In August 2001, 28 mentally ill patients burned to death while chained to trees in a village in India – a tragedy that shocked the country and forced sweeping changes in mental healthcare policy.
The patients were part of a faith-based “mental hostel” in the Erwadi village of Tamil Nadu. These privately run hostels housed people with mental illnesses and shackled them to their beds, trees, or to other patients through the day. They did not employ doctors or prescribe medicine, but instead encouraged their patients to pray for cures and engaged in regular canings to “drive out the evil.” When the Erwadi home burned down, the chained patients were unable to escape, sparking outrage and leading local authorities to impose a ban on such homes and order the immediate closure of all facilities that chained mentally ill patients.
India drafted its first Mental Health Policy in 2014
In India, mental illness is steeped in social stigma, and there is an evident lack of both the financial support and the mental health professionals needed to tackle the problem. According to the WHO’s Mental Atlas 2011, India only spends 0.06% of its health budget on mental health, and only has 0.3 psychiatrists for every 100,000 people – the latter being an alarmingly low statistic when compared to England’s 17.7. In fact, it wasn’t until late last year that the Indian government’s Ministry of Health decided to frame its first national policy on mental health – and one if its biggest challenges over the next decade will be to train more mental health professionals in order to provide psychiatric care to the estimated 20% of the population that is predicted to suffer from some form of mental illness by 2020.
The policy draws on sections of the Mental Health Care Bill, which was introduced in Parliament in August 2013. One key clause is the directive to decriminalize attempted suicide. India has the highest suicide rate in the world among people aged 15-29. There are 35.5 suicides per 100,000 people – six times higher than in the UK. And until late 2014, attempted suicide was a criminal offence punishable by up to one year in prison. However, in a baby step towards recognizing the rights of mentally ill individuals, the government has recently decided in favour of decriminalizing suicide, accepting that attempted suicide requires care rather than prosecution.
In a statement calling to increase awareness of mental illnesses through the policy, Dr. Harsh Vardhan, the then Union Health Minister, acknowledged that the government and policymakers have neglected mental health care in India and that there has been very little effort so far to provide services, particularly in rural areas – a shortcoming that the policy seeks to reform. However, the overall efficacy of the policy depends largely on whether the bill is passed in Parliament, which, although it is long overdue and is welcomed by most clinical professionals, is still raising concerns amongst doctors about overstretching an already burdened medical system.
Bringing mental health care to villages
The George Institute for Global Health is currently running a large-scale study in India called the SMART Mental Health programme that brings mental health services to the doorstep of more than 40 select villages in Andhra Pradesh, including some in designated Scheduled Tribe Areas. The project is funded by the Wellcome Trust, the Department of Biotechnology India Alliance and Canada Grand Challenge and is headed by Dr. Pallab Maulik, Deputy Director of The George Institute, India. It delivers low-cost, high-quality healthcare to the villages and seeks to improve the identification and management of mental illnesses in rural India.
The study is supported by an army of primary healthcare workers equipped with smartphone technology and is modeled on a similar village set-up that managed the treatment of cardiovascular disease. It uses a tablet-based screening tool that assesses common mental disorders like risk of suicide, depression and stress in adult occupants of each house in the village. The screenings use standardized tests and are administered by ASHAs (Accredited Social Health Activists), who are usually women who have married into the village and been educated until grade 8 or 10. The ASHAs have received the necessary training to be able to communicate these tests to the villagers in their local language, Telegu, in order to uphold the standards for informed consent.
The results of the preliminary screenings are then communicated to primary healthcare physicians who are also provided with tablets that can access the ASHAs’ entries for each person in the village. The physician’s tablets are equipped with the WHO’s Mental Health GAP-based algorithm to enable them to clinically diagnose and manage the individuals referred to them by the ASHAs. If a person meets the guidelines for common mental disorders, the physician advises him/her about an appropriate course of action, i.e. either prescribed treatment or a referral to a secondary physician. The physician’s decision is then communicated back to the ASHA, who remains informed about the person’s status – if they chose to receive medical help, or if they decided against pursuing treatment at all.
The ASHAs and the primary care doctors are compensated for their participation in this study, and the villagers will receive this service free of cost. The project is also focused on increasing awareness of mental health illnesses in rural India and will use videos and pamphlets and engage local theatre and folk groups to tackle the stigma associated with psychiatric conditions. In addition, it will work to involve religious leaders, village elders, local government, and traditional faith healers in the process, given their elevated status within the village community.
Much of the success of this project relies on the ASHAs and primary care doctors. The village doctors are typically heavily burdened, seeing as many as 200-300 patients a day. The project may thus be adding to an already saturated system where doctors may not have time to adequately assess a patient’s mental condition, ensure careful follow-up, or monitor potential side effects of prescribed medication. It also calls into question the scalability of such a labour-intensive programme. The purpose of this project will be to test those specific feasibility issues prior to developing a more rigorous study for scaling up this uniquely personalized healthcare intervention.
This study brings an awareness of mental health to villages and provides social and clinical support to families that have thus far been neglected. It is an important step in the right direction for bringing affordable healthcare into rural India and combating the deep-seated stigma towards mental illness.
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