The woman in the pale pink nightgown shrinks towards the bed. She rocks back and forth, her narrow back heaving. “Aiyo, moolai poiche, moolai poiche, moolai poiche! Saagachidaan, saagadichidaan, saagadichaan.” I’ve lost my mind, he killed me, she repeats, in a half-chant, half-moan. Her hair looks tangled and thin, drawn tight over a bump on her scalp like disused fishing thread. The doctor tells a nurse to bring in a sedative. “She’s floridly psychotic,” he tells the case manager standing beside him. “Hey! I’mno psycho!” snaps the woman, pausing mid-sway. She glares. “It’s all my son’s fault. I told him smoke was coming out of the fan. He did nothing about it, so my brain vanished. He ruined me!”
A sedative is administered. After a few moments, she is slowly led out to a nearby imaging center to get the lump on her head x-rayed. “It’s to rule out anything sinister, like a tumor,” the doctor says in a low voice. The woman’s daughter places a comforting hand on her shoulder. She shrugs it off. “Two thousand five hundred rupees is all a new fan would cost,” she mutters. “But you didn’t replace it. I’m alive, but you killed me.”
In a consultation room just down the corridor sits a tall young man with brilliantined hair coaxed into the shape of a tailorbird’s nest. He listens quietly as his 98-year-old father animatedly describes his son’s daily routine. It begins with him boiling milk “religiously” early every morning and devolves into shouting sometime around midday. The doctor writes out a new prescription, and hands it over to the father. “How are you?” she asks the young man. “As usual, doctor,” he says shyly, raising his head. “I have lots of turbulent feelings inside me. I always have these...firing feelings.”
Everyone you’ll meet at a psychiatric hospital has an origin story. Some of them begin with a gust of smoke or a sudden conflagration of “firing feelings”. Others start with a telltale stomachache, a failed exam, a love affair gone sour, then teetering totally off-script. Most of them amount to what the sociologist Erving Goffman delicately calls “self-supporting tales”. They tell you less about the speaker’s state of mind when they had their first (or latest) crisis than their need to shore up their constantly embattled self against any potentially discrediting information that might be uttered by a psychiatrist or caregiver, and live on forever in a case manager’s file.
Should you live in a big Indian city, a crisis could take you to a place like this: the Schizophrenia Research Foundation, or SCARF as it’s known in Chennai. And if it does, you’d have to count yourself among the luckiest few in the country.
It’s hard to tell precisely how many Indians suffer from mental health problems because we’ve few conclusive studies to go by, and because the stigma attached to mental illness means it’s under-reported in the first place. The National Commission on Macroeconomics and Health suggests a prevalence rate of 6.5 percent, the median of two existing estimates. By that reckoning, India has more than 78 million Indians with mental health problems – and a scarily low number of trained mental health professionals available to treat them. The 2011 edition of the WHO’s Mental Health Atlas noted that India had one psychiatrist per 3,32,226 people, one psychiatric nurse per 6,02,410, and one psychologist for 21,27,660 people.
To put this in perspective, Iran, which has about the same per capita income, does considerably better at one psychiatrist per 67,114 people, one psychiatric nurse per 13,405, and one psychologist per 45,6662 people. Both countries are under-served compared to prosperous Western countries like France, for instance, which has a psychiatrist per 4,474 and a psychologist per 2,088. But the wait for a psychiatrist or a psychologist in India sounds positively Beckettian.
This vacuum was addressed in 2011 in The Lancet, one of the world’s most distinguished medical journals. “In India, if every psychiatrist worked fulltime,” the authors observed, “they would succeed in treating less than 10 percent of people with mental health needs.” The resulting “treatment gap”, as the WHO calls it, is a staggeringly deep canyon
Confronted with the default option, though, the canyon doesn’t look all that bad. About 80 percent of the country’s psychiatric beds are located in the country’s 37 colonial-era “mental hospitals”, draughty, overcrowded, poorly managed constructions, deplorably suited to their anachronistic name. Through the 70s and 80s, these institutions earned press coverage that grew into an indigenous sub-genre of gothic horror. Among the recurring elements were patients being tied up or consigned to dank isolation cells, having little to no access to healthy food and fresh water. Reports frequently spoke of there being so few toilets patients relieved themselves in pails, or on their bedcovers. The closest these tales came to a happy ending was on the rare occasion when patients managed to break free through a broken door or window
In the intervening years, there have been some improvements, in part because some of these asylum horrors made it into damning reports by the National Institute of Mental Health and Neurosciences: “Quality Assurance in Mental Health” (1999) and “Mental Health Care and Human Rights” (2008). But Vikram Patel continues to take a dim view of them. Patel is a psychiatrist and researcher who founded Sangath, a Goa-based non-profit focussed on mental health. He runs the Centre for Global Mental Health at the London School of Hygiene and Tropical Medicine. “[Mental hospitals] are animal warehouses, where the animals are replaced by humans,” he says. “They suck up the lion’s share of our mental health budget, and they only offer an inflexible, highly biomedical kind of care.
This limited form of care does not see distress within a social context; it just sees those who suffer it as targets to be corralled and subdued (depending on the century and location) by chains, electroshock, medication—or threats. A recent investigation revealed that in Thane Mental Hospital a contingent of ward boys regularly intimidated patients through abuse and threats of starvation. Which seems to have been, in effect, part of the job description. A psychiatrist there assured the reporter that the ward boys were “trained in handling patients, and controlling any aggressive behaviour”. Another shocking investigation by Human Rights Watch, which investigated 24 government-run psychiatric hospitals between 2012 and 2014, found that women in institutions like Pune Mental Hospital were forcibly subjected to electroshock therapy. In other psychiatric hospitals they visited, nurses admitted to prying open the mouths of patients reluctant to take their medicines, or threatening them with electroshock therapy if they didn’t comply
All of it verges uncomfortably close to what the colonial powers had in mind when they constructed these asylums two centuries ago: exerting a “less conspicuous measure of social control” over people they called “the most unhappy Class of human beings”. As the historian Waltraud Ernst recounts in her 1987 essay, “The establishment of ‘Native Lunatic Asylums’ in early nineteenth-century India,” in 1802, the East India Company announced that it would open lunatic asylums “for the reception of both criminals and freely wandering insane Indians,” a measure “necessitated by the authorities’ concern with public peace and order which had frequently been disturbed by mischievous Indian lunatics committing violent actions.”
In other countries, mental health treatment is guided by public health strategies, which means that its various practitioners do a whole lot more than dispense medication. Their job includes reducing stigma, and pre-empting illness by identifying and tackling erosive stresses. It also involves assisting recovery, and responding to the needs of people of a wide range of ages and socioeconomic statuses. India did develop a community-based mental health program in 1996, but the number of places and people it can reach has been drastically limited by the shortage of trained professionals. As a result, according to a 2012 estimate, only 123 out of India’s 652 districts at the time had access to mental health care.
The nature of treatment remains correspondingly limited, adds Patel. “[Psychiatrists in India] do a quarter of what psychiatrists in Western countries are trained to do,” he says, “minus all the continuing care and community care.” The few places that go any further, Patel adds, are “miniscule islands of excellence in metros.”
SCARF is one such island. It’s one I’ve gotten to know well over the past ten years, since I first washed up on its shores along with a family member who had just been diagnosed with a psychiatric disorder. When the hospital was set up 30 years ago in a then-remote corner of northwest Chennai, they employed a psychiatrist and a psychologist; their staff now includes 10 psychiatrists, six psychologists, five social workers and an occupational therapist. On an average day, the waiting room is crowded with up to a hundred patients, each of them accompanied by a parent, or their entire extended family. All of them get free consultations with a psychiatrist and a case manager, usually a social worker that notes down everything the patients or their family members describe. The unwelcome spectral forms an elderly man sees perched on the sofa, the harsh imagined voices that accuse a young woman of harbouring lascivious feelings for her cousin, a young mother’s tendency to drop vegetables whole into a stewing pot of sambhar, or how she habitually forgets to pack her school-going children lunch.
The caseworker recounts these stories to the psychiatrist, and after a round of gentle questioning on the issues faced by the patient and their caregivers, a personalized course of treatment is charted out. Most patients are prescribed a course of medication – in many cases, subsidized or free. Some are asked to return to the hospital for day-care or spells of time at the vocational center while their caregivers are occupied.
Still others, in the midst of a crisis, are recommended a short stint of medication and rest in one of the hospital’s four short-term residential care centers, including one on its premises. The hospital has found other ways to extend its reach. In early 2005, the hospital introduced telepsychiatry for those affected by the tsunami in Cuddalore and Nagapattinam. And in 2010, they set in motion a mobile telepsychiatry van that roves around dispensing care in Pudukottai. The hospital is also a teaching institution for psychologists and social workers, and a prolific research center that’s turned out upwards of 200 articles in peer-reviewed journals.
Much of this research feeds back into treatment. As soon as new generations of medications are launched, researchers assess which ones work better on the Indian population, and rapidly restock their pharmacy. “We also keep evaluating our own programs, and feeding the results back into the treatment we offer,” says Thara Rangaswamy, a psychiatrist and the hospital’s founder. She cites the example of a recent study she conducted, published in the Lancet, which compared whether patients in rural Tamil Nadu, Satara in Maharashtra, and Goa fared better when they were hospitalized and medicated, or treated at their homes by community health workers. “We found that patients did far better when they were treated by lay workers administering psychosocial interventions,” she says. “It’s a hypothesis we had, but it helps to have proved it.”
Another feature that sets the hospital apart is that it doesn’t strictly fall into conventional hierarchy, with homegrown Nurse Ratcheds facing off against cornered McMurphys. If you wander through SCARF on an average working day, you’re likely to run into a number of its patients – one at the gate, ushering you in, another at the reception area, helping patients register, and yet another locating their files. You’re likely to encounter another few in the waiting room around the corner, at work directing patients and caregivers when it’s their turn to see their caseworker or psychiatrist.
The first one you’re likely to meet, sitting on a blue chair by the gate, is Bala. A short, deceptively youthful 40-year-old with a neatly groomed moustache and a distractible air, he doubles as the hospital’s security guard and indefatigable errand runner. In all his tasks, he is accompanied by a Greek-chorus-like din in his ears. “They are growing children,” he says, gazing at a spot behind me. “They laugh, they shout, and sometimes they say: ‘Did he die? Did he run away?’” Over the years, Bala has found that he can muffle their clamoring somewhat if he takes his medicines every day and keeps busy. So from morning to late afternoon every day, he skitters between the gate and the hospital, where he can sometimes be found running from room to room, ferrying files about, turning on water pumps, and turning off lights.
The voice-attenuating, calming power of repetitive tasks draws many men and women to the Vocational Training Center on the third floor of the hospital. “Some of our clients are dull and lethargic,” says Sasikala, an occupational therapist who runs the center. “So we offer them a structured rehabilitation, to serve some daily functional purpose. It’s like therapy, and it’s totally free.”
The therapy takes place in a large, well-lit room shaped like a horseshoe. At the entrance is a cast iron gate, padlocked to deter the occasional bolter. Every time a visitor comes up to the gate, a shadowy sentinel slumped on a plastic chair rouses himself out of a permanent half-doze and unlocks the gate. The center resembles crafts class at a conservative school, with men and women toiling quietly in separate wings. On one side, groups of women sit at several small tables, reading newspapers, weaving baskets out of plastic thread, embroidering handkerchiefs and putting together little vegetable sandwiches to sell to patients in the waiting room downstairs. At the other end, small groups of men sit folding newspapers into envelopes, and stand by a screen-printing machine cranking out white sheets of paper stamped with the SCARF logo.
In a small room to the side, a young man with dull eyes is slumped before a computer killing virtual mosquitos. It is part of a “cognitive retraining” exercise that’s intended to quicken his concentration and memory. At every third click, his instructor, a young woman (and fellow patient, as I learn when she later asks me, in urgent tones, “not to disclose anything” about her) admonishes him with terse cries of “More!” or “Why do you right-click?” When the program finishes, she shows me his scores in a notebook. “Yesterday, he killed 200, today he killed 289,” she says. “Improvement is there!”
A young man named Mani offers to walk me out. He is staying for a spell in the hospital’s short-term hostel after he went off his medication and struck someone on the street. He first came here six years ago after his morning prayers were disrupted by a vision of a holy man floating on a lotus. “Then I turned to the mirror,” he says, “and I saw an ‘om’ blazing in a gold disc, exactly in between my eyebrows. A filament of light appeared around my throat, and I thought my head would burst.” Despite having to go on anti-psychotic medication that dulled his senses and slowed him down, he went on to get a degree in computer science, and worked as a consultant in a prestigious IT firm. He’s since had to quit, and spends his mornings summoning patients in the outpatient department for their appointments, and his afternoons here, printing SCARF stationery.
Mani spends every night poring over textbooks about programming, which he hopes will help him find his way back into an IT firm when he gets out. But his occupational therapist is not likely to approve. “Greater the salary, greater the stress,” cautions Sasikala. She recounts the case of a solar engineer who spent some time in the center undergoing treatment after a psychotic break. When he returned to his job, he couldn’t meet his old targets and quickly unravelled. “I found him a job selling jute bags at a mall,” says Sasikala. “He now earns a fifth of what he did before. But he is peaceful.” Dr Sridhar Vaitheeswaran, a dementia specialist and the newest member of its staff, doesn’t think that all those with mental illnesses ought to be solely consigned to repetitive tasks involving crude artisanry. “We have an institutional model of rehabilitation in India,” he says. “A 30-year-old IT professional won’t be into making baskets. But there’s nothing for him there.”
Rangaswamy, the hospital’s founder, admits that it’s a “huge challenge” finding suitable jobs for patients from wildly disparate educational backgrounds. “There are only a few small companies, people we know, who hire them as front-office staff, as attenders at shops or petrol bunks,” she says. “We really wish we could do more.” A large part of the challenge, she says, is reluctance from potential employers, who tend to see those with mental health issues as unemployable. “They think they become violent, and that they’re untrustworthy,” she says. “It’s a huge deterrent.”
The problem, as Vaitheeswaran sees it, is that India is missing an entire sub-specialization of psychiatry: rehabilitation psychiatry. In Aberdeen, where he previously studied and practiced, patients were assigned a rehabilitation team composed of a psychologist, nurses, social workers, and rehabilitation specialists, including an occupational therapist. Together, this team helped patients out with individually tailored therapies, made home visits to make sure they were coping well and taking their medicines, and arranged appropriate jobs through employment agencies.
Some of these issues could be addressed in India’s new – and first – mental health policy, launched in October by the Union Health Minister Harsh Vardhan.
The policy recommended some much-needed initiatives, like providing mental health care at the primary health care level through increased funding to general hospitals that wanted to open or upgrade their psychiatry departments. It also advocates financial support and tax-benefits for those suffering from mental health issues and those who take care of them. And it calls for training many more mental health professionals: not just psychiatrists and psychologists, but nurses, social workers, and community workers.
To this, we must add one big, if emaciated elephant in India’s room: poverty. “There’s an increasing amount of evidence correlating abject poverty and severe mental health issues,” says Vandana Gopikumar, a social worker who was part of the government-appointed Mental Health Policy Group that prepared the policy. “And the majority of Indians are below the poverty line. Also, poverty is not just [being] poor: it’s the sum of all socio-economic determinants, micro-stresses that can influence or impact well-being: where I’m born, my parenting, my nutrition, my gender, my education, my access to health, employment, and housing...So for this policy to work, the Department of Health must work closely with the Departments of Disability Affairs and Social Welfare, and make a serious attempt to address these structural inequalities that may build distress.”
Then, there’s another elephantine problem. Without actual action, the most thoughtful, comprehensive policy amounts to a pusillanimous pile of wood pulp, as Rangaswamy from SCARF points out. “It’s very good on paper,” she says, “but it needs some direction and purpose. A policy says: this must be done. A program says: here’s how one does it.” And then, only a suitably hefty budgetary allocation would ensure that this program has any chance of reaching all those who need it. Until then, miniscule islands like this are likely to stay flooded.
Shruti Ravindran is a Mumbai-based journalist reporting on science, ecology, and health.