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Inequality and poverty ’cause mental illness’

As international health experts warn that clinical depression is set to become the main cause of disability, a researcher asks what are the main causes of mental illness.

Health experts are sending out an international alert that mental health problems are dramatically increasing worldwide with the World Health Organization (WHO) warning that depression is set to become the main cause of disability and second leading health problem by 2020.

One question that has resulted from this year's World Health Day (April 7) focus on mental illness is what triggers mental health problems.

In India, where the number of cases of clinical depression and anxiety is rising even more steeply than elsewhere, opinion is sharply divided on whether poverty is the main cause – a debate sparked off by a study by Dr Vikram Patel of London's Institute of Psychiatry.

Patel's 1996 study, Poverty, Inequality & Mental Health in Developing Countries, an updated version of which has been published in a book, investigates the relationship between poverty, disability and depression in the Indian state of Goa. He found that more than 40 per cent of adults attending primary health care clinics had a common mental disorder (CMD) such as anxiety or clinical depression. Women were two to three times more likely to have CMDs than men.

The study concluded that relative poverty, disability and gender were strongly associated with these disorders. According to Patel, poverty is an important "risk factor": clinical depression can be triggered by adverse life-events such as physical illness, housing problems and unemployment.

"Being poor means you are more likely to experience such events and you will have fewer resources to draw upon," Patel says. "The relationship between impoverishment and mental illness is bi-directional. Thus poverty can lead to mental illness which can worsen the economic circumstances of the person and their families."

Importantly, not all mental disorders are increasing in India. Patel specifically attributes India's growing incidence of anxiety and clinical depression to rising inequality, as witnessed in many other developing countries.

The latest WHO report on mental health, Stop Exclusion, Dare to Care, agrees. "Mental disorders occur in persons of all genders, ages, and backgrounds… poverty, war and displacement can influence the onset, severity and duration of mental disorders."

However, Dr Mohan Isaac, Head of Psychiatry at India's prestigious National Institute of Mental Health and NeuroSciences (NIMHANS), points to the resilience of India's family and social support networks.

He cites numerous studies of schizophrenia which have shown better recovery results in developing countries like Nigeria and India, largely because of their strong social support systems. Isaac, adds, "in the midst of poverty people still live a sane life; otherwise 38 per cent of this country living below the poverty line would be mentally depressed."

Patel concedes that the humour and spirit of those living in conditions that the rest of unequal India might buckle under, indicates how well the poor are able to cope.

The challenge for public health researchers, he argues, is "to identify the protective and nurturing qualities in those who do not become depressed when faced with awful economic circumstances… to help and prevent mental health problems."

What everyone, including Patel, agrees on is that women are at greater risk although experts give different reasons. Dr Sanjeev Jain, Associate Professor of Psychiatry at NIMHANS says: "There is a tremendous amount of depression in women. They tend to internalise situations."

Others argue that depression and low self-esteem among women is due to factors in the home such as a lack of identity, and domestic violence and abuse. "We've come across a tremendous amount of suffering in women in the training sessions we impart," says Dr Thelma Narayan, a community health worker who is helping formulate health policies at both national and state (Karnataka) levels.

There are no recent studies in India on the extent of CMD, but the National Human Rights Report 2000 says 20 to 30 million people "appear to need some form of mental health care" – about 20-30 per cent of the population.

India's National Mental Health Policy was formulated in 1982 using a model developed by NIMHANS. The policy envisages decentralised training in mental health for rural health workers, provision of basic drugs, developing a mechanism for community awareness and monitoring of the whole policy.

The government only began to implement it in 1995, but there is practically no awareness of common mental disorders among health professionals in rural areas and the sufferers themselves, says Dr Ali Khwaja of Helping Hand, a Bangalore-based counselling organisation. He believes the critical factor is not poverty but the lack of specialised primary health services.

Government officials are defensive. "It really isn't all that bad," says Dr Mallikarjunaiah, deputy director of health (family welfare) in Karnataka.

The southern Indian states of Tamil Nadu, Kerala and Karnataka recognise mental health problems both at government and social level. Community mental health centres exist in northern Indian cities like New Delhi, Patiala and Jaipur. But countrywide there are only 37 government-run mental hospitals, 3,500 psychiatrists, 1,000 psychiatric social workers and 1,000 clinical psychologists – all serving a population of one billion.

The government view on the availability and cost of drugs for primary health centres is yet again optimistic. Anxiolytics, a common drug to treat depression, is said to cost less than the treatment for tuberculosis. Dr K Sekar of NIMHANS cites a 2000 India and Pakistan study of rural patients that shows that half a month's wages of approximately $16 goes towards treatment. But, "treatment need not always be a medical response," says Dr Jain, reiterating that family and community support systems need to be reinforced.

Patel agrees, saying "preventative strategies aimed at strengthening protective factors in local communities may be a more sensible investment of scarce resources than duplicating the extensive health systems of the developed world."

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