Evidence and mental health in developing countries: are we “Erewhon”?
Pre-COVID-19, mental health in India was a serious public health challenge, but it has been suggested that COVID-19 may offer an opportunity for reform. In the blog below, Howard White (CEO, Campbell Collaboration) and Monisha Narayan (evidence synthesist specialist, Campbell, South Asia) discuss the challenge of using evidence during an infodemic to address the triple challenge of mental health in developing countries in a post-COVID-19 world.
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Howard White: In the initial days of the world coming to terms with this deadly pandemic [COVID-19], there was a barrage of both information and misinformation. This came from both experts and pseudo experts. Most would agree information is useful; however, in an emerging situation like this where there is such a range of information readily available and it is challenging to discern what is trustworthy, it can be damaging. How bad was the effect of this ‘infodemic’ in India?
Monisha Narayanan: The situation in India was bad. The void of mental health services was filled by armchair experts and professionals from ‘WhatsApp university’, who flooded social media platforms advertising counselling sessions and mental well-being. While it is a step in the right direction to ‘de-expertise’ mental health and empower lay-person interventions on a greater scale, it is a work in progress and has not yet reached those levels of proficiency. The saddest part is that religious fanaticism has squeezed its way in during these testing times, with prominent individuals holding public office openly proclaiming that a daily dose of cow urine will keep both COVID-19 and mental health issues at bay.
The sensation-hungry media has not done much to help either. Inappropriate reporting of deaths associated with mental health issues not accompanied by education or helplines does not help. Unscientific coverage contributes to reinforcing myths rather than helping to create understanding.
Howard White: So, what is the solution?
Monisha Narayanan: Promotion of the right information from recognised trusted sources. Mental health literacy services need to be accessible and reliable. Social media is one conduit that can help connect and direct people seeking help, but the content needs to be regulated and monitored. Official websites of government agencies need to be made more user-friendly and accessible. The general public has to be equipped with simple fact-checking tools. Only then can we start to properly address the mental health challenge in India.
Howard White: I first heard mental health issued as a priority policy issue in a developing country at a workshop we ran with the Africa Centre for Systematic Reviews and Knowledge Translation in Kampala in 2016. It was said that mental illness was not widely understood in the medical profession.
On my way to the airport a few days later, I mentioned this to the driver. He told me that, indeed, his brother had suffered from depression for some time. But depression is referred to locally as ‘having a heavy heart’, and the doctor actually treated him for a heart condition.
Mistaking mental conditions for physical ones may not be accidental because of the stigma attached to mental illness, which is not present for physical illness. In his utopian novel 'Erewhon' (an anagram of ‘nowhere’), published in 1872, Samuel Butler imagined a world in which physical illnesses, such as a cold, were a matter of shame to be hidden from public view, but mental illness held no such stigma. One hundred and fifty years later it seems that such a world is still nowhere.
Monisha, is stigma related to mental health also an issue?
Monisha Narayan: It certainly is. The age-old expression ‘Pagal hae kya?’ (Are you mad?) frames mental illness as a negative thing. Stigma in India transcends all boundaries and prevents affected persons from seeking and receiving help. To hide the condition and the perceived shame, it is common for family members and caregivers to confine people with mental health disorders in their homes or psychiatric hospitals.
Howard White: Tackling mental health involves paying attention to where people get their information from. Attitudes to mental health can be addressed through opinion leaders expressing support, or sharing their own experiences, to break down stigma. The reality of mental illness can be shown in TV shows, movies, and street theatre.
Monisha Narayan: We need a triple-pronged response that gets the right information in front of the right people: policy makers need to be aware of the huge costs associated with mental illness; the medical profession needs to be more aware of mental health issues and interventions; and responses need to be evidence based, including building the evidence base for traditional practices and remedies as well as other therapeutic approaches. With the proper use of evidence, we can end the mental health crisis.
Howard White: The ongoing COVID-19 pandemic has deeply affected the world as we know it. Life seen through the prism of the pandemic seems irrevocably different to how it was before. One positive aspect is that the world has suddenly become aware of the importance of mental health.
Monisha Narayanan: COVID-19 has completely changed our perception of mental health. Before this pandemic engulfed us, mental health was a taboo subject. Maybe the lockdowns, social distancing and other interventions that have been introduced to societies globally have helped us to focus our attention on mental well-being. No one has escaped the impact of the pandemic and we are all equally susceptible to ailing mental health. This became dramatically apparent when an elite gymnast withdrew from the Tokyo Olympics in order to prioritise her mental health. The global support she received demonstrates, I think, how the pandemic has given a voice to this important issue. If the mecca of physical prowess, the Olympics, has been impacted to this level, one can only imagine the challenges faced by other walks of life.
Howard White: Now that mental health is finally being acknowledged in this way, has the associated discourse changed in India?
Monisha Narayanan: While it would be fair to say the opportunity for introspection has been of value in creating a sense of awareness regarding mental health, the pandemic has also exacerbated pre-existing conditions. The confusion and chaos that prevailed in the initial few days after the discovery of the coronavirus left many scarred for life. The financially stable segment of the population was able to weather the intense lockdowns and flux in jobs; however, marginalized sections were the hardest hit, both economically and mentally. The situation was aggravated when people started losing their loved ones, some even after spending huge amounts of money for treatment. When deaths ceased to be mere statistics for the population, grief and trauma transformed into serious mental health conditions. Many people across the country say that we need a vaccine for mental health as well to refer to the intensity of the mental health problems in the country.
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Thank you to Monisha and Howard for these insights into the current mental health landscape in India. It is gratifying to hear that the opportunity for change is being embraced by the population in India and beyond.
Corresponding Authors
Dr Monisha Narayan
Howard White
Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.
