicide. And if the patient says yes, “I have death wishes, I don’t enjoy living, and I should die.” Not the active ideas of hanging themselves, but the passive ideas. These ideas have to be taken seriously and they have to be referred to a mental health professional, either a counsellor or a psychiatrist.
How much is mental health treatment in India affordable? Can everyone access mental health treatments? Because I’m not too sure of that.
Dr Manish Kandpal: Definitely, it is an issue, but what we can do or what we are planning to do is educate general health practitioners digitally about common mental illnesses. We started a programme in a particular district where there are 5-10 living physicians or government practitioners, so this could be one of the ways.
Not even 7 percent of health budget by the government percolates to the mental health sector. Is that true? Is that money enough?
Dr Nand Kumar: So, there are two aspects. One is that access to and the cost of treatment is much better in India than in the US and the UK. The cost in the UK and the US is so expensive, but in India it is quite economical compared to both countries. The second is the availability of doctors, so here comes the difficult part, because the distribution of doctors is unequal. In Delhi we have 150 psychiatrists, in Arunachal Pradesh we have 2, in Ranchi we have 20 and so on. So the major aspect of not getting treatment is awareness. We have Hindi mansik swasht patrika, a Hindi magazine for rural areas where people don’t understand English, and we offer mental health awareness in the easiest storey formats, so this is the way to make people aware.
Many believe those who can afford psychological help are the ones who stop complaining or speaking about their mental health, but that isn’t really the case. According to the WHO, 80% of the people are from rural and low-income sectors and not from the developed ones. Isn’t it sir?
Dr Manish Kandpal: Yes, there is no economic divide in mental health. It is equally prevalent in higher, richer or lower groups. There is no such divide in it, so what we see is that mental health or illnesses are equally prevalent or more prevalent in low socio-economic classes, but we also see that most of them are reluctant to go to the doctors. Most of them still go to a priest or a tantric for treatment. We generally find people suffering for years, even when they go to a psychiatrist.
Tell us a little bit about the importance of mental health and why we all even care so much about speaking about it.
Dr Aditya Kumar: Worldwide, we know the importance of physical health, but we don’t understand the importance of mental health. In 2017, our honourable president, Ram Nath Kovind ji, said India is facing a mental health pandemic. In the same year, a study was conducted and revealed that 14% of our country’s population is suffering from mental health issues. Whether it is depression or anxiety, due to stigma, the patient is not able to go to the doctor. So, it is a high time where we need to create more awareness. We’re already working with Tihar jail, where 16000 inmates reside, and our mental health foundation is working on various issues like suicide issues, anger issues, etc. It is the second largest jail in the world after the US, so its importance is great, but there is a lot of ignorance.
The reality of our generation is that they are spending hours on social media and it is affecting their mental health. So are you addressing this issue at all? If so, how?
Dr Aditi Rana: It is very true that social media is a blessing, but there are aspects that do cause distress and are causing snapchat morphea, so what happens is that people use filters on snapchat and start going to plastic surgeons. As I said, the mental health foundation works, as I said, holistically, so through our programmes we talk about and address these issues as well. A large number of participants are adolescents and adults who are active participants. Before closing, I would like to address one more thing. Doctors have been working too much due to this condition, and it is very important to address their mental health as well.
How do we continue this momentum of spreading awareness around mental health issues? It shouldn’t be that tomorrow covid 19 passes and we start taking mental health lightly again.
Dr Manish Kandpal: It is high time for us as a society to disregard mental health and mental illness. So the thing is, a single person or a single organisation cannot make it happen. It has to be the whole society that changes it and can be a mentally healthy society.