Covid-19: India is staring at a mental health crisis
The social and economic fissures exposed by the pandemic will result in mass unemployment, depleted social safety nets, starvation, increase in gender-based violence, homelessness, alcoholism, loan defaults and millions slipping into poverty. This post-Covid landscape will be a fertile breeding ground for an increase in chronic stress, anxiety, depression, alcohol dependence, and self-harm.
As the coronavirus disease (Covid-19) continues to take lives across the world, there’s another public health crisis that’s rearing its ugly head. This new danger may perhaps unleash more death and despair than the coronavirus itself.
Going by the history of pandemics, and the knock-on effects of an inevitable economic downturn, India is looking at a mental health crisis, with suicide-related deaths as its lead indicator.
After the stock market crash of 1929, the suicide rate in the United States (US) rose 50%; to 18.1 per 100,000 from the 12.1 per 100,000 from 1920 to 1928 and stayed at 15.4 per 100,000 between 1930 and 1940. In 2008, researchers from the University of Oxford and the London School of Hygiene & Tropical Medicine noted an extra 10,000 “economic suicides” across the US, Canada and Europe, due to the financial crisis. These suicides were attributed to the economic hardships post-recession.
The social and economic fissures exposed by the pandemic will result in mass unemployment, depleted social safety nets, starvation, increase in gender-based violence, homelessness, alcoholism, loan defaults and millions slipping into poverty. This will be a fertile breeding ground for an increase in chronic stress, anxiety, depression, alcohol dependence, and self-harm; leading to an overall rise in morbidity, suicides and the number of disability-adjusted life years linked to mental health.
At-risk populations include the 150 million with pre-existing mental health issues, Covid-19 survivors, frontline medical workers, young people, differently abled people, women, workers in the unorganised sector, and the elderly.
For a country with the highest number of poor and malnourished, and individuals with depression and anxiety, this is the perfect storm. How many suicides can we expect? India reported 1,34,516 suicides in 2018. Most independent estimates are far more. The World Health Organization (WHO) pegged 2016 suicides at 215,872, with a suicide rate of 16.5 suicides, against the global suicide rate of 10.5. History tells us that India should prepare for a large number of suicides, even in the thousands. Other than human suffering, suicide has an economic dimension, each death costs Rs 265,000 in the first year alone, says a study by Gopala Sarma Poduri in the Indian Journal of Psychological Medicine. Short-term costs include hospital expenses for the act leading to death, autopsy expenses, police investigations, funeral expenses, etc. Long-term costs include the lost income that could have been earned by the person till retirement, tax that the government lost from that income, among other things.
Given that the second wave is expected, most of these deaths can be prevented.
First, India can appoint a minister with a Cabinet rank as head of mental health and well-being, and create an emergency task force of public health experts in creating and executing evidence-based interventions.
Second, work on a war footing to push to implement the Mental Healthcare Act, 2017, (MHCA) that promises mental health care to all and introduce a suicide prevention policy. Many countries, including China, have been able to significantly reduce suicides after they implemented a suicide prevention policy.
India’s investment in mental health — the last Union Budget slashed it by 20% from Rs 50 crore to Rs 40 crore — will need a boost. According to estimates, Rs 93,000 crore will be needed to implement MHCA, 2017. This could come from the PM Cares Fund, corporate social responsibility initiatives, private equity, and perhaps, a new national lottery.
Rural India may be particularly susceptible to suicide due to the influx of migrant workers, and also because it is home to the at-risk farmer community. The central storage of pesticides in the farming community, decreasing the lethality of pesticides, and interventions to dissipate suicide contagions might be key.
At the centre of this should be a large public engagement campaign to increase help-seeking. This must be centrally driven, supported by state governments, and endorsed by influential people. Mental health and suicide should be treated as a public health crisis that needs immediate fixing. Mainstream media and social media giants can be roped in to create and spread awareness.
There is a good chance that alcohol addiction will rise after Covid-19. It will be beneficial to provide rehabilitation services that address both physical and psychological aspects. Community-based interventions such as Atmiyata’s community-based volunteers in Maharashtra and Gujarat, SCARF’s mental health mobile vans in Tamil Nadu, and Sangath’s VISHRAM, that used community health workers for the first line of treatment (depression fell by 22% and prevalence of suicidal thoughts fell by 51%), can be scaled.
To reduce the pressure on the overworked primary and secondary mental health task force, the focus should be on self, family, community and primary care. Group psychological support for the unemployed through non-profits and the community will help. Training millions in suicide prevention techniques and combining crisis intervention by providing psychological first-aid will help save lives and reduce emotional distress, preventing long-term trauma.
Digitally-mediated therapy and telepsychiatry (NIMHANS runs a successful telepsychiatry intervention in Karnataka) should be scaled up. A mental health startup incubator (funded by the Startup India programme) should provide the necessary impetus to spawn innovations that tap technologies like artificial intelligence, machine learning and chatbots. Use of low-tech like text messages can be highly effective in increasing awareness, decreasing stigma and inducing help-seeking behaviour.
Finally, every crisis is an opportunity. The 1918 global flu epidemic stirred many European countries to create national health services. While mental health woes can shave off 3-4% of GDP, every dollar investment has a return of four-six times. Mental health and suicide prevention interventions can not only save lives, but also make immense economic sense.
Nelson Vinod Moses is founder, Suicide Prevention India Foundation, and an independent journalist
The views expressed are personal