[Image by Utkarsha A Singh]
In a series of articles, Research Matters tries to shed some insights into India’s mental health concern through the lens of science. Part 1 can be found here, Part 2 here, and Part 3 here.
One of the essential steps for research on any disease is to study how it affects the population. Scientists study the factors that make an individual vulnerable to an ailment and the number of people the disease affects. These are epidemiological studies and are essential to assess the burden of a particular disease on a region, whether it’s a country, a state, or its districts. Based on these studies, governments can tailor their policies to help the people. These studies also serve as a goldmine of data for scientists, who study the cause and therapeutic strategies for a particular disease.
There are only a few epidemiological studies on mental illnesses in India that show us the prevalence of these illnesses across India through time. A survey of 2700 individuals in 1964 showed that on an average, 9.4 individuals per 1000 people suffered from mental illness in Puducherry. Another study on 1700 people in Lucknow, conducted three years later, showed a prevalence of 72 among 1000 people suffering from some form of mental illness. Both these studies focussed on urban populations. A study conducted in rural Lucknow in 1972 showed a lower prevalence of 39 individuals suffering from mental illnesses per 1000 people. These studies relied upon different methods to assess the prevalence of mental illnesses. Where some tests focused on patient case histories, others used personal interviews, resulting in studies with widely varied results. While one showed the prevalence of mental illnesses as 9.4 per 1000 individuals in Puducherry, another marked it at 102.8 in West Bengal.
Most of the studies conducted between 1964 and 2001 focused on clinically identified illnesses and did not cover non-psychotic conditions like obsessive-compulsive disorders, social phobias, and substance abuse. There was also a lack of follow-up studies using the same population that could show the trend for the spread of mental illnesses in different parts of the country. Only a single study conducted in West Bengal tracks the mental health status of the rural population over two decades using consistent testing methods. The study found a similar prevalence in mental illnesses, at 117 per 1000 individuals in 1972 and 105 per 1000 individuals in 1992. Although the data presented in this study is not enough to estimate the prevalence rate of mental disorders in the entire country, it is an excellent example of how research can allow policymakers to understand the change in mental health disease prevalence over a period of time.
Epidemiological studies are expensive because they involve surveys of a large population for an extended period. However, for the wealth of information that these studies provide, expenses made for such research is an investment towards a better future. Despite the scattered research on the prevalence of mental health in India, there is no denying that the last couple of years have been an improvement. The year 2016 saw the release of the Mental Health Survey conducted by the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. The Mental Health Care Bill of 2016 was enacted in 2017. This improvement in policy and awareness may boost organised research on mental health issues in India.
Mental health research includes epidemiological, psychiatric, biological, and cognitive studies which can be further categorised based on gender, geography, and culture. In this article, we will focus on the lesser researched topics of mental health in women and children. However, mental health research is a vast topic and encompasses far more than the following discussion.
Gender-based research on mental health in India
The Mental Health Survey of 2015–2016 shows that men have a higher prevalence of mental illnesses than women. However, individual disorders such as depression, anxiety, and neurosis have a higher prevalence in women. Women suffer from gender restricted risk factors that predispose them to depressive disorders. Prominent among these are antenatal depression, which affects women during the pregnancy, and postpartum depression, that occurs after childbirth. Both these disorders can lead to inefficient care for the child and also affect child care after delivery, translating to poor development of the child.
The prevalence of antenatal depression is 21.8% among new mothers in India, while postpartum depression plagues 19% of them. The maternal health issue remains divorced from its mental health aspect, and mostly focuses on the physical well-being of the mother and her child. Poor socioeconomic background and a lack of education are the risk factors for pregnancy-related depression commonly observed in other low- and middle-income countries. A study led by Dr. Patel on mental health in Indian and Pakistani women showed that about 23% of new mothers in these two countries suffer from postpartum depression. A predominant cause of this stress was the birth of a girl child. A child is highly vulnerable in its first year and needs constant support from its mother. Maternal support is of greater importance in developing countries where the family environment may be hostile.
Dr. Patel and his colleagues write, “Postnatal depression is associated with long term emotional, cognitive, and behavioural problems in children.”
Studies on substance abuse in women in India are recent and scattered. There is little to no information about the risk factors and social conditions under which these women succumb to drug abuse. More research can establish a national prevalence rate of substance abuse in Indian women.
Collectively, India lacks in research on gender differences along with cultural and racial patterns in mental illnesses. A study on the factors leading to common mental disorders like depression, anxiety, and panic disorders in rural Indian women sheds light on factors that protect them from mental illnesses. These are involvement in agricultural work, decision making, availability of a toilet at home, food security, and reduced shock to livelihood. Both the protective factors and predictors of mental illnesses in women have issues that may be specific to India. Research and treatment of mental illnesses must take into account the multiple facets of an Indian woman’s life. Research suggests that gender-based violence and bias needs to be taken into account while assessing mental health in women.
Research on the mental health of children
The most researched mental disorders in Indian children are intellectual disability, learning disorders, hearing and visual impairment, speech and language problems, autism, and attention deficit hyperactive disorder (ADHD). However, the lack of research on the impact of neurodevelopmental disorders on Indian children sets a limit to policy changes required to counter this problem. A 2018 survey on 3,964 children between two and nine years of age from Kangra, Palwal, Dhenkanal, Hyderabad, and Goa to estimate the prevalence of neurodevelopmental disorders. It concluded that one in eight children in this age group suffers from at least one neurodevelopmental disorder. Children between six to nine years are especially vulnerable, with some having more than one such disorder.
The study showed that certain babies had a high risk of developing neurodevelopmental disorders. It included babies having home birth, a low birth weight, delayed crying at birth, and those with premature birth, brain infections, neonatal illness, and stunting. Research shows that the identification and treatment of these risk factors early on are essential to counter the neurodevelopmental damage. It is thus amply clear that awareness about these risk factors is of prime importance.
As per the 2018 research, the prevalence rate for neurodevelopmental disorders ranged from 29 to 187 patients every 1000 children between the age of two and six years. A previous study had utilised the data from the 58th round of the National Sample Survey of 2002 to predict the prevalence of intellectual disabilities in Indian children. They found that 10.5 out of every 1000 children suffers from an intellectual disability. A comparison of the current prevalence rates to the results from studies conducted at the beginning of the 1970s reveals a comparable prevalence rate, with 94 per 1000 in urban populations and 81 per 1000 in rural populations for children below ten years. In contrast, studies conducted across schools in India in 1981 showed a higher prevalence rate of 207 per 1000 individuals. Overall, the prevalence rate for mental illnesses in children remained relatively consistent from 1978 to 2002. Still, the results were vastly different when the study focused on a community instead of schools.
Apart from neurodevelopmental disorders such as intellectual disability, language problems, and epilepsy, there are several specific disorders where epidemiological data is not available in India. These diseases include Angelman’s syndrome, Prader-Willi syndrome, Rett’s syndrome, Fragile X, Nicolaides-Baraitser syndrome, and Coffin-Siris syndrome, among others. These are genetic diseases that may cause extreme disability. Research about the prevalence of these lesser-known diseases will boost awareness and training towards the management of these diseases. A study on the status of research of ADHD in India points out the lack of community-based studies in India. There is no information on how the prevalence of ADHD has changed over time. Also, there is variability in assessment methods, making it difficult to compare available data on ADHD.
India’s contribution to global research: 10/66 dementia research group
About 66% of the total patients of dementia live in low- and middle-income countries, yet these countries have a meagre 10% contribution to the population-based studies for dementia. In 1998, researchers from all across the world came together as the 10/66 dementia research initiative to facilitate population studies in 20 countries in Latin America, the Caribbean, India, Russia, China, and Southeast Asia. India’s contribution to the publication record of this group is one of the highest. This contribution also adds to the global information pool where data from Hispanic and Chinese populations can be compared with India.
Research, such as that on ageing and dementia, help organisations such as WHO generate information packages that help in managing mental health problems in low- and middle-income countries. A study conducted in 2008 provided proof in favour of community-based programs in effectively managing the mental health of dementia patients and their caregivers. The results from the 10/66 research group have shown that tests for dementia diagnosis must be designed according to the cultural norms of the patient population. For example, the European population can identify a cello while Indians can easily recognise a sitar. Dementia tests generalised for a global population may have flawed predictions across different cultures. Researchers in India have taken up the task of translating tests for diagnosis of dementia to Indian languages. These culturally and linguistically relevant tests have shown positive results in India. However, all diagnostic tests require literacy. More research is necessary to develop diagnostic tests for people who cannot read and write.
Conclusion
Dr. N. K. Ganguly, the former chief of the Indian Council for Medical Research (ICMR), applauds the progress made in mental health research yet points out its unavailability to the masses.
In a compiled report of mental health research by ICMR, he writes, “The helplessness of the past has been replaced by considerable hope since conditions like schizophrenia that once were treated in closed institutions are being treated in general hospitals, in primary care services and through interventions at home. Early treatment is essential for better recovery.”
India has made commendable progress in mental health research and awareness in the last decade. However, there is a need for extensive population studies on mental health over long periods. Otherwise, we will never know whether the current policy changes had any effect on the status of mental health in the country. Rigorous population studies will also help determine the true prevalence rate of mental illnesses in the current times and strengthen policy decisions for the future.
With this, we culminate our series on mental health, through which we have realised that India is making slow yet steady progress in mental health policies, care, and research. We hope that the current mental health policies are rigorously implemented at various levels of governance, along with the collection of data necessary for future research. We also hope that this series is one of the many steps taken to increase awareness about all aspects of mental health in India.
- List of mental health helplines curated by The Health Collective India.
- List of mental health services and helplines curated by Covid Gyan.