I do not want to shock you friends! 1/7 Indians are mentally ill according to the Global Burden of Disease [GBD] 2019 data released last year by Ministry of Health and Family Welfare. 20 crore Indians need urgent mental health assistance, the report screamed. NIMHANS [National Institute of Mental Health and Neurosciences: Bangalore] gave a figure of 1/8 three years ago. Hence one member of our extended family is probably mentally ill, and many may not be aware too. So, any humiliation and stigma hurled at the mentally ill by any one on any platform will affect his own brethren. So be careful! Do not slaughter the minds of a loved one.
Why is the surge?
The human brain has not changed its size, shape, colour, texture, volume, or chemistry but the environment around has changed. Globalization does not allow human beings to meet, chat and make merry largely in the metros and in large parts of the country. ‘Disconnection’ between human beings is the biggest disease. What we are suffering, is worse than AIDS. When we walk we can connect but as we run we are lost, isolated and operate nearly as robots largely in dense cities and towns. The Emotional Contact Time between families has gone down. The rapid social change, increased pace of life all over is destroying the mind body orchestra. Social factors such as violence, gender issues, marginalization and economic issues also affect mental health. I am restricting this article to the data before COVID 19 on Suicides in India. Looking at the NCRB data 2019, I would like to pose the following arguments!
More than 1/5 of those who died of suicide were Daily Wage Labourers. Of the total suicides by men [97,613] the maximum were daily wage labourers [29,092] followed by self-employed [14,319] and unemployed [11,599]. Mental health is not only about feelings but probably also about food. Though Poverty Alleviation programs have been on the top agenda of the government, much more needs to be done. Mental Health Science is not Rocket Science, neither is it just an esoteric philosophy. It is not quantum physics but is largely a logical science though a lot of qualitative factors such as class, creed, culture, race, and geography may influence the course and the outcomes. I have been trying hard to convince bureaucrats, politicians and others that, health care workers who do house to house surveys for malaria, TB and other infectious diseases can also be empowered to screen those, who are mentally ill and ones who are contemplating suicide. But the resistance is huge largely due to stigma in the minds of the opinion makers. The stigma will break much faster when we hold the issue by the jugular and not with ‘touch me not gloves.’ Indians are in a mood to disclose, but we are scared to ask the right questions.
Family Problems: 32.4%
More than 1/3 deaths by suicides were due to Family Problems. Though the W.H.O does not value the ’causes of suicides’ in India report because they are generally reported by family members, friends and cops, yet it gives us an understanding of the major issues affecting families. Relationship crisis, Depression, financial issues, overcrowding and other reasons may dwell below the figures. Families are moving largely from huge joint families to nuclear families. More than 1/6 of those who end their lives are also housewives. They are also accounted for 51.5% of the total suicides among total female victims [21,359 out of 41,493]. Madhya Pradesh, Maharashtra, and Tamil Nadu record the highest numbers here. Family problems and the high suicides among women call for massive emotional empowerment of this group. Creative solutions need to be sought here. If the ‘UJJWALA SCHEME’ and ‘Swachh Bharat Abhiyans’ have caught the attention of the masses and has provided succour then Mental health programs through campaigns in villages, towns and cities can be blended with them thereby improving mental health. Mental Health is too important to be left to Mental Health Professionals alone said Late Prof N. N Wig of Psychiatry who worked with the W.H.O decades ago.
The Less Educated are more vulnerable
7/10 who died due to self-harm were either illiterate or studied till 10th std and if you add those who touched 12th std, the figures go up to 8.5/10. Well, this points to the fact that ‘Mental Health Vaccine’ needs to be injected right in the primary class. The vaccine metaphorically would mean a vibrant ‘Mental Health Software’ that is not prone to virulent attacks of a changing world akin to learning to ride a bicycle that can never be forgotten ever in one’s life. The ‘New Education Policy’ needs to address this on a war footing. The common refrain would be that the country does not have enough mental health professionals. India cannot wait for eternity for the adequate number of professionals and countries that have enough are also not doing so well. Yet the Ministry of Health needs to find more seats for MD [Psychiatry], MA [psychology], M Phil, MSW across the country. We do not need a Top Heavy Model for providing Mental Health reliefs either. We need to train a lot of Mental Health Soldiers across the country who are trained in Emotional First aid, identifying high risk individuals prone to self-harm and skills in accessing services. Religious Leaders, Social Workers and Community Leaders need to be enrolled for ‘suicide prevention’.
UP, BIHAR, Jammu & Kashmir, Nagaland, Manipur throw surprises
These states have the lowest percentages with Bihar having 0.5 % and UP on the other extreme having 2.4% suicide rates of the country. The impulsive interpretation would be that, these states have very low reporting. I would not like to believe that this could be the reason. Is it that the social cohesiveness is better or is there an inverse correlation between violence and suicide? I do not know. A thorough field-based research is the need of the hour in a few villages that may closely represent the demographic profile of the states. Are there new leanings? We should not underestimate the resilience of different groups in the country. India is a ‘symphony without synchrony’ where the asynchrony is beautiful.
Maharashtra + Tamil Nadu + West Bengal + Madhya Pradesh+ Karnataka = 49.5% of the Total
These states have topped the total figures for the country whereas the remaining 24 states and the 7 UTs are responsible for the rest 50.5%. These states are on the top for some time. Uttar Pradesh the most populous state has one of the lowest figures. The reasons are not very clear.
A total of 1.39123 suicides were reported in India in 2019 an increase by 3.4 % from 2018! New Research suggests that approximately 50% of suicides are not related to mental illness. The reasons may be impulse, loss of meaning, low frustration tolerance and other reasons that need further research. Suicides should never be politicised. I had written to the Andhra Pradesh High Court and the Supreme Court of India to conduct a Psychological Autopsy after the death of Rohith Vemula. Ditto with the sad demise of Payal Tadvi a Post Graduate medical student in Mumbai some time back. The politicization of ‘suicides’ cause a lot of agony to those who are ill and others who are in great distress. They may just tip over with disastrous consequences. Resorting to a Psychological Autopsy can clear the air and the true facts most often may be ascertained
India does not have a ‘Suicide Prevention Policy’: Dr Lakshmi Vijayakumar who founded the mental health help line ‘Sneha’ in Chennai had this to say, “suicide prevention is not solely or even primarily the domain of mental health practitioners providing interventions for suicidal individuals. While not losing sight of the substantially heightened suicide risk for people with mental disorders, suicide is a complex and highly stigmatized issue in India, as it is elsewhere. Suicide prevention planning should be grounded in a broader public health approach framed around multispectoral collaboration and equal acknowledgement of the socioeconomic and cultural determinants of suicide and suicide prevention in India.” Suicide in India is a complex public health tragedy in need of a plan: Lancet 2018 : Gregory Armstrong Lakshmi Vijayakumar.
I have been conducting suicide prevention workshops for the last two decades and so are hundreds of other Mental Health Professionals across the country. But this is not enough. We cannot reverse the process of ‘rapid pace’ and ‘globalization’ that boasts of ‘vision’, ‘mission’ statements for its benefactors but aims only at profits. Tectonic changes across different sectors are a must. Organizations do not have ‘Mental Health Policies’ that are inclusive and not aimed at excluding those who are distressed. The Disability Act 2017 recognizes 21 disabilities and protects the rights of the mentally ill. The Mental Health Care Act 2017 does the same but Suicide Prevention cannot be a linear activity by mental health professionals alone but need to be associated with major policy changes.
Mental Health Professionals need to spend 50% of their training in communities. Classroom training & running OPD’s and Hospitals are important but looking at the socio-cultural underpinnings, cultural wisdom and learning non-traditional techniques are as important. The ‘Patch Adams’ like compassion can only be learnt by being with people in their environments.
Suicide Prevention is a Public Health Issue. In fact, the Suicide Report must be under the aegis of the Ministry of Health as it is no longer a crime. Media Guidelines of reporting suicide has been flouted repeatedly more so recently causing a lot of damage to those who are ill on treatment and those in severe distress.
(Author: Dr Harish Shetty MD is a psychiatrist at the Dr L.H. Hiranandani Hospital , Powai, Mumbai)