Friday, 10 October 2014

Unchain The Maladies

October 10, 2014. Today is WHO Mental Health Awareness Day.

Mental illnesses, for whatever reasons have received very little attention, from the population in general, and the medical profession in particular. Law makers haven't had much time to look at the issues related to mental health either. As a result, we have an acute shortage of trained medical personnel, paramedics, counselors, treatment options and facilities, laws to deal with complexities arising out of mental illnesses, support for the mentally disabled, and the biggest lacuna of all - a proper understanding of mental health by the society at large and even the patients themselves.

It would be easy to rattle off statistics stating which organisation says how many doctors per 1000 population or how many hospital beds per 1000 population, but such an insertion here is not the idea behind writing this post. Those statistics are available on any number of websites of any number of organisations. The purpose behind writing this post is to discuss briefly and touch upon the various issues related to mental health which need to be addressed urgently. This assumes special significance as the statistical websites also dish out rates at which mental illness is growing. Almost exponentially with time. As if India's population and mentally ill population were fighting a race as to which outgrows the other.

Mental illnesses or disorders are a broad range of disorders. There are disorders like Major Depressive Disorder, Bipolar Disorder, Borderline Personality Disorder, Schizophrenia, and various varieties of neuroses and psychoses, forming a part of these affect disorders. Then there are developmental disorders like Down's Syndrome. There are also many learning disorders like Autism, ADHD, Dyslexia etc., some of which also qualify as developmental disorders. These disorders affect people from newly born babies to nonagenarians, or a rare centenarian. So one notion that needs to be dispelled is that all people with a mental disorder are MAD. Or Mental. Well mental means having to do with the mind, and if a person is not mental, I'm sorry, it means that that person does not have brains up there. So, all human beings are mental in that sense. And as we can see clearly, there is a method (of classification) even in madness.

The only physical illness that comes even close to the affect disorders is cancer. Just like cancer, these disorders are easier to treat and remission is more achievable if the disorder receives attention and treatment early on. The more one drags one's feet about seeing a professional and taking the prescribed treatment, the longer the treatment takes, and the lesser chances of the disorder going into remission. Then there is always a chance of relapse, like metastasis. Treatment involves chemotherapy, psychotherapy and talk therapy plus lifestyle changes. Changes in diet, exercise schedule and meditation. One very strange thing with mental illnesses is that patients, and society in general, are very resistant to the idea of medication. I haven't seen anyone dissuading a cancer patient from taking chemotherapy, despite the havoc it wrecks on the healthy cells as well. Yet when it comes to mental illness people react to chemotherapy as if a healthy person were being poisoned. Or worse still, that a mentally ill person is so weak that he or she is not able to fight the disease on his/her own and has to depend on medicines. Why this segregation? Why the discrimination with the mentally ill? Nobody insinuates that a diabetic is not able to fight insulin impairment on their own because they are weak. Neither are insulin shots or metformin tablets frowned upon. Why the double standards?

The basic premise behind this discrimination is again the presumption "It's All in the Head", addressed in my last post. This is the result of total ignorance and callousness of society towards mental health issues and mentally ill patients. It's a case of us and them. And people are so proud of and blissful in their ignorance!!

Most mentally ill people are not dangerous. A very small percentage of them become violent and pose a threat to society. But mostly, if they are violent, the biggest risk they pose is to themselves. Suicide is the ultimate form of danger to the person. But other self inflicted injuries are not very uncommon, and some of these injuries may be suicide attempts. Well, what prompts a person to take his or her own life? Pain. The pain of living a life without any joy, any hope, any motivation, any meaning. Just breathing, eating and eliminating are not enough for a human being. Everyone is born with a brain. And when that brain goes out of control, and despite desperate efforts if the brain refuses to yield back its control to its owner, or refuses to work as efficiently as it once used to, the human being sans that brain feels so helpless that living day to day and trying to appear normal becomes worse than hell. The pain is so much that if is not constantly addressed by medication, family support and psychiatric help, freedom from pain is enough to motivate a person to take their own lives and move beyond the pain. The pain is as bad as the pain of cancer. Alas it is invisible! And the world thinks it is all in the "Head".

Another fact that needs reiteration is the disproportionately small number of mental health care professionals available, when compared to the population size. Doctors do not prefer to specialize in Psychiatry. It is not as glamorous or lucrative as surgery or cardiac intervention or some such other uber ultra super specialization. The medical community itself shows little respect towards their psychiatrist colleagues. A neuro person is a neuro but a psychiatrist is a shrink. Psychiatric inpatients are difficult to handle and hence, even nursing staff prefer to keep away. The ultimate exhibition of callousness on the part of nursing staff is the ill-treatment they mete out to the psychiatry ward patients. Laughing at their crying or other eccentric behaviour, using physical violence against even non-violent patients, and in some extreme despicable cases, sexual abuse of  and /or sexual assault on patients, specially female patients. There is an even greater shortage of trained counselors and psychotherapists. Even the available personnel are first lured away by corporate setups and schools, where working conditions are more convivial, salaries are attractive and there is less morbidity to deal with. Hence the pool of trained professionals to actual work clinics and hospitals is minuscule. So who deputizes or temps? Of course untrained casuals, who end up doing more harm than good.

The mentally ill also need a lot of care at home. They need acceptance and compassion from family. They need their family members to become caregivers. But due to different circumstances in different households, often that does not happen. The biggest obstacle in care-giving at home is acceptance. Family members are reluctant to accept the diagnosis, and the implied prognosis. They may see the signs and symptoms, but may defer seeking professional help. It is a matter of great "shame" that they have a mentally ill family member. And then comes the ubiquitous theory of  "It's All in the Head"! The patient is not mentally ill. He or she is just mentally "weak" and if the mentally "stronger" family members scold, threaten or cajole the person into becoming "bolder and stronger", that's all. That's all that's required. No medical or professional help. One of the worst forms of this non-acceptance on the part of family members is the beating or use of physical violence against the patient. The father, mother, brother, uncle or whoever, believes that a good beating or locking up of a patient will cure them pronto of any affectations. Such incidents make one wonder who is actually the mentally sick person here? Another really cruel practice is discussing the patient with others in derogatory terms in front of the patient, as if the patient were just a piece of furniture or prop kept there. And in India, every one is an expert on anything and everything. So what different is psychology or psychiatry? Everyone becomes a pop psychologist and starts counselling the patient. This further pushes back the patient from whatever gains he or she may have made from treatment. Mentally ill family members are often seen only as a burden to be cursed day in and day out. They are hindrances in the enjoyment of life by other family members. Parents, brothers sisters, friends, how can you do this? What if it was you?

Mentally illness takes a different turn altogether when society starts viewing a mental disorder as a supernatural phenomenon. Schizophrenia is often deemed to be possession by the demons. Exorcism and other equivalent rituals are performed on the mentally ill to drive away the evil spirits. The patient is thus deprived of the requisite medical help. The patient's condition often worsens. Sometimes such rituals are dangerous and may even claim lives of the mentally ill.

The socio-economic status of the patient’s family plays a big role in the fate of the patient. Families belonging to higher SECs (Socio Economic Class) can afford the treatment and care. They are also more aware of mental health issues and have the basic education to understand the complexities involved. However, the lower the SEC the patient’s family belongs to, the more difficult it is for the patient to get the treatment and care. Many families, unable to manage their daily living, cannot afford to take care of an economically unproductive member. The amount of effort, money and resources involved in caring for the mentally ill, makes it an impossible task. One member of the family keeping watch over the mentally ill one, translates into two economically unproductive members of a family, which needs each member to earn something daily, just to survive. So the mentally ill are turned on to the streets to fend for themselves. Some beg, some simply languish. Some also bear the brunt of brutality at the hands of a society which just needs an outlet for its frustrations. Or just an object for crude enjoyment - enjoyment that they feel the more affluent society denies them. So the poor, homeless, witless, and pathetic mentally ill are sometimes shooed away, laughed at, stoned, kicked and often beaten by passers-by. 

Treatment of mental disorders is expensive too as it is a long drawn out process. It may take years to cure or at least bring to remission any episode of Major Depressive Disorder. Bipolar, Personality and Schizophrenic disorders are even more expensive to treat. Care giving at home is also proportionately expensive. In most cases, patients are not able to care for themselves. It may extend to others in the family too. A depressed mother may neither be able to care for herself nor for her children. They all need to be taken care of. Consultation, chemotherapy, psychotherapy and followups are all expensive affairs. Plus, there is loss of productivity, especially economic productivity, on part of the mentally ill persons. Yet mental disorders are still not identified as disabilities under the Indian statute. There are some guidelines of the Ministry of Social Justice and Empowerment, dated 2002, which purport to bring certain kinds of mental illnesses as per IDEAS (Indian Disability Evaluation Assessment Scale) under the ambit of disability. However the last piece of legislation in context of mental illness is the Mental Health Act 1987. There are many individuals and bodies working even now to get the draft Mental Health Act, 2013 approved. Getting medical insurance for mental illness is another herculean, if not impossible, task.

And there was the Indian Lunacy Act, 1912, which though repealed and replaced by the 1987 Act, continues to exist in spirit, if not in letter. According to this Act, the mentally ill or "lunatics" were to be segregated and kept in confinement in order to protect society from their "dangerous" presence. There are many institutions for the mentally ill, still called Lunatic Asylums, where the mentally ill are kept in chains. The infamous incident at Erwadi (TN) where 28 inmates were burned to death as they could not escape the fire, due to being chained to their beds, is a very painful reminder of this practice. There have been fires at mental hospitals in Russia and New Zealand too, where mostly women and children perished in the fire. Due to lack of enough hospital personnel, the practices of chaining patients is adopted for violent patients. But being chained for being ill? As if being mentally ill was a grievous crime?

It is said that prevention is better than cure. One may see a number of health camps dealing with the heart, diabetes, cancer obesity, dentistry, wellness and what-not. I am yet to see a camp for promotion of mental health at any hospital in any metro, what to say of smaller cities. We are a society obsessed with academic achievement. Hence, everyone talks about IQ; no one about EQ (Emotional Quotient). Resources are scarce and the population is ever increasing. Hence, physical fitness, academic excellence, sporting and extra-curricular achievements, receive the attention of schools and parents. But no one prepares a child for dealing with LIFE. Mindfulness practices are never taught. Meditation, moderation, dealing with failure as well as success; these topics do not find space on any school curriculum. Parents are quick to enforce discipline and comb through every assignment, yet never spend time teaching life skills to the child. "It's OK. We love you, no matter what." That's all that is required to make a child blossom into a well-balanced and secure individual.

Even in offices, health camps never focus on mental health. At the most, there may be some discussion on stress busting or reducing work stress. That is not enough. It is like telling people to eat a well-balanced meal at any other health camp. Nothing specific; only general wisdom. No education is given whatsoever on what are the signs and symptoms of mental illness. A person maybe mentally ill but may not know it. He or she may simply not be aware of what his or her changed mental state - thoughts and beliefs - imply. So instead of shying away from mental illness, or only glancing at it obliquely in health camps, there need to be camps focused solely on mental health, if prevention is to be a serious alternative to treatment of mental illnesses.

In conclusion, it would be enough to say Unchain. Unchain society from the chains of rusted beliefs. Unchain the mentally ill from bearing the cross of the stigma they are chained to, and forced to carry with them. Unchain the mentally ill from the metal labels of "Weakness" welded on their foreheads. Unchain the collective family consciousness from the locks of "burden" in the form of mentally ill family members that they feel they are chained to. Unchain knotted beliefs and attitudes. Unchain minds. Unchain spirits. Unchain the mentally ill. Unchain the maladies from which our mental health system suffers.


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