Is Mental Healthcare Equally Accessible To All Indians?

According to the WHO, mental health is not just the absence of mental disorder - it is defined as a state of well-being in which every individual realizes their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community.

How many Indians can really say that they are living in a state of well-being that allows them to realize their full potential? More specifically, amongst those that fall within the marginalized sections of our society, how many are truly receiving quality mental health services? 

Social Inequality is not a new phenomenon and the reality is that it not only contributes to poor mental health, it also determines the quality of care received. 

Since the World Mental Health Day theme this year is, ‘Mental Health In An Unequal World', we looked into how diversity and mental health intersect in India. 

Here’s What We Found on How Social Inequalities Are Shaping Mental Health in India:

India’s long history of categorizing its population based on religion, class, caste, language, and regions has led to the creation of a socio-political system that is fraught with inequalities. And the COVID-19 pandemic has further widened the gap amongst different groups. 

According to reports by the Indian Psychiatric Society, there was a 20% increase in cases of reported mental illness during the first nationwide lockdown that was imposed in March 2020. 

In response to the lockdown, government and private hospitals had to shut down outpatient services - including psychotherapy and psychiatry - for several weeks. Unfortunately, this affected people in rural and remote areas of the country disproportionately. People could not access medications for their mental health, which are often provided for free at government centre's. 

But the question remains, was mental healthcare accessible to the masses even before the pandemic?

Mental Healthcare and Financial Status

Research increasingly suggests that many common mental health concerns are largely shaped by social and economic structures within a society. 

Studies show that lower socioeconomic status (SES) is closely linked to higher rates of depression. Furthermore, researchers have found a bilateral relationship between socioeconomic conditions and mental health concerns. Living with a mental health condition negatively impacts an individual’s earning capacity and employment status - which worsens their economic status and ultimately leads to higher risks of mental illness. 

Studies also indicate that children and adolescents with low social-economic status are 2 to 3 times more likely to develop mental health problems than their peers with high SES.

According to Oxfam India, healthcare in India is a ‘luxury’ - “with 63 million people being pushed into poverty each year due to health care costs—2 every second.” Their research found that 80% of healthcare in India is offered by the private sector, making mental health care unaffordable to the underprivileged. 

Mental Health And Other Marginalised Communities

Mental Health and Religion

Individuals from minority communities are at a higher risk for developing mental health concerns. According to researchers, sadness and anxiety are more likely to be reported by Muslims as compared to upper-caste Hindus. This is the case even after controlling for age, education, assets, expenditure, state of residence, and rural residence.

The hostile socio-political environment that some communities live in can exacerbate existing mental health conditions and trigger an emotional upheaval in members of the targeted communities. The rise in violent crimes against minority communities in recent years, the increase in the number of lynchings, and protests against the Citizenship Amendment Act - all these factors have created a tense and fearful atmosphere for religious minorities. 

If our goal is to make mental health accessible, isn’t it time we recognise the deeply entrenched biases against marginalised communities as contributing factors to poor mental health outcomes? 

Mental Health and Caste

Studies have repeatedly found that members of marginalised castes are at a much higher risk of experiencing chronic illnesses, specifically mental health issues. 

Furthermore, researchers have pointed out that when a woman from the Dalit community faces violence, she does not have the necessary economic or social support to access much-needed mental health care. 

Beyond the concern about access to care, research also points to the limited scope of psychotherapy when it comes to addressing the unique experiences of people from marginalised castes. 

Mental health frameworks need to be more inclusive of the systemic realities of the lived experiences of people from marginalised castes. 

Mental Health And Sexual Orientation

India is home to 1.4 billion people. Beyond cultural and social diversity, we also have a diverse population with respect to sexual identity. 

According to 2021 data from Ipsos (a multinational research organisation), 3% of the Indian population identify as homosexual, 9% identify as bisexual, 1% identify as pansexual and 2% identify as asexual. 

Interestingly, 17% identify as not heterosexual (excluding 'do not know', and 'prefer not to answer'). But, given the stigma and discrimination around homosexuality in India, it is likely that many individuals are still hiding their true identities. 

As Meyer's Minority Stress Theory suggests, members of sexual minority groups are subjected to chronic psychosocial stress in the context of pervasive prejudice, discrimination, and stigma within their social environments.

In India, the situation is compounded by social, religious and cultural traditions and rigid notions of masculinity and femininity. 

According to reports, trans women are often admitted to male wards despite a clear expression of their gender. Reports also show that transgender individuals avoid free government healthcare services and prefer self-medication or private healthcare. And women from sexual minority groups feel there is a strong stigma associated with mental illness due to which they do not seek out mental health services. 

Additionally, negative medical interventions or non-inclusive services that have led to traumatic experiences often deter individuals from getting the help they need.

When we consider mental health in an unequal world, it is important to recognise that inequality also emerges in the context of one’s sexual identity and orientation.

How Can We Change The Narrative?

Inequality will persist so long as we continue to hold on to an ‘us vs them’ stance, so long as we consider some people superior, more worthy and more deserving of quality care. 

Firstly, it is up to the people in powerful positions to facilitate change - whether that change comes from within the mental health field, governmental bodies, social organisations or individuals who are relentlessly campaigning for equal rights - the need of the hour is a synchronised effort across all verticals. 

Secondly, we need to reflect on our individual responsibility on these issues of inequality. How can we contribute to creating a system that is just? One of the most crucial aspects of driving this change is to make practical improvements in our interactions with members from marginalised groups. We also need to make greater efforts to be more inclusive and tolerant on all fronts - personal, professional, educational or otherwise. 

We need to humanise, legitimise and organise the fight against inequality. Every individual should get the same recognition for their mental health concerns - and while we work towards this, we must proactively ensure that marginalised groups do not continue to suffer in silence. How?

By speaking up when we see injustice and protecting the rights of those whose voices are constantly sidelined. 

For those who are driven to action by numbers, consider this:

The World Health Organisation has predicted that ignoring mental health could reduce India’s economic growth by $11 trillion in 2030.

So, what role are you going to play in reducing the mental healthcare gap in India?

References:

2021 World Mental Health Global Awareness Campaign - World Mental Health Day Theme - World Federation for Mental Health. (2021, March 19). Retrieved from World Federation for Mental Health website: https://wfmh.global/2021-world-mental-health-global-awareness-campaign-world-mental-health-day-theme/#:~:text=Mental%20Health%20in%20an%20Unequal%20World&text=2020%20highlighted%20inequalities%20due%20to,living%20with%20mental%20health%20conditions.

‌Galhotra, A., & Mishra, A. (2018). Mental healthcare Act 2017: Need to wait and watch. International Journal of Applied and Basic Medical Research, 8(2), 67. https://doi.org/10.4103/ijabmr.ijabmr_328_17

How Inequality Endangers Our Mental Health. (2017, June 15). Retrieved from Inequality.org website: https://inequality.org/research/inequality-endangers-mental-health/

‌Ideas For India. (2020). Mental health disparities in India. Retrieved from Ideas For India website: https://www.ideasforindia.in/topics/social-identity/mental-health-disparities-in-india.html

Makurah, L. (2018, December 18). Health Matters: Reducing health inequalities in mental illness - UK Health Security Agency. Retrieved from Blog.gov.uk website: https://ukhsa.blog.gov.uk/2018/12/18/health-matters-reducing-health-inequalities-in-mental-illness/

‌Murali, V., & Oyebode, F. (2004). Poverty, social inequality and mental health. Advances in Psychiatric Treatment, 10(3), 216–224. https://doi.org/10.1192/apt.10.3.216

Nakkeeran, N., & Nakkeeran, B. (2018). Disability, mental health, sexual orientation and gender identity: understanding health inequity through experience and difference. Health Research Policy and Systems, 16(S1). https://doi.org/10.1186/s12961-018-0366-1

‌Social Inequity and Access to Mental Healthcare in India During the COVID-19 Pandemic - Medical Humanities. (2020, June 25). Retrieved from Medical Humanities website: https://blogs.bmj.com/medical-humanities/2020/06/25/social-inequity-and-access-to-mental-healthcare-in-india-during-the-covid-19-pandemic/

Srivastava, K., Chatterjee, K., & Bhat, P. (2016). Mental health awareness: The Indian scenario. Industrial Psychiatry Journal, 25(2), 131. https://doi.org/10.4103/ipj.ipj_45_17

‌Tackling social inequalities to reduce mental health problems: How everyone can flourish equally A Mental Health Foundation report. (n.d.). Retrieved from https://www.mentalhealth.org.uk/sites/default/files/MHF-tackling-inequalities-report_WEB.pdf

‌The unequal mental health toll of the pandemic | The Health Foundation. (2021). Retrieved from The Health Foundation website: https://www.health.org.uk/news-and-comment/blogs/the-unequal-mental-health-toll-of-the-pandemic

‌Yu, S. (2018). Uncovering the hidden impacts of inequality on mental health: a global study. Translational Psychiatry, 8(1). https://doi.org/10.1038/s41398-018-0148-0