Image by Utkarsha A Singh
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. Part 1 can be found here.
“India has among the highest prevalence of mental illnesses globally. Our National Mental Health Survey 2016 found that close to 14% of India’s population required active mental health interventions. About 2% suffered from severe mental disorders. Nearly 200,000 Indians take their lives each year. If one includes attempted suicides the number goes up substantially… These are worrying statistics… This leads us staring at a possible mental health epidemic.”
President Ram Nath Kovind issued this grave concern while addressing the inaugural gathering of the World Congress of Mental Health in 2017. Although rapid urbanisation and the riveting grip of an economic boom has made India the fifth largest economy in the world, statistics show that it has one of the highest rates of depression. About one in seven Indians suffer from varying degrees of mental distress, and this number has doubled between 1990 to 2017.
How does one quantify the impact of a disease on a country? To calculate this, the World Health Organization relies on two types of data: the number of years a person has lost because of the disease resulting in early death (YLL or years of life lost); and the number of years an individual has lived with the disease (YLD or years lived with disability). The sum of these two gives the disability-adjusted life years (DALY), where one DALY equals one year without full health. This method is called the Burden of Disease.
Research published in The Lancet reports the state-wise burden of mental disorders within India. It categorises the states according to their socio-demographic index, which represents the level of progress within each state. The researchers calculated the index using income, education, and fertility rate. The study revealed that the majority of Indian states housing a large part of the population have a low progress index. It classified mental disorders within the country according to the socio-demographic index of individual states.
Around forty-five million Indians suffered from depressive disorders in 2017, and a few states were worse off than others, found the study. Most of the southern states including Maharashtra and the northeastern states of India had higher numbers of depression patients than central and north India. Kerala, Karnataka, Telangana, Tamil Nadu, Himachal Pradesh, Maharashtra, Andhra Pradesh, Manipur, and West Bengal have the highest prevalence of anxiety disorders, the study reported.
The study points to a higher number of depression and anxiety patients in the economically forward regions of southern and northeastern India (Figures 1 and 2). While this could be reflective of the reality, one ponders whether the low numbers of depressive and anxiety disorders in the densely populated states of north and central India may stem from a lack of awareness or in-depth diagnosis in these areas.
A gender-based analysis revealed that depressive and anxiety disorders were more prevalent in women than in men. The study also found that people more than 45 years of age were more prone to depressive disorders. Around 3% of women and 3.8% of men suffered from depression due to bullying victimisation, whereas childhood sexual abuse contributed to depression in 5% of men and 8.3% of women. The authors also discuss the high prevalence of eating disorders in women. Whereas a poor self-image and peer pressure could be the cause behind this data, cultural norms such as women eating after everyone else in the family could also be a contributing factor.
Figure 1: Socio-demographic index of India along with the population size. The image was created by the authors with data via The Lancet, from research on the burden of mental disorders across different states of India.
Figure 2: Data via The Lancet from research on the burden of mental disorders across different states of India.
Another distressing mental disorder gripping children in relatively poor states of the country, like Uttar Pradesh, Madhya Pradesh, Bihar, and Assam, was developmental intellectual disability. In these states, the research published in The Lancet found 10.8% of children with reduced brain development. Lead poisoning is the only contributing factor for this disorder. The national health portal warns about lead exposure in children explaining that even a low amount (5ug/dL) can cause learning disabilities. Another study states that the level of lead in the blood of children in India ranged between 6.55–7.26 ug/dL and was capable of reducing their intelligence quotient (IQ) by four points by the age of ten years.
While young children might be exposed to lead, adults suffer from substance abuse –– the hazardous misuse of alcohol and illicit drugs. The National Drug Dependence and Treatment Centre (NDDTC), a part of the All India Institute of Medical Sciences (AIIMS), surveyed substance abuse in India. They sampled 4.7 lakh households across all the states and union territories in the country. Apart from this, they surveyed around seventy thousand individuals suffering from drug addiction for the use of illicit drugs. The report highlights 14.6% of Indians consumes alcohol, out of which 5.2% –– projected as 5.7 crore people –– are severely dependent on it.
Another research published in The Lancet suggests that use of alcohol at an early age increases the probability of alcohol dependence disorders. A countrywide survey targeting 4000 households per state found that about 2.8% of the population uses various forms of cannabis, 1.14% uses heroin, 0.52% uses opium, 0.96% uses synthetic opioids, and 1.08% uses sedatives. The adolescent population uses inhalants more (1.17%) than adults (0.58%). The use of other drugs, such as cocaine (0.1%), amphetamines (0.18%), and hallucinogens (0.12%) is rare in India. The report also enlisted a separate category of abuse by people who injected drugs (PWID). This fraction of the population not only suffers from the adverse effects of the drug, but also other diseases originating from risky injection practices. We have shown the states at high risk of various forms of substance abuse in Figure 3.
Figure 3: States most affected by substance abuse in India. Image created by the authors with data from a report on nationwide substance abuse.
The research published in The Lancet concluded that poverty, lack of education, and urban residence significantly contributes to substance abuse in India. The authors of the study point out that marriage is also a factor that impacts the mental health of Indian women, in contrast to high-income countries where marriage results in a lower incidence of mental disorders. Discussing the causes of this particular difference, the authors write,
“This difference could be related to the traditionally low social rank of women within Indian families and the high prevalence of intimate partner violence reported by married women in India (about 40%) — a risk factor linked to common mental disorders in women. Other factors that might be related to the increased prevalence of common mental disorders in married women include the excessive use of alcohol by husbands and problems with in-laws. This cluster of interlinked factors might create an environment that contributes to the development of common mental disorders in married women in India.”
Marriage might be a source of woe for many Indian women, but old age adds yet another burden. India has long been a traditional society with multiple family members sharing the responsibility of elders at home. Rapid urbanisation, nuclear families, and irregular working hours have shifted the focus away from the family, making our elders feel neglected. India has a steadily growing elderly population, where 8.6% of the population or 104 million people are above the age of 60 years.
A study conducted in 2011 across seven Indian states –– Himachal Pradesh, Punjab, West Bengal, Odisha, Maharashtra, Kerala, and Tamil Nadu –– revealed that 40% of individuals above 60 years suffer from psychological distress, with physical or emotional abuse being the driving factor for 61.6% of the cases in the group. Another study conducted on the elderly in Goa reports the presence of anxiety disorders resulting from dependence on children. A recent study from Delhi shows that higher levels of financial and emotional dependence on children make the elderly more vulnerable to abuse.
The glaring reality of all these studies is that not only do the elderly suffer psychological stress but that we pay very little attention to it. Scattered reports from small samples restricted to specific states reveal that we tend to ignore mental health concerns in the elderly population. As a country, we also suffer from a lack of information about the causes of mental stress, which becomes evident from a WHO report from 2011 where Shubha Soneja of HelpAge India writes,
“Discussions with primary health care workers revealed that they do not look for elder abuse in older patients. They do not consider this a health issue and neither do they feel the need to intervene and try to reduce elder abuse as they consider it more as a social problem, and not a health care issue.”
The younger population is suffering from developmental disorders, and the older population falling prey to depression and anxiety. The maintenance of good health is still a luxury in the country. India has limited resources and a population of 1.3 billion. We need policies and infrastructural facilities to support the mental health issues of one of the largest and diverse sets of people in the world. In the next part of this series, we shall focus on the infrastructure and government programs supporting mental health care in India.