Voices in their heads: How India deals with mental disorders
A month after her only novel The Bell Jar was first published in UK in 1963 under the pseudonym of Victoria Lucas, American poet Sylvia Plath did what Esther Greenwood, the mentally disturbed protagonist of her novel couldn't. She committed suicide. While writers have been known to pass through fits of emotional excess, their moods feeding their creative hunger, to most people it would seem that a successful poet like Plath had as little reason to suffer from depression as did actor Robin Williams, who killed himself in August 2014.
Closer home, actor Deepika Padukone recently came clean on her struggles with depression. Among non-celebrities, however, any sign of deviating from the expected and usual, emotionally and behaviourally, is viewed with a sense of horror. And so the condition festers unheeded till it spirals out of control as in the case of 44-year-old Partha De from Kolkata, who was discovered to be living with the skeletons of his sister and the family's two pet dogs.
"Mental disorders can be divided into two broad groups - severe mental disorder, such as schizophrenia and bipolar disorder and common mental disorder (CMD) such as depression, anxiety and others. Across time, history, cultures and countries, the percentage of prevalence of severe mental disorders do not differ too much. This is because these are predominantly genetically caused. But the percentage prevalence of CMD will vary depending on the psychological atmosphere and social milieu. Broken homes, professional and relationship-related stress are some of the factors that contribute to rise in the prevalence of CMD," says psychiatrist Nimesh Desai, director of the Institute of Human Behaviour and Allied Sciences (IHBAS), in New Delhi.
When 23-year-old architect Bhavna (name changed) started behaving uncharacteristically last June, her parents were as much at a loss as she was. "I had stopped talking to people and would have crying spells. My hands had started to shake," recalls Bhavna, who lives in New Delhi. Her parents first took her to a general physician and then a psychiatrist. "Often, people are in denial. The need for counselling and therapy is looked upon as a weakness," she says. It becomes difficult for a person with a history of mental illness to lead a normal life, socially and professionally.
"It is difficult to find marriage proposals even for other members of the family," says Shoba Raja, special advisor at Basic Needs, an international organisation that works for people with mental illness. Delhi-based psychiatrist Sunil Mittal remembers the time when a friend didn't want to park his car outside his clinic because he didn't want people to think he had a mental problem. Bhavna's father would like to speak of the difference treatment has made to his daughter, but fears "things could be difficult if word of her illness got around".
Psychiatrists believe that it is this fear that causes more than 50% of cases to go unreported. "It is acceptable to say that I have physical health issues but where is the language to communicate that I have anxiety or get panic attacks," asks clinical psychologist Monica Kumar.
Raja agrees. "Often, unless the symptoms are very severe, people do not recognise their problem as a mental illness," she says. The situation is worse in rural areas where schizophrenia and bipolar disorders are often believed to be cases of possession by evil spirits. "In almost 90% of the cases of severe mental disorder, the first approach is a faith healer," says psychiatrist Hamid Dabholkar from Satara.
Poor access to medical care is partly to be blamed for this. "Hospitals are mostly concentrated in cities and big towns. 80% of medical care available for mental health is in the private sector, which is expensive," says Dabholkar.
There is no insurance coverage for a person with a mental disorder. The WHO Mental Health Atlas 2011 states that the government's expenditure on mental health in was only 0.06% of the total health budget. The country has only 0.301 psychiatrists per 100,000 people. Treatment at the hospitals too leaves much to be desired. "The focus is too much on medication," says Desai.
Electro Convulsive Therapy, a procedure in which electric currents are passed through the brain, intentionally triggering a brief seizure, continues to be practised at most places. At IHBAS, ECT is practised in its modified form with patients first being anaesthetised and their condition being closely monitored. Attending doctors insist the most patients are clueless about the procedure and that they feel no pain, but the restlessness of the patients suggest otherwise. "Make my brain like yours," a young man pleads as his eyes droop under the effect of the anaesthesia.
However, it is true that attitudes towards mental health disorders and the quality of care available in the country has improved. "We get 900 patients every day at the outpatient department. About a hundred of these will be fresh cases," points out Desai. IHBAS was established in compliance with the directives of the Supreme Court in response to a public interest litigation in 1993. A section of the sprawling campus still retains the cells of the former Shahdara Mental Hospital on the site of which IHBAS was built. Barred rooms and concrete beds bear testimony to a more primitive approach to the treatment of the mentally ill.
Following a Supreme Court request of 1997, the National Human Rights Commission (NHRC) has been regularly inspecting and reviewing the activities of all mental health institutions since 1999. India also came up with a National Mental Health Policy in 2014. The Mental Healthcare Bill 2013 was proposed in Parliament in 2013. Still, abuse and rights violations - both by family members and by hospitals cannot be ruled out. The rehabilitation of patients poses a further challenge.
"Mental illness is viewed as a kind of disability. Those with limited means fear that the mentally ill person will become a burden," says Bangalore-based psychiatrist Sudipto Chatterjee. He adds that giving proper vocational training to patients so they can be gainfully employed might ameliorate the issue. Santosh K Chaturvedi, head, psychiatric rehabilitation services, at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, believes few employers are interested in employing a person with a history of mental disorder.
As a step towards ensuring that patients are not cut-off from their natural surroundings, Desai says "only 0.5% of the patients coming to IHBAS are hospitalised. Their stay is kept to a minimum and families are encouraged to stay with them." This is in some measure close to the community-based treatment that doctors like Dabholkar propagate. Meanwhile, in the comfortable drawing room of a private facility, Pooja (name changed) looks out of the window at the clear summer Delhi evening and asks the nurse if may she go out. "Not alone," is the answer. Next, she asks for permission to phone her mother, who, when the call goes through is preparing to step out. "You are going shopping?" Pooja asks, her eyes lighting up at the thought, as any young girl's would. Then she replaces the telephone receiver and walks over to the window to look out once more at the world that has decided she doesn't fit its structure.
Stigma to mental illness
Today, Nimtesh Singh (name changed), a businessman from Ranchi, can sleep peacefully and laugh about his problems too. Until May, however, his life was different. In mid-February, Singh started suffering from acute depression and anxiety. Initially, family members thought it was a result of the huge debts Singh had accumulated. They hoped his condition would improve soon. But that was not to be. He couldn't sleep.
"On March 15, he created a huge ruckus in the colony; throwing bricks and beating random people. He was completely out of control," says Singh's younger brother.
Family members consulted many therapists, who declared that Singh was suffering from a mental illness and prescribed anti-depressants and mood-relaxing medicines. However, a consultancy session at the Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) revealed that Singh was actually suffering from Vitamin B12 deficiency, an element found in animal meat and dairy products.
Medical superintendent and psychiatrist RINPAS, AK Nag says that a drop in the level of vitamin B12 causes acute depression, paranoia and hallucination coupled with fatigue. "The patient's mental health was actually propelled by physical deficiencies," he says, adding that Singh, a vegetarian, didn't consume even dairy products and this had led to his condition. Recalling his worst days Singh says, "Hearing 'mental dawa' (medicine) and psychiatrist triggered violence. I had lost control over myself."
Sometimes, Singh had to be cornered, put in a car and taken for treatments, often in a violent condition. "This is a glaring example of the family delaying treatment. There is a stigma attached to consulting a psychiatrist," says Nag. Doctors in Ranchi say that most cases of mental illness come in for treatment at the critical state and the biggest challenge for RINPAS is rehabilitating these patients. In many cases, patients are just left at the hospital, driven out of their homes or found wandering the streets. "Out of the 500 inmates, 105 are such patients. If they remember their address, we can take them home. Or they stay and work with the hospital until they recuperate," he says. Jharkhand currently has two state-run institutes, RINPAS and the Central Institute of Psychiatry (CIP), run by the state and Centre respectively.
-- Anbwesh Roy Choudhary
Psychological illness growing in urban life
Amitava Dasgupta (name changed), a 66 year-old retired bank employee of Bansdroni in south Kolkata, has been confined to his flat since the mid-1990s. He doesn't attend any social functions or travel anywhere. The reason? He suffers from fear psychosis and shows symptoms of paranoid schizophrenia. He fears his enemies are all around and are waiting to kill him. His condition stems from an incident in the past: during a clash, miscreants attacked his family, set his mother on fire, and destroyed his home.
Another patient, thirty-year-old Bipasha Ghosh (name changed) has been suffering from a psychotic disorder after the untimely death of her mother. She became careless of her food and personal hygiene and is largely confined to her room. She is now being treated at the state-run Pavlov Mental Hospital in Kolkata, where Partha De is also a patient.
Partha De at Pavlov Mental Hospital in Kolkata. (HT photo)
"Patients range from adolescents to grown-ups. The Robinson Street skeleton case is a rare one of psychotic disorder. But we attend to many patients who confine themselves to their rooms because of some phobia," says professor Pradip Kumar Saha, director of the Institute of Psychiatry.
Sharmistha Sarkar, a psychiatrist at Pavlov Mental Hospital, believes cases of psychological disorder are increasing in urban settings. Some of this, she believes, is a result of the alienation brought on by increasing digitisation.
"People feel more comfortable spending time with their mobiles, on the internet and on social media. Different kinds of crimes are being reported," says Sarkar, who is part of the team of psychiatrists attending to Partha De. Incidentally, West Bengal does not have adequate number of mental hospitals. There are only five government mental hospitals, which together can hardly accommodate 1000 patients.
Pavlov has around 250 beds to accommodate a rush of 500 resident patients. A team of 15 doctors and 35 nurses attend to these patients, who stay at the facility, and the 200 patients who attend the OPD daily. Sources say the hospital actually needs at least 60 doctors and 150 nurses.
-- Shubhendu Maiti
Locked in a room since 2012 to protect him, family
Now locked away in a room since 2012 for his own protection, Raj Patel was once a cheerful 10-year-old who loved to swim and play video games. He was friendly and enjoyed school, and he and his two sisters were lavished with attention and praise by their parents, a businessman and a homemaker. That was in 2003.
Over the following year, his parents separated, he lost touch with his mother, his father moved in with another woman, the family business failed, and Raj was forced to drop out of school. Last month, local activists and police officials knocked on his father's door and 'rescued' the young man. He was covered in lice and faeces, emaciated and unkempt, sitting naked on a mattress in a filthy bare room carpeted in soiled newspapers, a room that had been locked from the outside. It had been three years since the 22-year-old had stepped outdoors. At a nearby hospital in Nerul, he was diagnosed with schizophrenia.
The problems began soon after the disintegration of his parents' marriage. "He became withdrawn and irritable. He would spend most of the day in his room, muttering to himself," says Rushabh. "I thought he was just depressed and would get better over time." Instead, as more siblings arrived, Raj got worse. In 2010, he stopped leaving the house. "I went to a psychiatrist and described his symptoms. Raj was no longer leaving the house, so I could not take him with me," says his father.
The psychiatrist told Rushabh his son was most likely schizophrenic, and prescribed antipsychotic drugs. The medicines seemed to help; Raj was still withdrawn but no longer violent. Six months later, when the family's financial condition worsened, they stopped buying Raj's medication. Instead, in 2012, they began locking the door to his room to protect him and the rest of the family. Raj's only human contact was when his father or sister passed him his meals.
Dr Samir Parikh, national director of mental health and behavioural sciences at Fortis Healthcare says this is a common mistake made by impoverished families. Raj was only discovered because his stepmother went to a local activist, Gopal Saha, for help in getting the family's electricity connection restored. "I went to see her flat and that's when I found out about Raj," Saha says. Raj will now be treated at DY Patil Hospital for two months, free of cost.
With no police proceedings against the family and their financial situation still unsteady, Saha says he is trying to find other shelter for Raj.
-- Abhishek Rawat
* 70 mn: Approximate number of people suffering from mental illnesses in India
* 3000: Number of psychiatrists in India
* 11500: Estimated requirement of psychiatrists
* 500: Number of clinical psychologists in India
* 17250: Estimated requirement of clinical psychologists
* 400: Number of psychiatric social workers
* 23000: Estimated requirement of psychiatric social workers
Source: A NHRC 2012 publication
A patient at the Institute of Human Behavior & Allied Sciences (IHBAS) in New Delhi. (HT photo/ Gurinder Osan)
Another patient at the Institute of Human Behavior & Allied Sciences (IHBAS) in New Delhi.(HT photo/ Gurinder Osan)
A patient receives Modified Electroconvulsive therapy (ECT) treatment at the Institute of Human Behavior & Allied Sciences (IHBAS) in New Delhi. (HT photo/ Gurinder Osan)
In India, any sign of deviating from the expected and usual, emotionally and behaviourally, is viewed with a sense of horror. (HT photo/ Gurinder Osan)
A patient at the Institute of Human Behavior & Allied Sciences (IHBAS) in New Delhi. For most, the condition festers unheeded till it spirals out of control.(HT photo/ Gurinder Osan)
A patient receiving treatment at the Institute of Human Behavior & Allied Sciences (IHBAS) in New Delhi.(HT photo/ Gurinder Osan)
A digitaly stitched panaromic view of the OPD at the Institute of Human Behavior & Allied Sciences (IHBAS) in New Delhi.(HT photo/ Gurinder Osan)