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By Keya Acharya Health experts warn that mental health problems are increasing sharply worldwide. According to the World Health Organisation, depression is set to become the main cause of disability and the second leading health problem by the year 2020. In developing countries, inequality, poverty and gender are significant factors contributing to mental illness
Health experts are sending out an international alert that mental health problems are dramatically increasing worldwide, with the World Health Organisation (WHO) warning that depression is set to become the main cause of disability and the second leading health problem by 2020. One question that has resulted from this year's World Health Day focus on mental illness is: what triggers mental health problems? In India, where the number of cases of clinical depression and anxiety is rising even more steeply than elsewhere, opinion is sharply divided on whether poverty is the main cause-a debate sparked off by a study by Dr Vikram Patel of London's Institute of Psychiatry. Patel's 1996 study, Poverty, Inequality & Mental Health in Developing Countries, an updated version of which has been published in a book, investigates the relationship between poverty, disability and depression in the Indian state of Goa. He found that more than 40 per cent of adults attending primary health care clinics had a common mental disorder (CMD) such as anxiety or clinical depression. Women were two to three times more likely to have CMDs than men. The study concluded that relative poverty, disability and gender were strongly associated with these disorders. According to Patel, poverty is an important 'risk factor': clinical depression can be triggered by adverse life-events such as physical illness, housing problems and unemployment. 'Being poor means you are more likely to experience such events and you will have fewer resources to draw upon,' Patel says. 'The relationship between impoverishment and mental illness is bi-directional. Thus poverty can lead to mental illness which can worsen the economic circumstances of the person and their families.' Importantly, not all mental disorders are increasing in India. Patel specifically attributes India's growing incidence of anxiety and clinical depression to rising inequality, as witnessed in many other developing countries. The latest WHO report on mental health, Stop Exclusion, Dare to Care, agrees. 'Mental disorders occur in persons of all genders, ages, and backgrounds... poverty, war and displacement can influence the onset, severity and duration of mental disorders.' | 450 million suffer from some mental disorder: World Health Report 2001 |
|  | The poor bear the greatest burden of mental disorders: they are constantly exposed to stressful situations, and they have little or no access to mental healthcare | | The World Health Report 2001, titled New Understanding, New Hope, records some startling facts: | • Mental health is the leading cause of ill-health and disability worldwide. Some 450 million people suffer from mental and behaviourial disorders.
• Despite this, mental healthcare infrastructure is very poor. There is only one psychiatrist per 100,000 people in over half the countries in the world. Forty per cent of countries have less than one hospital bed reserved for mental disorders per 10,000 people.
• Mental healthcare programmes are not a priority in many developing countries. And yet, the poor often bear the greatest burden of mental disorders, both in terms of the risk of mental disorders and lack of access to treatment. Constant exposure to severely stressful events, dangerous living conditions, exploitation, and poor health in general all contribute to the greater vulnerability of the poor.
• Data from cross-national surveys in Brazil, Chile, India and Zimbabwe show that common mental disorders are about twice as frequent among the poor as among the rich (Patel et al. 1999). In the United States, children from the poorest families were found to be at increased risk of disorders in the ratio of 2:1 for behavioural disorders and 3:1 for comorbid conditions (Costello et al. 1996) • Migration by indigenous people to urban areas in search of a viable livelihood does not bring improved social well-being. Rather it often results in high rates of unemployment and squalid living conditions, exposing migrants to social stress and increased risk of mental disorders because of the absence of supportive social networks. | | • Conflicts, including wars and civil strife, and disasters affect a large number of people and result in mental problems. Millions are affected by natural disasters including earthquakes, floods, typhoons, hurricanes and similar large-scale calamities. Such situations take a heavy toll on the mental health of the people involved, most of who live in developing countries, where capacity to take care of these problems is extremely limited. Between a third and half of all the affected persons suffer from mental distress. The most frequent diagnosis made is post-traumatic stress disorder (PTSD), often along with depressive or anxiety disorders.
• Governments the world over have lagged behind in approaching the issue of mental health, both in terms of allocation of funds and the evolution of a comprehensive mental health policy. Forty per cent of countries have no mental health policy and over 30 per cent have no mental health programme. Around 25 per cent of the countries have no mental health legislation. For mental health policies to benefit from mainstream government programmes, the report stresses the need for intersectoral collaboration between government departments. |
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However, Dr Mohan Isaac, Head of Psychiatry at India's prestigious National Institute of Mental Health and NeuroSciences (NIMHANS), points to the resilience of India's family and social support networks. He cites numerous studies of schizophrenia which have shown better recovery results in developing countries like Nigeria and India, largely because of their strong social support systems. Isaac adds, 'In the midst of poverty people
still live a sane life; otherwise 38 per cent of this country living below the poverty line would be mentally depressed.' Patel concedes that the humour and spirit of those living in conditions that the rest of unequal India might buckle under, indicates how well the poor are able to cope. The challenge for public health researchers, he argues, is 'to identify the protective and nurturing qualities in those who do not become depressed when faced with awful economic circumstances... to help and prevent mental health problems'. What everyone, including Patel, agrees on is that women are at greater risk although experts give different reasons for that. Dr Sanjeev Jain, Associate Professor of Psychiatry at NIMHANS, says: 'There is a tremendous amount of depression in women. They tend to internalise situations.' Others argue that depression and low self-esteem among women is due to factors in the home such as a lack of identity, and domestic violence and abuse. 'We've come across a tremendous amount of suffering in women in the training sessions we impart,' says Dr Thelma Narayan, a community health worker who is helping to formulate health policies at both national and state (Karnataka) levels. There are no recent studies in India on the extent of CMD, but the National Human Rights Report 2000 says 20 to 30 million people 'appear to need some form of mental health care' -- about 20-30 per cent of the population. India's National Mental Health Policy was formulated in 1982 using a model developed by NIMHANS. The policy envisages decentralised training in mental health for rural health workers, provision of basic drugs, developing a mechanism for community awareness and monitoring of the whole policy. The government only began to implement it in 1995, but there is practically no
awareness of common mental disorders among health professionals in rural areas and the sufferers themselves, says Dr Ali Khwaja of Helping Hand, a Bangalore-based counselling organisation. The southern Indian states of Tamil Nadu, Kerala and Karnataka recognise mental health problems at both government and social levels. Community mental health centres exist in northern Indian cities like New Delhi, Patiala and Jaipur. But countrywide there are only 37 government-run mental hospitals, 3,500 psychiatrists, 1,000 psychiatric social workers and 1,000 clinical psychologists-all serving a population of one billion. The government view on the availability and cost of drugs for primary health centres is yet again optimistic. Anxiolytics, a common drug to treat depression, is said to cost less than the treatment for tuberculosis. Dr K Sekar of NIMHANS cites an India and Pakistan study last year of rural patients that shows that half a month's wages of approximately $16 goes towards treatment. But, 'treatment need not always be a medical response,' says Dr Jain, reiterating that family and community support systems need to be reinforced. Patel agrees, saying, 'Preventative strategies aimed at strengthening protective factors in local communities may be a more sensible investment of scarce resources than duplicating the extensive health systems of the developed world.' (Keya Acharya is a correspondent for Panos Features, where the above article first appeared)
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