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Disentangling India’s mental health distress – All elephant and no more room

Read time: 1 min
16 Oct 2020
Disentangling India’s mental health distress – All elephant and no more room

[Image Credits: Dan Meyers via Unsplash]

On the 3rd of September, 2013 residents of Bengaluru woke up to a chilling news headline that read ‘Watch out, there is a Psycho on the loose’. The man in question was M. Jayashankar, a truck driver from Salem, Tamil Nadu, who had twice escaped from prison and was under trial for the rape and murder of 13 women. By the time he was caught again, Jayashankar was accused of 30 cases of rape, murder, and robbery. He was also declared mentally unstable and had earned the sinister nickname of ‘Psycho Shankar’.

Who was Psycho Shankar? All we know is that he targeted lone women on highways and farmhouses. Many of his victims were sex workers, whom he abducted from roadside dhabas. He travelled with a machete and killed anyone who resisted him. His criminal record has an uncanny similarity to that of Gary Ridgeway or the Green River Killer, a psychopath from Utah, USA. While a lot is known about Gary’s childhood history of trouble and violence, nothing is known about M. Jayashankar. In 2018, he killed himself in the cell of the jail he was imprisoned in. His tragic life came to an end not with the sympathies of being a psychiatric patient but as a villainised Psycho.

While criminal psychopathic behaviour is rare, mental ailments like depression and anxiety are not. In India, it is estimated that around 28–83% of mental disorder patients and 86% of alcohol abuse patients do not get the required professional help.

Untreated psychiatric conditions can lead to serious downstream effects as the disorder worsens and affects the individual’s professional and social ties. Sometimes, it can also result in loss of immunity and make the body susceptible to infections. Isolation of a mentally ill patient under these circumstances may aggravate the mental trauma. Besides, the person might be attacked in society when they are unable to respond normally. All these factors can make life intolerable and fog rational thought, leading to suicide. If one counts from the 1950s, it is estimated that globally, 90% of suicide cases were caused due to mental illnesses.

Often, apprehension and judgment come in the way of reaching for help, and many of us are largely uninformed or have a stigma towards those suffering from mental illness.

In a series of articles, Research Matters tries to shed some insights into India’s mental health concern, its different aspects, including the lack of awareness about mental health in general — through the lens of science. The intention here is to bring out the often-hushed issue of mental health in public conversation so that the stigma around it disappears, and it is easier, for those who need, to seek help. Besides, only a society that is aware can demand research and drive policy change around the vital issue of mental health.

What’s mental illness? The conversation starter

The World Health Organization (WHO) states that a mentally sound individual must be able to realise their capabilities, cope with regular stress, and be productive towards the community.

In his 2011 book, The Psychopath Test: A journey through the madness industry, journalist Jon Ronson talks about the difficulty in separating the ‘insane’ from the ‘sane’. The reason behind this, he says, is the excessive picking out of odd human behaviour with a fine-tooth comb. He discusses the over-categorisation of mental disorders with Robert Spitzer, a psychiatrist, and professor of psychiatry at Columbia University, the USA. Prof Spitzer is also the creator of the Diagnostic and Statistical Manual of Mental Disorders, or DSM — a diagnosis bible for mental health concerns.

On his interaction, writes Ronson,

“When I asked Robert Spitzer about the possibility that he’d inadvertently created a world in which ordinary behaviours were being labelled mental disorders, he fell silent. I waited for him to answer. But the silence lasted three minutes. Finally, he said, “I don’t know.””

It is difficult to put a name to mental illnesses. Some disorders, like the autism spectrum disorder, may have characteristic features, while those like the rare Alice in Wonderland Syndrome, may not have any that are known to clinical practice. The Diagnostic and Statistical Manual of Mental Disorders (DSM) was first released in 1952 to solve this problem of recognising a psychiatrist disorder. Researchers and clinicians across the world worked for a decade to compile the fifth edition of this manual, called DSM5, in 2013. Written lucidly to target a worldwide audience, it combines new research and clinical experience that helps in the proper diagnosis of mental illnesses. However, it does not present any treatment methodology.

The DSM5 manual describes five axes to be observed by an individual trying to identify a mental disorder. The first axis is the clinical symptoms that affect a patient’s daily activities like eating. The second axis considers personality and mental retardation that have long-term effects. The third incorporates injury and viral infections that affect normal brain function, while the fourth axis focuses on social changes such as divorce, unemployment, or death. The last axis looks at a global assessment of a patient’s mental functions. This five-axis analysis helps doctors establish the predominant factor and its interaction with other factors that result in a mental disorder. However, there is no clear line demarcating a mentally ill and healthy individual. There are multiple shades of grey in between the different axes defined by the DSM manual. A psychiatrist categorises certain behaviours as a mental illness only when there is a drastic and worrisome change in the behaviour of a person.

Since we are social animals, culture plays an important role in determining how people understand mental distress. Dr. Narayanan Gopalakrishnan, a senior lecturer in social work in the College of Arts, Society, and Education at James Cook University, Australia, reviews the various aspects of mental health that can be affected by culture. He says, “The perceptions of the aetiology of a disease can be very different across cultures. Cultures vary across how they seek treatment from the mainstream. And cultural groups can vary across the stressors they experience.”

In a multicultural country like India, this interplay of cultures may lead to confusion regarding mental health. And, that’s what Dr. Jhilam Biswas, Director of Psychiatry, Law, and Society at the Brigham and Women’s Hospital, found in a study. She and her colleagues analysed the differences in the diagnosis of mental illness between patients in India and the USA. The study reports that depression patients in India commonly report physical symptoms such as pain and dysregulated sleep, whereas patients in the USA reported more psychological issues such as hopelessness or pessimism. The authors suggest that social stigma associated with mental health might make people in India perceive depression as a physical disease rather than a mental one. This idea was supported by the finding that ‘family embarrassment’ was a big barrier towards accessing mental health care.

Types of mental illnesses: a broad categorisation

Dr. Vikram Patel, a well-known Indian psychiatrist and author of the book Where there is no Psychiatrist: A mental health care manual, uses case studies to explain six kinds of mental illnesses in India.

  • Common Mental Disorders (CMDs): These include anxiety, depression, and may have other subcategories such as panic, obsessive-compulsive behaviour, and phobias.
  • Bad Habits: These include substance abuse and alcoholism.
  • Psychoses: These are severe mental disorders such as schizophrenia, bipolar disorder, and brief episodes of mania caused due to infections within the brain.
  • Developmental disorders: These occur in babies who have either a genetic disease or mishaps during childbirth that prevent normal brain development. These babies suffer from learning disabilities and might take longer to attain developmental milestones such as feeding, movement, development of speech, and social relations. Examples of such disorders are intellectual disability, Down’s syndrome, Angelman’s syndrome, autism, and dyslexia.
  • Mental health problems in children: These disorders are specific to children and might be caused by the family environment or genetic factors. These include dyslexia, hyperactivity, conduct disorders, bedwetting, and depression. There is a high probability of their mental health improving during adulthood.
  • Mental health problems in the elderly: Older people might suffer from dementia or depression stemming from loneliness. Dementia involves a decline in memory and personality so much so that the person is unable to perform activities of everyday life. Although dementia occurs in older people, it is not a sign of normal ageing. Common types of dementia are Alzheimer’s, Huntington’s, Parkinson’s, etc.

This list of mental illnesses not only helps in better diagnosis but also busts many myths behind mental disorders. A separate class of mental disorders for children and older people helps in identifying the cause of a particular behaviour rather than blaming it on bad parenting or old age respectively. Similarly, putting addiction and alcoholism in a “bad habit” category allows these problems to be treated as illnesses rather than as a lack of willpower or choice. However, there is a growing school of thought within the neuroscience community suggesting that different mental disorders are interrelated.

India is entering a new decade with the highest alcohol consumption in Southeast Asia and a quarter of teenagers weighed down by depression. We hold a biased attitude towards mental illnesses and yet look forward to economic development. All this, and more, can come only through knowledge, awareness, and open discussion about mental health. That is why we at Research Matters are starting to look at different aspects of mental health and its state in India. Stay tuned for our next part of this series, focusing on the prevalence of various mental disorders across the country.

List of mental health helplines curated by The Health Collective India.
List of mental health services and helplines
curated by Covid Gyan.