A study published by Lancet in 2017 estimated, one in seven Indians, about 197·3 million people, comprising 14·3% of the total population of the country are suffering from mental disorders; which has almost doubled since 1990. National Mental Health Survey-2015-16, though presents a relatively skewed picture and pegs the prevalence at around 10.6%, which in the case of adolescents in the age group of 13-17 years stands around 7.3%, nearly equal in both genders. NMHS estimated that about 9.8 million adolescents aged 13–17 years need active mental health care intervention and that this number would be greater if the entire age spectrum of childhood and adolescence is considered.
India only has 0.75 psychiatrists per 100,000 population.
Mental health still hasn’t become a public health priority and shows an alarming level of treatment gap, ranging from 28-83%, which has been linked with stigma, lack of awareness, and inadequate availability of or poor access to services. Negating the most quoted estimate of 3800 psychiatrists in India, a study published by the Indian Journal of Psychiatry suggests, the total number of psychiatrists in India currently is around 9000, which means about 0.75 Psychiatrists per 100,000 population.
In order to meet the current need of the population in the country, the study makes a conservative estimate of at least 3 Psychiatrists per 100,000 population and highlights that even if population growth rates and attrition rates of psychiatrists are taken as 0%, India requires 2700 new psychiatrists annually to fill in the gap in the next 10 years. However, every year only 700 psychiatrists are trained in PG seats.
If we look at the allocation of the budget under National Mental Health Programme, it has gotten substantially reduced from 0.44%, of the total budget allocated to MoHFW in 2010 to less than 0.06 percent of the total 65012 crores budget allocated in 2020. If we look at the indirect costs associated with mental illness, resulting from loss of productivity, and economic opportunities due to disability, a study published in the Indian Journal of Psychiatry, makes an assumption of loss of productivity in nearly half of the about 13 crore estimated cases of mental illness and estimates an annual loss of Rs.3,43,200 crores to the country due to lack of productivity and depicts that investing in the implementation of MHCA, 2017 by the government will yield 6.5 times return on investment and a conservative estimate of the cost of implementing the same amounts to the tune of Rs. 94,073 crore annually, excluding the cost of infrastructure for implementing agencies and rehabilitation centres and the cost of human resources to run those rehabilitation centres, which would increase it many folds.
Currently, information available on mental health is grossly inadequate and interventions are fragmented and derisory, especially with regard to the mental health of children and adolescents. There is no comprehensive and methodologically strong national epidemiological study on children and adolescent mental health. National Mental Health Survey focuses mainly on the 13-17 years age group. Though, if we talk about child mental health, the findings of one of the studies exclusively conducted to assess the prevalence of child and adolescent psychiatric disorder in Bangalore city, explains the context better.
Estimates suggest that while about 12.5 percent of children aged 0-16 years are facing psychiatric disorders. The psychiatric morbidity among 0-3 yr old children is as high as 13.8 percent, besides certain genetic or developmental disorders, nutritional deficiency and lack of care have been identified as key reasons for mental disorders among younger children in this age group. The study highlights only 37.5 percent of the families perceived that their children had any problem.
Certain conditions identified in the research as mental disorders are commonly not seen as a problem, for example, ‘Pica’ a commonly found behaviour among younger children and sometimes in pregnant women or adults, gives an urge to eat non-food items like chalk, soil, hair, etc. is a mental health issue and is associated with multiple conditions including nutritional deficiencies and stress. Similarly, Disruptive Behavior Disorder (DBD), makes children show patterns of uncooperative and defiant behaviour.
Children of conflict-ridden stressful family environment or, where caregivers themselves are facing conditions like Oppositional Defiant Disorder, depression, or anxiety are more likely to develop DBD. A number of studies have also associated DBD and ADHD behaviour disorders with ‘Low Birth Weight’. LBW is common in rural parts of India and many times it’s a result of a deliberate choice made by eating less to prevent the chances of expensive C-sections by poor families. Thus, clearly mental health cannot be seen in isolation, and a number of factors may influence it, which could vary as per age, gender, class, or cultural context a person belongs to, and how commonly prevalent practices affect children or certain gender the most are aspects that need to be understood well.
The figures published by NCRB indicate a significant increase in the number of suicides committed by students in the last five years. More than 10,000 students committed suicide in the last two years, which means every day approximately 28 such suicides are reported and that’s alarming. Also, since section 309 of IPC, holds committing suicide as a criminal offense thus, the number could be expected to be much bigger, as often such cases are hidden to avoid investigation.
If we look at the cause wise distribution of suicides, NCRB Report on Suicides in India 2019 suggests the most prevalent causes of suicides among people below 18 years of age include family problems, failure in exam, love affair, illness, marriage related issues, and causes for a significant number of suicides are unknown. Category indicated as miscellaneous include a range of causes, reported in two-digits, like illegitimate pregnancy (other than extramarital), hero worshipping, indebtedness, poverty, physical/sexual abuse, impotency/infertility, unemployment, addiction, death of a dear person, etc.
Mental health as a subject still flummoxes a lot of people, the way condition like ‘depression’ is confused with sadness and casually used by people without really understanding what it means trivializes the issue. Sadness is not depression, confusion is not a hallucination, inability to learn quickly is not ignorance always; it could be Dyslexia or ADHD as well.
Often, people facing mental illness are seen as people of weak willpower and low self-esteem, facing results of their inability to make the right choices or efforts. Such perception often makes others indifferent to the sufferings of those dealing with mental illness, also making it difficult for the one to seek help because of fear of judgment or stigma and it hardly becomes a serious issue until a person commits suicide.
Some of the recent incidences of student suicides during lockdown for reasons like difficulty in attending online classes, the inability of parents to afford the cost of education, death of a popular film actor, etc. clearly indicate that how additional stress caused by lockdown and media to the already distressed young people just pushed them over the edge, as reaching the stage of committing suicide takes long and brings attention to the fact that once children reach the stage of understanding complex emotions like fear, shame, guilt, and anger.
They need support from adults to learn how to navigate through difficult emotions. While the need to make children develop certain habits for better physical health is given but the aspect of mental wellbeing is often not adequately engaged with, resulting in children engaging in unhealthy coping behavior like addiction, self-harming, etc.
The biggest challenge is, children are hardly encouraged to express themselves, and obedience is valued more than a child’s interest and sometimes even capacity and can be seen with regard to choices of subjects or career or a life partner. Further, practices like body shaming, bullying, violence, broken or conflict-ridden family, etc. silently depletes inner resources like confidence, sense of worth, self-image, and esteem, which supports the mental resilience of a person.
Rohith Vermula’s suicide was caused by the HU administration and their caste-based atrocities and indifference.
Since, as compared to home, children or young people spend most of their time either in school or colleges thus, the role that these institutions play in determining what they feel about themselves cannot be overlooked. Especially, if schools fail to give an enabling and empowering atmosphere to children, it will eventually impact their ability to stand for themselves even as adults and that’s what is happening in India’s reputed institutions like AIIMS, IIM, and IITs, where a number of Dalit students succumbed to the pressures of caste-based hostility and committed suicide.
If we look at various child-specific policies, none of these has thrust on ‘mental health of children’ for example, National Mental Health Policy identifies children just as one of the vulnerable groups in general, without much emphasis on their vulnerabilities. National Mental Health Programme also doesn’t have any special emphasis on the mental health of children. Currently, Rashtriya Kishore Swasthya Karyakram is the key adolescent related policy that has a vision of adolescents becoming able to realize their full potential by making informed decisions about their wellbeing and health, including mental health.
Though policies like the National Youth Policy and the New Education Policy, 2020 also talks about holistic development and integration of mental health dimension in NEP 2020 is a much welcome move by the government in this direction. Still, none of these policies helps
in completing the picture and the focus on mental health remains fragmented. Going forward, the causes and implications of mental morbidities for different age groups need to be understood, the way maternal and child health is looked at on a continuum for effective programmatic interventions.
National Education Policy 2020 could be instrumental in strengthening the existing body of knowledge around the mental health needs of children and young people, provided the possibilities that it brings are adequately leveraged upon. ‘Emotional abuse’, is though often talked about and recognized as one of the issues of child protection. Currently, no data is presented in this regard, and the response is largely focused on violence.
Looking at the provisions, if we broadly take into account the aspects of ‘institutional factors’ and ‘social factors’ that might be influencing the mental health of children adversely, some of the provisions made toward (a) promoting better cognitive development; (b) reducing academic pressure and dependence on coaching; (c) multiple entry points and academic credit bank (d) distributing exam pressure by adopting suitable models (e) reducing hostility by sensitizing students on human values, equity and respect for diversity (f) improving access to education for women and transgender people (g) counselling support, etc, could be helpful to a great extent in addressing stressors related to education affecting the mental health of students while, the provision to (d) facilitate access to the protection services to children facing a risk of any kind, (e) Life skills, could be helpful in addressing social factors putting children in risk or stress. Still, there are some questions that policy doesn’t have clear answers for.
National Education Policy 2020 though has focused on developing life skills but this has been envisaged mainly around Fit India Movement- focusing on physical fitness; sports- to develop collaboration, teamwork, discipline, self-direction, and service & participation in a community service program. While all these must favourably influence mental health, though skills of direct relevance like, developing healthy coping behaviour to deal with difficult emotions, knowing when to seek help, sense of self, flexibility, adaptability, decision making, etc. are important life skills that could be helpful in developing self-esteem. If we look at National Mental Health Policy, there as well ‘life skills’ have been mainly envisaged around discussion on gender and social inequalities, indicating the need to identify specific support needs in the first place.
Second, despite multiple cases of student suicide in premier higher educational institutions, like AIIMS, IIT, IIM because of caste-based harassment and anti-reservation mindset, the NEP 2020, doesn’t recognize the higher vulnerability of ‘socio-cultural identities’, categorized as SC, ST, OBC and Minorities, the passing mention to strictly enforce all non-discriminatory and anti-harassment policies, which already exists since ages and doesn’t really serve the purpose. After Rohit Vemula’s suicide, the investigation revealed how the university stopped paying his monthly stipend of 25,000 rupees allegedly because he raised issues under the campus’s Dalit-led students union. Thus, the policy should have acknowledged and proposed suitable measures to address the situation, which the policy doesn’t talk about.
Third, the policy broadly focuses on SEDGs, categorized as ‘women and transgender’. It talks about sensitizing students on gender equality, gender identities and makes the provision of the ‘Gender Inclusion Fund’ as well but is completely silent about educating children on ‘sex and sexuality’. Can gender identities be discussed without discussing sexuality and spaces of acceptance be created for such people? According to a study published in the Indian Journal of Psychological Medicine, the suicide rate among transgender individuals in India is about 31%, and 50% of them have attempted suicide at least once before their 20th birthday.
Additionally, NCRB indicates unintended pregnancy as one of the causes of suicides. According to a study conducted with unmarried women of age 15-24 years, one in six participants acknowledged pregnancy from a non-consensual sexual encounter, and such reports were more frequent among those who obtained a second-trimester abortion and the study heavily emphasizes the need for sex education among in-school and out-of-school young women. While the policy recommends declaring regions of the country having large populations of educationally-disadvantaged SEDGs as ‘Special Education Zones’ (SEZs), where all the schemes and policies could be implemented to the maximum. Though, without ensuring acceptance for gender-based diversity in educational spaces, change might not be effective enough.
The convergence of existing mental health interventions of NMHP and RKSK could now be easier. Though, at this stage, how things might unfold is not clear, as there is little evidence on the effectiveness of school mental health services and counselling through trained teachers envisaged under District Mental Health Programme or Kishore Swasthya Karyakram. Findings of a recent study published in Journal of Family Medicine and Primary Care, indicate the presence of negative attitude toward individuals suffering from mental illness among the teachers, about 70% of teachers in this study showed overall agreement to personal and perceived stigma toward the depression case in the vignette.
Considering the possibility of quality issues among school-based counsellors, the need of having certain guidelines cannot be ignored to prevent chances of stigma. Parity of esteem is fine, as long as early direct interventions don’t distort the self-image of a child, protecting that should be the priority and is certainly an aspect of capacity building of those involved in decision making and providing services.
Works as Programme Manager with Praxis
Views expressed are personal.