The World Health Organization (WHO) defines mental health as – “a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”
All of us need mental wellbeing, and all of us can experience mental health problems at some point or the other in our lives. However, the risks of poor mental health are not equally distributed. As understood by the bio-psycho-social model of mental illness, the probability of developing any mental health problem is influenced by a multitude of factors, most importantly genetics and our environment in which we are born, lead our life, and age. People at the greatest disadvantage are also the most vulnerable to mental ill health. This unequal distribution of risks in known as the mental health inequalities
Social Inequalities and Mental Health
Social inequalities are omnipresent in the society that we live in. They can be overt like racism, poverty, discrimination based on sexual orientation, or seemingly less obvious like bullying, sexism, and social exclusion due to disability or age. Drawing inspiration from George Orwell’s Animal Farm, one might want to ponder – All men are equal, but are some men more equal than others?
Not every individual has an equal opportunity to thrive. Too many childhoods begin from a position of disadvantage, and many adults find their journey to mental and physical health obstructed by circumstances beyond their control. These circumstances may comprise of (but are not limited to) being a part of a marginalized/minority group or experiences like abuse, discrimination, exposure to natural calamities etc. These negative effects accumulate over a person’s lifespan and the cumulative disadvantage may even be carried forward inter-generationally. There is a strong body of research to suggest that individuals who face adverse childhood events (ACEs) grow up to constitute one-third of all adults with mental illness. Dropping out of education has been associated with substance misuse, anxiety and mood disorders along with increased risk of suicide. Various studies have also established the link between physical disability like visual or hearing impairment and developing a major depressive or anxiety disorder.
Many reports that looked at the intersection of social factors and health status in India brought up the contrast between the well-being of different social groups. Religious minorities, scheduled castes and tribes, differently-abled individuals, women – both single and widowed, workers from unorganised sector and individuals from LGBTQI community always fare the worst on health and development indicators. Additionally, inadequate representation of the aforementioned groups translates into bias at the level of policy making and implementation.
The bidirectional relationship between poverty and mental health has been well-recognised and evidenced. Poverty brings with it stress, debt and other social problems, thus causing more mental health problems and hampering recovery from already existing ones. Concepts like ‘social gradient’ and ‘social causation’ suggest that the further down a person is on the social ladder, higher is the risk of developing mental illness. Au contraire, mental illness can be seen as a determinant of lower socio-economic position. The decreased ability to work and discrimination in jobs pushes an individual into economic disadvantage and causes a downward shift in the social class. Thus, the lower socio-economic strata should be seen as a potential target for preventive action.
Unmet health needs lead to absenteeism from school/work, increased suffering, shorter life expectancy, increased stigma, and poorer investments in mental health delivery services. Beyond the individual and family, the unmet health needs act as a roadblock for economic and overall development of the nation, thus perpetuating the vicious cycle. Access to mental health is a right, and should not be a luxury.
Mental health does not exist in vacuum. It is a product of the interaction between the individual and the system – government, law enforcing agencies, educational institutions and the economy. When we look at mental health through an individualised lens, we put the burden of getting better/ maintaining optimal health on the said individual. Organizations, society and government are equal shareholders and should carry this responsibility. Of course, it is easier said than done since a collective responsibility would require the persisting, albeit ignored, inequalities to be acknowledged and to let go of denial.
The WHO definition of mental health that we referred to at the beginning, implies that to be mentally healthy, an individual needs to be able to cope with the normal stressors of everyday living. However, unless the basic requirements of nutrition, education, housing and employment are met, the playing field will not be level.
The theme for the 2021 World Mental Health Day has been very aptly chosen as ‘Mental Health in an Unequal World’. With the job losses/job insecurity, loss of lives, physical distancing and social isolation, the COVID 19 pandemic has made our world a little more unequal. The already prevailing treatment gap for mental illnesses, which was around eighty percent as per the National Mental Health Survey, has also widened further.
So, What Can be Done?
The first step would be to acknowledge that mental health inequalities exist. Following that, the change has to occur at various levels in the form of better systemic measures, enhancing community assets, and individual resilience. Mental health is not just about disorders but also about mental wellbeing. The shift to a rights-based approach and the implementation of the Indian Mental Health Care Act (MHCA 2017) has been a promising step in this direction. But, there’s still a long way to go in implementing what lies in the paper. Reducing mental health inequalities is a herculean task and the mental health service providers may not be equipped enough to single-handedly address it. A collective responsibility includes the individual right up to the community members and administration, not to mention the paramount role media can have. That been said, it is important on our part to ensure that every individual feels heard, understood and their struggles respected. Shifting the focus from symptom control to a holistic, recovery-oriented approach while working alongside communities and families might help accomplish some of these objectives.
Mental health “for all”, can only be achieved “by all”!
(Dr Parul Mathur is a Psychiatrist with NIMHANS, Bangalore. Dr Debanjan Banerjee is a consultant old-age psychiatrist, Kolkata and member, International Psychogeriatric Association)