The emergence of suicide prevention as a public health challenge requiring urgent national action has been painfully slow globally. The urgency has been slower in middle- and low-income countries where "ailments of the body" have been prioritised over "afflictions of the mind" given the shoestring health budgets on which these countries operate and the general stigma attached to psychiatric illnesses. This has come at huge costs.
According to the World Health Organisation (WHO), 75 percent of suicides happen in low- and middle-income countries. Globally, every 40 seconds someone dies by suicide; it is one of the three major causes of death in the economically-productive age groups between 15 and 44 years and it is the second leading cause of death among the young population between 15 and 29 years. About 8,00,000 people commit suicide every year globally and this is likely an understated figure because of the unreliability of statistics coming from many countries. The World Suicide Prevention Day, that is observed on 10 September every year, is only a recent phenomenon.
There is poor availability of data on suicide and suicide attempts given the fact that committing suicide is a criminal act in many countries — only 60 WHO member states have good quality data that can be used to estimate suicide rates. Suicide is estimated to contribute about 2.4 percent of the global burden of diseases by 2020. However, only 28 countries in the world have targeted national suicide prevention plans.
Global and Indian mental health
India is one of the top 10 countries in the world in crude suicide rates, according to the WHO database. South Korea with a crude suicide rate of 36.8 per 1,00,000 population tops the list followed by Guyana (34.8), Lithuania (33.5), Sri Lanka (29.2), Suriname (28.3), Kazakhstan (24.2), Russia (22.3) and Japan (23.1). As per 2012 data compiled by the WHO, India had a suicide rate of 20.9 for both sexes, an age-standardised suicide rate of both sexes at 21.1, age-standardised suicide rate of 16.4 for females and age-standardised suicide rate of 25.8 for males per 1,00,000 population.
Though the Indian crude suicide rate is around the average for some other countries, but given the large population size, about one-third of all the suicide deaths in the world are in India.
The importance, or the lack of it, of mental health in India's national health priorities is more than apparent in skimming through the following WHO statistics: There are 0.3 psychiatrist, 0.07 psychologist, 0.07 social worker, 0.12 nurse for servicing a population of 1,00,000 people. Moreover, there are only 2.1 hospital beds/admissions for 1,00,000 population.
This adds up to a huge burden of mental disorders — 2,443 disability-adjusted life years per 1,00,000 population.
“Most countries, including India need to increase resources — human and financial — for mental healthcare. This is clearly a commitment within WHO’s Mental Health Action Plan 2013-2020, adopted by all health ministers,” Dr Shekhar Saxena, director of the department of mental health and substance abuse at the WHO told Firstpost.
Globally, about one in 10 have mental disorder but only one percent of the global health workforce is working in the field. On an average, there is less than one mental health worker per 10,000 people. However, this average falls precipitously for low- and middle-income countries to less than one mental health worker for 1,00,000 population whereas the rate rises up to one per 2,000 people in high-income countries, according to the WHO's Mental Health Atlas 2014 report.
There is a median of five mental health beds for 1,00,000 population in low and middle-income countries and 50 for high-income countries.
Even within the general silence that pervades issues around mental health, the most neglected type of mental health promotion programmes, according to the UN, are the ones dealing with maternal health promotion and violence prevention towards women and children.
For India, suicide, depression and alcohol dependence (one of the highest in the world) are all matters of concern for the UN's health agency.
The Mental Health Bill that was passed by the Rajya Sabha in August this year seeks to replace the Mental Health Act, 1987. The Bill guarantees every person the right to access mental healthcare and treatment from the government, it decriminalises suicide, upholds the right of every person to specify how she would like to be treated in case of a mental health event, requires insurance companies to provide for insurance of mentally ill persons, among other features.
Though experts and activists have applauded the Bill calling it a step in the right direction, there remain many gaps in the text.
“There are very useful aspects to the Bill — the decriminalisation of suicide, the tenor and the narrative of the language of the Bill, the acknowledgement of the rights of the individual — these are all pertinent points,” said Dr Alok Sarin, a leading Indian psychiatrist based in Delhi and a mental health activist.
But major challenges will remain at the level of implementation.
“The mental health review commissions will require new mental health oversight and regulatory systems which will include the executive, service providers, the judiciary and civil society to participate. This will require both infrastructural and funding support. Lacking this, many provisions of the Bill may be rendered rather ineffective,” Sarin added.
The Bill does not peg an expenditure estimate to implementing the provisions under the Bill and also does not specify if the financial load will be shared by the Centre and the states. Many cash-strapped states will find it difficult to meet the requirements under the new legislation, if passed by the Lok Sabha, unless the Centre pitches in.
It also does not specify penalties for non-compliance with provisions.
“The access to care is clearly not something that can be argued with. The whole question, however, is whether legal recourse is the best way. Along with legal recourse, other interventions are needed and this is something that has perhaps not been adequately debated," Sarin argued.
“The advanced directives are another area that are a complex, societal intervention, that we have taken an ideological position on, but perhaps we haven't debated this enough,” he said highlighting some of the weaknesses but adding that the Bill is “very well-intentioned".
Additionally, psychotherapists complain that the Bill doesn't recognise the importance of their work as well as the work of community workers and traditional healers though it does recognise other streams of medicines like unani, siddha, homoepathy and ayurveda.
“Psychotherapy is a deep understanding of life — it is very nuanced, layered. One of the problems of the Bill is that it doesn't recognise the work of psychotherapists. In some dimensions the Bill is progressive, yet it continues to stress on a medical model of human suffering and hence reduces emotional and psychic distress to a biomedical illness,” said Dr. Honey Oberoi, professor of psychology at Ambedkar University in Delhi.
“It (the Bill) gives primacy to the body, which it must; however, the roots of mental breakdown lie as much in social and psychic reasons. There is no conception of a person as having a life history, relational conflicts or his or her psyche being impacted by social inequalities and oppressive circumstances such as caste, poverty etc.," she added.
Different people will need different kind of care and the fact is that counsellors, community health workers, traditional healers are also colleagues, she said adding that in India the mind, body and soul have never been divorced from each other.
India needs to develop a strategy for training human resources for mental healthcare. There should be a large role for non-medically trained professionals and even lay counsellors but with adequate training.
Like in many other countries, mental health is stigmatised and neglected in India. However, many evidence based strategies exist for decreasing stigma and providing services for persons with mental disorders, WHO said.
“A large proportion of mental disorders can be looked after by non-specialist healthcare providers. The National Mental Health Programme in India has some very effective strategies and these need to be implemented on a wider scale and more effectively,” Saxena said.
The devil certainly lies in the detail given the magnitude of the problem, the stigmatisation of mental afflictions, the funding requirements and the imperative of servicing people in the nook and cranny of districts in India.
“The question remains: Has the discussion been enough, and how much is ever going to be both enough and necessary,” Sarin said.