This week, a poster campaign by the Ministry of Health and Family Welfare has been called out by various individuals as being reductionist and inaccurate in its proposed methods to “cope” with depression.
The criticism is well deserved. Those of us who have experienced depression know that many of these tasks are inconceivable under the weight of malaise and dread that is part of the experience – particularly the idea that one can “think positive.”
#Depression is a state of low mood that affects a person's thought, behaviour, feeling & sense of well-being. One must take up activities that keep him or her boosted in order to cope with depression. #SwasthaBharat #MentalHealth #LetsTalk pic.twitter.com/UJR3X7GwL2
— Ministry of Health (@MoHFW_INDIA) June 26, 2018
Many have also objected to the failure to include psychiatric medication and therapy in the poster.
However – “thinking positively” about the poster for a minute – a holistic approach to mental illness is something that users and survivors of psychiatry have been campaigning for decades. In 2016, the Bapu Trust for Mind and Body Discourse, Pune, organised the conference of the International Network Towards Alternatives and Recovery, which highlighted many of these themes, so this is a welcome step away from the biomedical model.
Unfortunately, the Ministry itself doesn’t follow the poster’s approach, when it comes to providing ‘coping mechanisms’ for depression or any other mental health issues.
Mental illness itself is split between ministries – the Ministry of Social Justice and Empowerment (MoSJE), and the Ministry of Health and Family Welfare (MoHFW). It’s not just about two different ministries; it’s also two different approaches.
Those who experience barriers to participation in society on account of their mental illness are considered to be persons with disabilities for the purposes of the Rights of Persons with Disabilities Act, 2016, and other policies and programmes under the Department of Empowerment of Persons with Disabilities (DoEPwD), under the MoSJE. As a disability, the focus of the DoEPwD is to fulfil state obligations to remove barriers to participation of persons with psychosocial disabilities.
As a health issue, the focus of the MoHFW is to provide treatment towards healing.
Both of these approaches are to be governed by recent reaffirmation of the human rights of persons with disabilities, which include recognition of personal autonomy, and choice and control over services provided in the community.
However, people with psychosocial disabilities find that services for their well being are overwhelmingly considered under the health domain, as can be seen from the allocations by these two Ministries:
(in INR crores)
When we look at the allocations within the Ministry of Health, an overwhelming amount of the Ministry’s expenditure goes towards the maintenance of the National Mental Health Institutes – which are primarily in large cities – with a relatively smaller portion going towards the District Mental Health Programme:
(in INR crores)
The breakup of expenditures under the DMHP varies from state to state, and data is extremely hard to come by, but in Tamil Nadu, significant resources have been utilised towards procurement and disbursing medication, as can be seen from this chart based on the figures obtained.
(INR Crore)
Basically – wherever mental health services are available, the focus is already entirely on medication “to cope.”
If one looks at the overall expenditure on mental health envisaged under the ongoing XIIth Plan, there was a substantive allocation envisaged towards community based mental healthcare, as can be seen from this chart.
Unfortunately, recent research has shown that a staggering amount of this allocation remains unspent.
(percentage)
These are just the limitations within the domain of health. Coming back to the disability perspective, only four out of the 29 States and seven Union Territories have had programmes for persons with psychosocial disabilities framed by the department of social justice/welfare.
What of the other elements of the ‘holistic approach’ in the poster then? Mental Health and disability haven’t been mainstreamed within the policies of other departments or ministries. Even where it has, there is no disaggregated data to measure the impact.
Moreover, it is time to recognise that individual coping mechanisms, be they medication or yoga, fail to recognise the well established fact that depression is no mere “chemical imbalance” – it has deep roots in the impact of violence, abuse and social marginalisation upon people. Dr Dainius Pūras, UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health, who has notable expertise on mental health and pediatrics, made this point on the occasion of World Health Day in April 2017:
“Biomedical interventions will remain as an important treatment option for severe depression and other mental health conditions. However, we should not accept that medications and other biomedical interventions be commonly used to address issues which are closely related to social problems, unequal power relationships, violence and other adversities that determine our social and emotional environment. There is a need of a shift in investments in mental health, from focusing on "chemical imbalances" to focusing on "power imbalances" and inequalities."
Eating fruits would be great for people across economic strata if only the Public Distribution System included them as part of the nutrition package, unlike the overwhelming importance it gives to rice and wheat.
Creativity by way of Art Therapy has been extremely effective in managing mental health conditions, unfortunately it is yet to be recognised as an option in mental health treatment as part of the rights under the Mental Healthcare Act, 2017.
Sleeping for eight uninterrupted hours a day would be great for a hormonal new mother, who instead takes on the major chunk of childcare and domestic work, sending her on a one-way ticket to postpartum depression.
Staying clean is considered by upper castes as an act of transgression by Dalits who are penalised for accessing water and sanitation facilities, by means that can only be described as terrorism – the Swachh Bharat Abhiyan which makes a guest appearance in the corner of the poster might do good to address this. Even persons from Dalit, Bahujan and Adivasi communities who have access to mental health services like therapy have pointed out the failure of the mental health system to even understand caste based marginalisation, as illustrated in this Twitter moment by @RachelleDBA.
The poster seems to consider depression as a manageable condition as long as you have the privileges of gender, class and caste; unfortunately, mental health issues are not discriminatory, even if the systems that perpetuate them are.
Amba Salelkar is a lawyer with the Equals Centre for Promotion of Social Justice. This data contained in this article is taken from a report on the cost of exclusion of persons with psychosocial disabilities, a pilot study undertaken for Transforming Communities for Inclusion Asia, in the State of Tamil Nadu, India. You can write to contact@equalscpsj.org for a copy of the report. Views expressed in the article are the author’s own.