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The interveners

Mental Health
Close up for comfort: two patients at the Institute of Human Behavior and Allied Sciences in New Delhi. Often abandoned by their families, many of the women on the ward stay on even after recovery. Photo: Cheena Kapoor

For the past 20 years, Geeta* tried everything to cure her son.

She sold precious family ornaments and her prized gold chain. She took him to faith healers, temples, and astrologists across India.

Out of desperation, she even married him off.

But nothing worked. Ram*, 45, continued to remain elusive: he talked to no-one but himself; he was socially withdrawn and often delusional, seeing things that no-one else could.

At times he was also violent, knocking Geeta to the ground on more than one occasion.

‘I’ve suffered a lot. I tried everything but nothing worked. I spent all my money,’ says Geeta, who lives in a rural outskirt of Bangalore, the capital city of Karnataka state in southern India. Ram sits quietly next to her, looking off into the distance.

‘I felt that an evil spirit had done black magic on him. I was fearful of being at home with just him. It’s very sad because the community treats us badly.’

But not long ago, Geeta and Ram got some answers. Ram was diagnosed with schizophrenia and put on antipsychotic medication. He has now slowly begun communicating with her after two decades of withdrawal.

Ram was put in contact with with India’s public healthcare system after Nagaveni, a community health worker, recognized his symptoms such as hallucinations and general apathy.

She referred him to a nearby primary healthcare centre, eventually connecting him with a psychiatrist.

Nagaveni had to visit the family a handful of times to convince them that Ram could benefit from medical attention.

‘They kept taking [him] to faith healers,’ said Nagaveni. Because of their lack of success on that front they finally agreed to let her take him for help.

An estimated 150 million people across India are in need of mental healthcare interventions, both short- and long-term, according to the country’s last National Mental Health Survey (2015-16).

The survey, which involved almost 40,000 people in 12 states, found the overall prevalence of mental illness was 10.6 per cent. Between 70 and 92 per cent of those in need of care failed to receive any treatment. According to the World Health Organization, India has the highest rate of suicide in Southeast Asia, at 16.3 per 100,000 people.

Despite the alarming figures, mental health has been sorely neglected in India, rooted in stigma, taboo and myths.

The lack of awareness about the symptoms of mental illness corresponds to the lack of services, including a severe shortage of trained professionals and infrastructure, resulting in a mental health crisis of epic proportions.

There are just 0.3 psychiatrists and 0.07 psychologists per 100,000 people in India. In comparison, in wealthy countries there are 6.6 psychiatrists per 100,000 people.

A position of trust

Recognizing the dearth of professionals, staff from the National Institute of Mental Health and Neuro Sciences (NIMHANS) and the government of Karnataka began to consider ways in which the treatment gap could most effectively be reduced. How could care reach those who need it?

They realized that community health workers, known as Accredited Social Health Activists (ASHAs), could in fact hold the key.

There are more than 800,000 ASHAs across India who act as an interface between the community and the public healthcare system. The acronym forms the Hindi word for ‘hope’. Based in villages, ASHAs are local women aged between 25 and 45 who have completed 10th grade schooling. They are selected from the community in which they live and are tasked primarily with basic maternal and child health services, including counselling women on contraception, pregnancy, safe delivery and breastfeeding, and facilitating vaccinations. They don’t receive a salary, but get small cash incentives for their interventions.

‘ASHA workers are very trusted members of the community – known in every household,’ according to Anish Cherian, from the department of psychiatric social work at NIMHANS.

Because of this, Karnataka decided to train ASHA workers on basic mental health. The initial training lasts for just one day, but is then continued one day per month by medical officers.

It includes teaching ASHAs how to recognize a range of mental health disorders. They are also taught basic counselling, how to refer patients to a professional at the primary healthcare level, and how to begin an open dialogue about mental health in their communities.

The approach isn’t an attempt to overhaul the system, but rather to make use of the existing workforce

‘Most patients need basic interventions,’ says Cherian, who is involved with the training. ‘They just need someone to talk to, to sit with them and support them.’ He feels ASHAs are in a unique position to offer such services.

In the last year Karnataka has trained more than 22,000 ASHA workers.

The approach isn’t an attempt to overhaul the system, but rather to make use of the existing workforce. And given community health workers form the backbone of most developing countries’ health systems, it’s a model that could easily be replicated across the globe.

‘Increasing the number of psychologists and psychiatrists alone won’t help – that would take another 150 years to fill the gap,’ says Chetan Kumar, a Bangalore-based psychiatrist.

This is not India’s first attempt at bringing mental healthcare to the community.

India has a National Mental Health Programme which envisions that by 2025 each of the country’s 712 districts will have a district-level programme with a mental health team comprising of a psychiatrist, psychologist, psychiatric social workers and nurses available at the primary healthcare level.

But as of 2015, the programme was only prevalent in 27 per cent of districts.

Gaps in the system

While using ASHAs for basic mental healthcare may seem like a no-brainer, experts cite a few fundamental shortcomings.

For one, ASHA workers are already overburdened with other work commitments. They look after thousands of people and are increasingly responsible for other health services such as non-communicable disease prevention.

‘Are ASHA workers being overburdened? Yes of course, there’s no question of that. The solution isn’t dumping more responsibilities on them,’ says Vikram Patel, an Indian psychiatrist who is professor of global health and social medicine at Harvard Medical School.

‘Identifying people with the most serious mental health problems like schizophrenia and dementia and locking [them] into the existing health system faces a challenge: there’s no existing healthcare system. We have to continue efforts to produce specialists.’

Greg Armstrong, who researches mental health provision in India at the University of Melbourne, agrees. He says that while ASHAs could fill a gap in the system, they are simultaneously creating demand for treatment when often the ‘nearest psychiatrist might be six hours away’. He also finds the model fails to address the structural and social issues that are often the cause of mental health problems such as poverty, child marriage and domestic violence.

Back in Bangalore, Geeta is optimistic the medication will not only help her son, but help to combat the stigma the family has faced in the community.

‘I want him to get better. He’s my only son,’ she says.

Training ASHAs on mental health may not be the ideal solution to combating India’s mental illness crisis, but it may be the country’s only hope for now.

*Not their real names.

Sophie Cousins is a health writer based in South Asia. She’s currently writing a book on women’s health in the region.

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