The biggest threat to India’s economic boom? A mental health crisis

At the time of writing, India’s Covid-19 epidemic is one of the worst in the entire world. Second only to the US in its total cases, India now accounts for just under a fifth of Covid-19’s viral footprint, with 7 million cases and climbing and more than 100,000 deaths.

Since 25 March, the day lockdown was unveiled, India’s daily case numbers have increased by more than 13,000 per cent. And while the daily change has shown tentative signs of deceleration, India’s Covid-19 situation is still thoroughly uncertain. What awaits its economy – hit hard by declines in commerce, industry, investment, tourism – and its development journey are difficult to predict.

Covid-19’s claws aren’t consigned to the wallet and the hospital ward, either. Tearing through cities, states, and townships the country over, the virus has thrown Indians’ mental health into apparent disarray.

A March survey by the Indian Psychiatric Society – conducted prior to the country’s steep rise in daily cases – suggested that mental illness across the board had risen by a fifth. After its first publicised incident in March, hundreds across the country have since fallen victim to suicide, including several high-profile celebrities and Bollywood stars. Half of Indian children experienced symptoms of anxiety disorders during the initial lockdown, and just under two-thirds of 18-32-year-olds reported significant loneliness, with nearly two-fifths of them reporting “strong impacts” on their broader mental health.

Unsurprisingly, those affected most intimately by the virus face stronger effects. A limited survey suggests that more than one-third of frontline doctors and nurses are depressed and anxious. Local reports claim that 30 per cent of Covid-19 patients are “mentally disturbed”, and sufferers face stigma from neighbours, family, and friends for carrying the disease.

Emergency services in Gujarat, a state that has borne a large brunt of Indian fatalities, describe a doubling of calls on its suicide hotline up to July, with 800 cases of “self-injury” and 90 self-inflicted deaths in the same period. One psychologist in the state said on record that cases of depression and obsessive-compulsive disorder (OCD) have risen by as much as 70 per cent.

At the same time, psychiatric consultations across India have plummeted by up to 50 per cent. As well as endangering the newly mentally ill, the decline puts those with pre-existing mental health conditions – a group that will likely face harsher blows from Covid-19 – at significant risk, too. Adishi Gupta is the co-founder of Mental Health Talks India (MHTI), an online mental health advocacy platform. “The pandemic has regressed my mental health journey,” she told The Independent.

“The past traumas that I had managed to work through over the last few years seem to have reversed because of being stuck and away from most of my anchors. I am more cynical than optimistic about mental health in this country”, she says.

Safe recoveries for substance abusers have proven troublesome. Alcohol bans led many problem drinkers – a chronic issue for India’s urban poor – to enter dangerous withdrawal, with complicated cases reportedly doubling in the first phases of lockdown. Three alcoholics near Chennai even died after consuming hand sanitiser as a substitute for drink.

Mr A is a 35-year-old employment consultant. His name amended to ensure anonymity, he was made redundant in May after two months of lockdown, and his neighbour, a long time sufferer of heart problems, died of Covid-19 shortly afterwards. Mr A was soon feeling unhinged. Already distressed by unemployment, he developed an irrational paranoia around his own heart function and suffered acute panic attacks and anxiety. Mr A sought help at the Central Institute of Psychiatry (CIP), one of India’s most historic and cutting-edge psychiatric hospitals, and is on his way to recovery.

Yet he’s among the lucky ones.

Many sufferers of severe mental illnesses (SMIs) like schizophrenia and bipolar disorder can’t access their treatments. Largely unable to admit new patients, the CIP reports that inter-state transport restrictions and financial shortages force many to forego regular consultations and prescribed medication, triggering relapses into chronic symptoms like paranoia and delusions.

“Private vehicles have had to be booked by distraught family members (at considerable cost) to transport patients to secondary or tertiary mental healthcare centres,” says Professor Basudeb Das of the CIP, which has established a special triage centre to treat those already receiving inpatient care.  

“Alternatively, patients [may] rely on private mental healthcare providers, where services can be accessed with short waiting times, although these services are too expensive for those who may be most in need,” he adds.

And while it makes for troubling reading, the evidence so far is likely an under-estimate. India’s vast population – combined with low civic engagement and sometimes-sclerotic administrative infrastructure – can render data collection a thankless task.

The shock was a long-time coming, though. “The mental health system in India was already in crisis,” says Professor Das. “The pandemic has merely brought the deficiencies of the delivery system into sharper relief.”

Das points me to a dizzying range of frightening statistics. In India, 10.6 per cent of the population suffers from a mental disorder: a number which, at 140 million people, exceeds the combined populations of the UK and France. An estimate from 2017 suggests the true figure is around 40 per cent higher, at 197 million. It will likely have increased in the years since. More than a third of all global female suicides occur in India, and nearly one-fourth of those by men. Suicide is the second leading cause of death among young Indians, creating nearly as many casualties as road traffic accidents and deaths through childbirth.

At the same time, the proportional contribution of mental disorders to the total Indian disease burden has almost doubled since 1990. And amid what Das describes as various “systemic deficiencies” in India’s psychiatric infrastructure, it seems that Covid-19 is proving a catalyst for an issue long-brewing under the surface.

It sounds extraordinary, but 2019 data suggests that there are just 9,000 psychiatrists in the entire country – around one-twentieth the population of Guildford – and the vast majority are private practitioners, making them inaccessible to those lower on the socioeconomic ladder. More widely cited data, including by the government in 2013, suggests that there are fewer than half that number. And how many mental hospitals? Thirty-eight.

A government of neglect?

The Indian government has not been unresponsive to the Covid-19 mental health crisis. Supplementing the interventions of several non-profits, private hospitals, and universities, the central government in Delhi unveiled a telemedicine system for rapid electronic prescriptions and fresh guidelines for primary healthcare workers in addressing mental illness. State authorities in Kerala recently introduced a psychological support team, and the government in Madhya Pradesh has restored its Happiness Department.

Against the broader backdrop of government policy, though, these new instruments will seem piecemeal to many. Mental health accounts for less than 0.5 per cent of the total Union Health Budget, falling short of the lowest OECD country’s share  by a factor of 10, and forming around the same share as Bangladesh: a neighbouring economy only one-tenth the size of India’s.

“The mental health crisis in India is abysmal,” says Ayushi Khemka, who founded MHTI alongside Adishi Gupta in 2018. “We got our first ever national mental health helpline only a few days ago. We have a long, long way to go.”

Over the long-term, government initiatives have often run into problems. Despite being launched in 1982, the district mental health programme – a scheme modelled on community psychiatry initiatives in the West - is functional in only 17 per cent of its 739 districts. Anywhere between 68 and 98 per cent of patients will therefore depend on secondary healthcare units, sometimes located dozens of miles away from their homes, and further distanced by lockdown measures since March.

There are glimmers of hope, though. In 2017, the Modi government ratified the Mental Health Act, a wide-ranging law that decriminalised suicide, mandated the rights of the mentally ill to live in dignity regardless of race and sexual orientation, and carried practical moves for the mentally ill to secure their own treatment and medical records. And together with the national mental health policy of 2014, a foundational text that called for more funding and education in mental health, the direction of travel may at least be promising.

Yet not everyone is convinced. Abhishek, a 23-year-old recent graduate, works at a startup in Delhi. “No, the culture is not improving, it's getting worse and worse day-by-day. I'm not optimistic about the future, seeing the state and environment around me.

“The Act is for name only. Nobody cares or gives a shit about it. Trust me. There's not a single politician here who works for people's basic welfare, let alone mental illness. To them, mental illness is limited to that person in the asylum.”

Professor Das has doubts about the Act’s viability, too. “While ambitious and progressive in character, [it] requires immense financial resources to implement,” he says, citing “conservative estimates” that suggest an overall cost approaching £10bn.  

“To put this in context, the federal budget allocated for the mental health programme in the financial year 2019,” Das warns, “was only £4.2m.” This represents a funding gap of 99.96 per cent.

The problem of stigma

India’s problem with mental health isn’t all institutional. It’s also one of attitudes and stigma. A 2018 report commissioned by the Live Love Laugh Foundation (TLLLF), a mental health non-profit, uncovered several alarming findings. In a survey of 3,556 Indians, 83 per cent were found to be fearful or judgmental against the mentally ill. Sixty per cent believe that the mentally ill are weak-willed, 47 per cent would describe them as “retards”, and 40 per cent ordain sufferers as “irresponsible” or “careless”.

Perhaps most perniciously, just under 70 per cent claim that those with mental illness “should not be given any responsibility”, and three-fifths agree that they “should have their own groups”, with “healthy people” not at risk of being “contaminated by them”.  

The problem is borne of ignorance. A 2016 study found that adolescents could identify cases of depression under controlled conditions in just 29 per cent of cases. Schizophrenia and other psychotic conditions were identified in less than 1-in-50.

Anna Chandy is the chairperson of TLLF, the executor of the 2018 poll. Founded in 2015, TLLF aims to give hope to every person experiencing stress, anxiety and depression. "While there is some awareness on the role of psychiatrists and clinical psychologists,” in India, Chandy said, knowledge of broader actors like “psychotherapists, counsellors and mental health social workers is minimal”.

India’s national mental health survey, conducted by researchers at the National Institute of Mental Health and Neuro-Sciences (NIMHANS), reveals that very few of the country's domestic languages even have words for classical mental illnesses, or for “mental health” itself.

And where new descriptors are being adopted tentatively, their spread is limited predominantly to urban dwellers, and those digitally and functionally literate and versed in English. Traditional linguistic substitutes, like chinta (meaning worries) and bhayamgaundi (confused) in Bengal, are rarely used by professionals.

Leaning too closely on traditional understanding brings risks, though. Ancient “mental health" practices are often imbued with superstitions, like beliefs in witchcraft, wizardry, and black magic. According to Women In Need, a non-profit that delivers health and poverty relief for Indian women, many will trace their mental illness “to the sins of a past life” – an affliction that can entrench women’s anxieties and create a religious aversion to seeking help.

India’s problems with awareness, visibility, and stigma run in a vicious cycle with its medical system. There are no comprehensive national guidelines for counselors and psychotherapists, says Chandy, and a review found that psychiatry teaching is often limited to a few hours a week for medical students. A medical exam may contain just “one short note” on mental health, and the curriculum is broadly “laced with the dogma of psychoanalysis”: an approach founded by Sigmund Freud in the 1890s, which traces mental illness to the repressed sexual fantasies of childhood.  

While things are far from ideal, Dr Sonali Gupta urges a longer-term view. A Mumbai-based clinical psychologist and author, Gupta has been in practice for more than 15 years. “From 2004-2005 when I started my career, the mental health culture has seen a sea of change.

“More and more people are reaching out when it comes to couples’ work, anxiety, mood swings. In my personal work, people across the age groups are accessing therapy. One of my oldest clients is about 80 years old. It’s heartening to see more men reach out for therapy sessions now as compared to 15 years back.

“Mental health conversations [are] finding a way in media discussions, pop culture. But the work that lies in front of us is massive”, she says.

The social media revolution?

The suicides of several high-profile Bollywood actors over lockdown turned a lot of heads. Social media influencers like Mental Health Talks India are hosting regular meetings and facing “constant” demands for live sessions. Structural trends are behind them, too, with internet consumption increasing by 50 per cent since 2011, and India is second in the world for the frequency of using Instagram.

“Things are changing as we speak. I created Mental Health Talks India on Instagram more than two years ago because of the stigma that I was personally facing,” says Ayushi Khemka of MHTI. “Apart from a few, there were hardly any online initiatives at that time which were talking about mental health. Cut to today, almost every third person on Instagram is talking about mental health.”

“Our online work has doubled almost,” adds Adishi.

“Now, who actually benefits from these conversations that are primarily online and in English is anybody’s guess. It’s a tiny fraction of the large Indian population – a fraction that comes from a particular class, speaks a certain way, has access to such platforms and so on.”

What’s more, India has not been immune to the wholesale psychological pressures wrought by social media. It may provide a forum for sufferers to connect and discuss their experiences, but nearly 45 per cent of Indian respondents in a survey reported “freaking out” while scanning social media during Covid-19.

“As much as I would love to fill your readers with rays of hope and sunshine, I’m not sure that would be genuine,” Ayushi says.

How India’s mental health will evolve by the New Year, then, is uncertain. The doors of cinemas, restaurants and cafes may be creaking open in select states, but anecdotal reports suggest a dark picture.  

Abhishek, the 23-year-old in Delhi, is pessimistic. “By the end of 2020, I don’t think it's gonna be normal. Our mental health is only getting worse.

“Lockdown was expected based on world cues, but it was very sudden. The way it was implemented, no one got to prepare for it. People are hardly wearing masks and following precautions, even though our cases are making records daily.”

One problem is the intense stigma associated with carrying the disease. “The current situation in India regarding Covid-19 is bleak,” says Leah Pattinson of Women In Need. “Countless numbers of those infected [are] concealing symptoms and remaining at home. Many have died and therefore the true mortality rate may never be known,” she says. The stigma has even spread to doctors, some of whom have been assaulted and prevented from treating Covid-19 patients.

“Tragically in August, a member of our team lost her mother to Covid-19,” Pattinson says. “She was denied admission in private hospitals, and in the government hospital staff refused to touch her. She died without medical intervention.”

The psychology of poverty

A problem perhaps more serious than the disease, though, is its effect on India’s economy. While spare capacity has been recovered since the initial shock of the virus – and will recover still more once a vaccine is introduced – analysts fear that declines in investment spending will ripple over time and buckle development.

Those most affected by a sluggish economy will be India’s extreme poor. Analysis by The Financial Express suggests that poverty will double across the country, with around 354 million people estimated to lose lifelines of regular income. The International Labour Organization went even further. As many as 400 million workers in the informal economy – sectors not captured by documentation, tax, regulation, subsidies, and other government instruments – will fall into poverty, it says, and all while India faces a structural absolute poverty rate of over 10 per cent.

The pandemic’s effect on their mental health has likely been devastating. Good statistics are hard to come by, but one study of 1,200 auto drivers – a common occupation among the urban poor – found that three-quarters were anxious about their work and finances. The mental health of India’s homeless population, running at 1.8 million people, lies in danger, with researchers stressing a “dire need” for recalibration in providing treatment.

Seasonal workers and those in insecure occupations are often more sensitive to economic fluctuations. One paper raised concerns about a preponderance of “fear and panic behaviour”, “post-traumatic stress symptoms, confusion, anger, and depression” amid the economic slowdown.

While they stoke demand for mental health treatment, compressed incomes and unemployment will only decrease its availability. Some 80 per cent of Indian healthcare is provided privately, and income serves unsurprisingly as the country’s leading source of health inequality, alongside educational attainment and gender. Across the board, 80 per cent of rural areas – structurally deprived compared to India’s urban centres – do not receive adequate medical treatment.

Social inequality itself has even been identified as a risk for mental health. Yet India’s bias against mental health still rears its head in research. Of all the papers published on health inequity from 1990 to 2016, a meta-analysis found that mental health formed a primary topic in just 4.5 per cent of cases.

For India’s political mainstream, the problem of mental health for India’s poor is sometimes too sizable to ignore. Bankrupted farmers, for example, have been committing suicide at such alarming rates for decades that otherwise-aversive policymakers have had to intervene, raising regulation in the country’s distorted agricultural markets (albeit without much success). Nearly 300,000 farmers have killed themselves since 1990, and one state, Maharashtra, reported around 10 a day by 2014. And in an economy partly dependent on agriculture, lockdown and the economic slowdown have proven devastating catalysts.

How farmers will adapt to the coming – and partially present – perils of climate change poses a still more daunting challenge. The direct physical and economic effects aside, dramatic ecological change is a major risk factor for mental health, with temperature rises implicated in boosts to suicide, and floods in Tamil Nadu feeding rises in PTSD, depression, and addiction.

For some, these extreme economic and political realities shine a light on the government’s essential neutrality on mental health. As much as Delhi talks the talk and pledges reform, its failures to effect practical change in the socioeconomic realm give due space for its critics, with still-undermanaged agricultural markets one such smoking gun.

School’s out

The same applies to India’s school system, argues Prateek Sharma, a mental health activist.

Passing one’s final exams can spell the difference for an escape from poverty or a life below the breadline. On the government’s watch, though, the costs of education have spiralled since the 1990s, with general all-age expenses rising fourfold in the last decade alone. As well as shutting out India’s poorer families, the financial burden can create intense pressure for students to succeed, both at school and beyond: 37 per cent of India’s students report some depressive spectrum disorder, and several high-profile suicides on university campuses have triggered backlash.  

In place of structural change to India's education system, though, Modi’s response has been to publish Exam Warriors, an easy-read book on exam stress, in 2017. While “written in a fun and interactive style” to “spread smiles during examinations”, Exam Warriors will no doubt offer little relief to those undercut by pandemic.

A toxic mixture of school shutdowns, diminished incomes, and foreclosed futures has put India’s young in the psychological firing line. The crisis is especially bad for women. A group already burdened by discrimination and unfair expectations, Leah Pattinson warns that hits to education will slow down much needed progress in women’s mental health. “These young women are contending with the insecurity and stress of losing precious time at college,” Pattinson says. “I believe it will take longer than five to 10 years before we see any tangible improvements in women’s mental health in India.”

Even women who have entered the middle class, either through birth or education, face fresh challenges, Pattinson warns. “Being more educated, women are aware of their rights and the legislation that protects those rights, but the weight of cultural conditioning prevents many middle-class women from exercising them. Knowledge can be power, but for some it can lead to tremendous frustration.”

For Adishi Gupta of MHTI, Covid-19’s impact on student psychology is compounded by some families’ still-conservative attitudes. “Students and youngsters have had to leave college hostels and go back to their parents’ homes. Now, in India, a lot of young kids keep the fact that they are seeking therapy hidden from their family due to the immense taboo,” she says.

“I have seen so many people around me, friends and acquaintances, who are now stuck at home, unable to access therapy because of the pandemic,” says MHTI’s Ayushi Khemka. “And since a lot of the people live in small houses with large families, there’s hardly any space for many of us to have online therapy sessions with some privacy. This is just the tip of the iceberg.”

Tech to the rescue?

For all its problems of cultural adoption, remote therapy and telehealth have emerged as promising suitors for India’s recent surge in mental health demand. “Every crisis presents an opportunity,” Professor Das says.

On the day of lockdown, the government unveiled new Telemedicine Guidelines to orient remote therapists, and, like hundreds of counsellors, psychologists, and institutes across the country, the CIP followed suit. In a similar vein, new apps and startups have risen from the woodwork to treat anxiety and depression, and with so-far impressive results.

These digital tools may hold promise, but there’s reason to doubt their immediate effect. One estimate suggests that less than 10 per cent of the population is digitally literate. And while India boasts one of the fastest-growing telecommunications sectors in the world, just 38 per cent of Indians with phones use them to surf the internet: around half the median average for emerging economies. Access for the extreme poor, then – or those often most in need of a digital psychiatry solution – will be more elusive still.

In the era of Covid-19, the growth of digital therapy is one move among many towards remote styles of working, and India has proved no exception. In urban centres and city economies across the country, businesses have decentralised rapidly, with Zoom, Slack and WhatsApp the new meeting rooms of modern offices. The change has brought corresponding effects for people’s mental health, too.

Even before the pandemic, survey data suggested that 48.5 per cent of India’s private-sector workers suffer from depression or a generalised anxiety disorder. India commits more overtime than any other country bar the US, and its private sector working week clocks an average of up to 50 hours in length. And with employees locked down from seeing friends and family, pressure to commit more hours from the top-down has only increased – so much so, in fact, that two-thirds of India’s remote workers are feared to be sleep deprived.  

“With greater connectivity and technology, there is no real end to the work day. My concern is that possibly around November and December, a lot of people will start experiencing burnout, if they haven’t already, that is,” says Sonali Gupta, a Mumbai psychologist and the author of Anxiety: Overcome It And Live Without Fear.  

At the same time, that India could adapt to remote work in the main and boast a sizeable private sector at all is something to be admired. Its development journey - an economic history quite remarkable to behold - boasts the halving of absolute poverty since the 1990s and an increase in national income per head of around 350 per cent since 2002.  

The continued relief of poverty should remain the government’s highest priority, including and especially in issues of mental health. While tech solutions have their place, basic social welfare programmes - ensuring food security, income streams for the unemployed, subsidised healthcare - can map on to India’s broader development plan while delivering big gains in mental health, and not least amid the chaos and deprivation wrought by its Covid-19 epidemic.

That said, the ways in which development is pursued and its eventual ends present a complicated picture. If development remains at least partly funded by greenhouse gas emissions, then the risks of climate change may come to bear on mental health, and particularly on India’s vulnerable and suicide-prone farmer community. Likewise, if development entrenches India’s moves towards corporatisation, long hours, and high-pressure white-collar work, then the overall wellbeing of its workforce will remain under question.

A powerful driver of India’s growth has been its enormous population. Measured in 2018 at around 1.35 billion people, it may provide a vast low-cost workforce, but any trouble in mental health could prove overwhelming by necessity. Indeed, even if India was ‘doing well’ on a percentage basis for mental illness, the multiplier of its population risks making any burden, however unrepresentative, completely suffocating.

Ensuring a mental health system that works mustn’t be viewed as an expense or an outflow, either. In an important sense, it’s what will enable – or destroy – India’s economic journey altogether. “Unless this apparently endless supply of manpower is adequately trained and made employable for the job market, this ‘demographic dividend’ will likely morph into a ‘demographic disaster’”, says Professor Das of the CIP.

“For a developing country that wishes to lift its people out of poverty, a productive and mentally healthy workforce that is able to contribute in meaningful ways to the economy and social life of the country is essential.”

Group think

For India’s mental health crisis, there can be no easy solutions. It requires a shift in attitudes, sustained bursts of political will, a complex balance with broader goals, and all while encompassing the full range of India’s rich variety in people, places, things, and work.

One solution to watch, though, could be the community mental health programme. Focused predominantly on deprived villages and townships, these programmes take treatment from the clinic to the community through plainclothes personnel and lay volunteers, tasked with raising awareness, relieving stigma, delivering primary treatment, and boosting interpersonal cohesion.

As well as increasing Indians’ access to treatment, community mental health is at pains to emphasise the systemic character of mental illness: far from an isolated and personified affliction, they claim, it’s instead a mirror to problems of oppression and disempowerment in the community at large, whether they run on lines of caste, wealth, class, gender, race, and so forth. In this vein, programme practitioners themselves are even encouraged to recognise, vocalise and disengage from their privileges when consulting with patients.

Plus, away from the concrete chock-and-block of India’s psychiatric hospitals – an ongoing source of stigma and isolation – and white-coated doctors, patients are treated in everyday settings like tents and across open fires, with community therapists, friends and family at their side. In suppressing stigma and drawing mental health to its socioeconomic roots, such an approach would therefore seem to kill two birds with one stone.

One community programme targeted at schizophrenia tripled patients’ adherence to their psychiatric programmes compared to standard treatments. The Ashagram Clinic, which mixes family counseling, conventional psychiatric medicine and awareness-raising, was found to significantly reduce the burdens of schizophrenia for its patients. Focused on epilepsy, another has used innovative “family-level screening tools” to great success across 75 tribal villages.

Research suggests that community programmes will enable India to ‘scale up’ in its delivery of mental health treatment. With standard psychiatric streams overburdened, and its medical system altogether distracted by essential physical illness, these programmes develop ‘community capacity’ in treatment, cultivating rich, bottom-up foundations for more systematised and streamlined developments down the line.

However promising, community mental health programmes’ success will hinge on India’s approach across the board. Against a backdrop already cast in uncertainty, how the Covid-19 catalyst will precisely change the game is impossible to say.

The virus has revealed India’s festering crisis in mental health. Its wounds will only worsen with every month of continued neglect. And whether Covid-19 becomes a warning light for future change – or a death knell for millions of minds – we can only speculate. For Indians’ sake and ours, let’s hope it’s the former.