Why Combating Depression Involves Addressing Inequalities

While the prime minister's World Health Day speech was timely and important, it missed the points on the roots of depression that were addressed by UN special rapporteur Dainius Pūras.

Representative image. Credit: PTI

Representative image. Credit: PTI

Depression gets a lot more coverage in mainstream media than other mental health conditions for several reasons. It is largely considered to be a ‘manageable’ condition, without any apparent violent outcomes outside of the individual. Those affected by it still retain some agency to express their viewpoints, and include several high profile personalities. Anti-depressant medication, to correct ‘chemical imbalances’, has entered into popular cultural lexicons. Even discussions on the mental healthcare Bill, recently passed by both houses of parliament, tend to focus on the decriminalisation of the attempt to commit suicide, again perceived as an outcome of depression.

Available information on the statistics on the prevalence and likelihood of development of depression is on the rise. However, given the overall lack of awareness and marginalisation of persons with psychosocial disabilities, the theme of this year’s World Health Day as ‘depression’ is still important. Two important people aired crucial views on addressing depression – the Indian prime minister, Narendra Modi, and the UN special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Dainius Pūras – that create both opportunity and guidance on the way forward.

Modi is to be appreciated for staying within the social model of disability during his widely broadcast ‘Mann ki Baat’. He addressed the issue of depression from a non-medical perspective and spoke of the need for a ‘psychologically conducive environment’. He also provided simple yet effective examples of how friends and family could identify psychosocial vulnerability. The factors leading to depression identified by his speech seem discomfiting – particularly the reference to ‘students in hostels’ facing loneliness, in light of constant attempts to frame recent suicides by Dalit students solely as mental health issues. Pathologising inabilities to cope with situations runs the risk of placing the onus on the individuals to cure themselves, as opposed to recognising the structural imbalances that lead to the isolation or vulnerability of the person to psychosocial disability.

This is recognised by the statement of the special rapporteur, who points to an increasing evidence base that higher prevalence of depression is “…strongly linked to early childhood adversities, including toxic stress and sexual, physical and emotional child abuse, as well as to inequalities and violence, including gender based inequalities and gender based violence, and many other adverse conditions which people, especially those in vulnerable situations such as poverty or social exclusion, face when their basic needs are not met and their rights are not protected.”

For this, he proposes interventions at the population and the individual level, which are of relevance for India’s evolving mental health policy and the attainment of Sustainable Development Goals. At the population level, it is suggested that mental health must be scaled across policies and services in general health, education, poverty reduction and violence prevention, to reduce major risk factors and strengthen the resilience of individuals, families and communities.

The newly enacted Persons with Disabilities Act provides for 5% reservation in poverty alleviation and developmental schemes for persons with disabilities (including persons with psychosocial disabilities). The predecessor to this Act, the Persons with Disabilities Act 1995, had a similar provision mandating a 3% reservation, but even in a state like Tamil Nadu, across departments, the specific allocation to persons with disabilities remained stagnant at 0.2% of the total expenditure for the last five years.

There is no data on how much of this is accessed by persons with psychosocial disabilities, as there is hardly any disaggregated data maintained on the nature of impairments of the persons who participate in government programmes. Persons with psychosocial disabilities are further alienated from these programmes because of the system of certification of ‘mental illness’, which takes place often at the state-capital level. The costs of travelling and obtaining the certificate is more than the government’s benefits.

The special rapporteur makes crucial observations while discussing interventions at the individual level, regarding the use of biomedical interventions in the treatment of depression and suicide prevention, one that has been spoken of by users and survivors of psychiatry for decades. He states that “…the use of psychotropic medications as the first line treatment for depression and other conditions is, quite simply, unsupported by the evidence.” While conceding that medication may have its place in the management of other mental health conditions it is stated that “…(t)he excessive use of medications and other biomedical interventions, based on a reductive neurobiological paradigm causes more harm than good, undermines the right to health, and must be abandoned.”

The special rapporteur speaks of cost-effective psychosocial interventions that may be provided by general care workers instead of by psychiatrists. This can be provided by strengthening existing systems of community health workers, including by increasing their numerical strength and ensuring living wages for the work that they do and perhaps developing a system of peer support in line with similar models piloted in other developing nations.

In the aftermath of a new mental health legislation and a recent mental health policy that was championed as ahead of its time, the special rapporteur’s words come as guidance and a warning for the way forward.

Hopefully, the prime minister’s commitment towards persons with psychosocial disabilities sees, as the Special Rapporteur advocates, a shift in investments in mental health, from focusing on the now controversial “chemical imbalances” to focusing on “power imbalances” and inequalities. The prime minister may be right in calling for the “expression of depression instead of its suppression”, at the risk of invoking a Tamil popular culture reference, dismantling structures of oppression may be a close second. Prevention and management of mental health conditions may involve more than engaging in community service and yoga – persons with mental disorders experience vulnerabilities that need to be concretely addressed.

For instance, on the question of employment, OECD statistics have found that persons with mental health disorders are two to three times more likely to be unemployed and more likely to be dismissed, which leads to further escalation of their conditions. The Persons with Disabilities Act 2016 has an awkwardly worded chapter on ‘Skill Development and Employment’ which mandates all establishments (government and private) to enact equal opportunity policies, but only requires that government establishments not discriminate against persons with disabilities in matters relating to employment. While reconciling these two may require an eventual Supreme Court intervention, the overall legislation permits discrimination against persons with disabilities if there is a legitimate aim, which can easily go against someone who is struggling to meet work targets on account of their disability in a private workspace. These are difficult conversations both at the personal and policy level – but as the slogan for World Health Day goes, “Let us Talk”.

Amba Salelkar is a lawyer with the Equals Centre for Promotion of Social Justice. The organisation focuses on policy and budget advocacy towards furthering the rights of persons with disabilities.