Decoding a Life Cycle Approach to Mental Health with Dr Pratima Murthy

Introduction: You are listening to Decoding Impact, a podcast by Sattva Knowledge Institute hosted by Rathish Balakrishnan.

Welcome to Season Two of Decoding Impact. Every fortnight we will engage leading thinkers and practitioners to understand what it takes to solve systemic problems at scale. For all the curious changemakers committed to understanding the trade-offs and incentives to make this world a better place, this one’s for you.

Rathish Balakrishnan (RB): [00:00:37] India is grappling with a severe mental health crisis, with over 197 million Indians diagnosed with mental disorders as of 2017. A wide treatment gap aggravates this further. The good news is that there is a growing recognition of the importance of mental health in the country. However, a thorough understanding of what it entails, what forms mental well-being and how it should be approached and conceptualised is lacking. Mental well-being is intertwined with economic, cultural, social and other factors at various stages of an individual’s life. Effective interventions, therefore should be contextualised to these aspects. How can public policy, market solutions and community solutions be designed with these in mind? Joining us today to share her reflections on making mental health a key part of India’s development agenda is Dr Pratima Murthy. Dr Murthy is the Director of NIMHANS, where she has been pivotal in initiating Tele MANAS and establishing the state-of-the-art Centre for Addiction. In over two decades of experience, she has held various consultant advisory roles. She has worked with the National Human Rights Commission to improve care for persons with mental illnesses. Her expertise in the area of mental health and in shaping substance abuse prevention strategies both in India and abroad has helped in making a lasting impact on public health. Welcome, Dr Murthy for today’s episode.

Dr Pratima Murthy (PM): [00:02:13] Thank you very much for inviting me.

RB: [00:02:16] Dr Murthy, I want to start by setting the context in terms of why the issue of mental health is an incredibly important part of India’s development agenda today. While there is growing recognition of the problem, it would be great if, from your expert perspective, you can lay out what is the state of the sector today in some sense, and why is this a critical issue for our discussion.

PM: [00:02:38] I think we all need to understand how critical mental health is in a country’s developmental agenda. Mental health actually affects all aspects of our lives. You mentioned some of those aspects, maybe the economic aspects, the cultural aspects, the social aspects. There are also biological aspects that influence one’s mental health or one’s proneness to illness. So I think it’s very important to take cognisance of all of these elements when we’re looking at mental health. So I think it’s important to construe mental health as a spectrum from well-being, which involves not just physical well-being, but also mental well-being, resilience, and then of course recognising that there are times when we fall ill, just as we have a fever, just as we have a headache, it’s possible to have psychological distress or a diagnosable mental disorder which might need treatment. So being able to recognise that becomes very, very important, and for that, I think we also need to understand that this involves some kind of a process which is quite different. For example, when we’re young children, the kind of issues around mental health and mental illness may differ from when we are much older. Still, I think it’s very important to understand that mental health and wellbeing underlies a huge amount of what social development is construed, and of course that translates into a thriving community. So I think that’s why it’s very important to pay attention to good mental health.

RB: [00:04:16] Thank you for sharing that. I think the two things that I can bag from what you just said, Dr Murthy, is, one, the fact that this continuum is important to recognise that mental health is not just an illness question. It starts from an issue of fitness in some form. What does your wellbeing look like? And the second is, as you rightly highlighted, the interconnectedness of mental health across various aspects that we are considering today. Today, as you see where we are in India, is there a recognition of both this interconnectedness and in terms of the spectrum across various stakeholders that are involved in the mental health situation?

PM: [00:04:56] The best way to answer that is possibly a yes and a no. I say yes because there are several policies in India which have looked at. We have a National Mental Health Policy. We have a National Mental Health Care Act. We have a mental health programme in more than 700 districts in the country. But I think given that a significant amount of the population has a mental disorder, perhaps the focus has been on identifying and treating such mental disorders or mental illnesses as we call them, so much so that we have taken the spectrum of well-being and mental wellness a little for granted perhaps. I think the Covid pandemic has taught us that when there is distress – and distress can occur due to a variety of reasons – there might be temporary psychological distress when maybe we lose a relationship when we have some important life event happening, when we have interpersonal difficulties, when we have financial distress, when we undergo any kind of disappointment, we might be transiently low, transiently depressed, transiently dysfunctional, not be able to sleep well, lose our appetite, et cetera. So there are points like this where we might have the resources to overcome these ourselves with some simple strategies that we might take, which is really called self-help. Two, being able to communicate such distress to others around us, which means that we need to have good social support in place so that we can turn to people and be able to speak to them about our mental distress.

Just as I would say I have a headache. I might have the thing to say, “Look, I’m feeling anxious about this. I’m feeling upset about this. I’m not able to sleep over this.” Unfortunately, I think there has generally been a stigma around talking about one’s mental health and well-being because there is an assumption that we need to be in control of our mental state 100% of the time. We don’t do that about other bodily functions, so why should we do that only about our mind? So really the focus is on how can I, for example, have a reasonable amount of control over the way I think, the way I feel, the way I interact with my environment, and my interpersonal relationships. How can I maintain a sense of calm or equanimity? When that is disturbed, what can I do to make sure I get help so that that distress doesn’t translate into something more formidable? That’s very important. But at the same time, it’s also very important to recognise that when I do feel upset for a prolonged period where my routines are disturbed for weeks on end, I know where to reach out to so that I can turn to somebody to help me to relieve that and then become functional again. So really recognising those elements of it becomes very, very important.

RB: [00:08:09] Beautifully said. One of the recurring themes that we discuss in this podcast is the issue of vocabulary and mental models. We say that we spend a lot of time discussing solutions, but sometimes the challenge is that the vocabulary to describe something and the mental model with which we approach a particular problem are very, very different. What you just told me is that do I have the vocabulary to describe how I feel from the fact that I’m feeling well, to I’m feeling anxious, I’m not feeling well, and then there is a prolonged period of sadness. I think, across people for me to communicate to even my partner, for example, I’m not sure if it’s consistent and accessible for everyone; and as you rightly said, the mental model of how we approach mental well-being is also very different. It sort of seems like if I have a fever, it’s not my problem, it’s the problem of me being in the wrong circumstances. But if I’m feeling anxious, it’s probably my problem because I’m not strong enough. And I think that there is a very strong articulation of whose fault is it in some sense when you look at it. I don’t know if that resonates with you as well.

PM: [00:09:11] Yeah, I think the primary place we begin with wrongly is about whose fault it is. In fact, contrary to what you said, even for headaches, we probably take ownership more easily than for a feeling. So that’s one problem. And this vocabulary relates both to mental well-being as well as mental health. So for example, I mentioned, you know, thoughts, feelings and emotions. It’s equally important. For example, nowadays people are talking about this a lot – how can I be a little kinder to myself, be more accepting of some of my feelings, etcetera, take ownership of that, but at the same time also realise that there are ways in which I can control my emotions to an extent that I learn from experience how to deal better with my environment. Now we must also understand that our mental makeup depends on a whole host of things. One is, of course, a biological predisposition with which we are born. I mean, just as we have certain thresholds in terms of our blood pressure or body weight, for example, there’s a biological tendency for some of these things. Similarly, a large part of temperament is something that might be inherited. Our sensitivity, our temperaments, there is a certain biological component to that, but that doesn’t mean that we cannot regulate it or cannot be in control of it.

PM: [00:10:37] It’s also issues like gender. We know, for example, that women in India perhaps face much greater psychological distress. When you look at the suicide rates recently, we’ve just had World Suicide Prevention Day, it’s an important time to kind of ponder on suicidality. And we know that there are about 7 to 8 lakh people across the world who die from suicide. And we know that so many issues related to gender inequality, financial difficulties, domestic violence, and multiple roles that women have to take up, many of these are important gender-based issues that might be responsible for different kinds of psychological distress among women. We also know that in minority and marginalised communities, psychological distress is likely to be more. We know that poverty is also a driver of psychological distress, so there are many social elements, cultural elements that we also need to take into consideration along with the individual determinants, but also the social determinants that even if you have a lot of distress, if you have good social support, you’re likely to be better able to handle that distress and come out of it more resilient, than if you don’t. So I think this interconnectedness between the various things becomes very important and we need to look at how different sectors can kind of contribute to this better well-being of people.

RB: [00:12:22] I was recently watching this Netflix documentary. They talk about how you live to 100 and what they call the blue zones that have shown high longevity, and it was interesting that, of course, diet and meals are a part of it, but what they cover is community connectedness and various cultural forms of integrating connectedness into the way people live, and also the Ikigai, which is a sense of purpose, which goes back to what you said, that taking a full view of our lives is critical for us to solve for it. But I want to come to the question that I had, which is, as you highlighted, you know, the problems that children face, adolescents face, adults face, et cetera, it’s very clear that the kind of challenges people face which impact their mental health are different at different life stages. I’m the father of a 13-year-old son, and I just dropped him off today morning at school and his deep anxiety that one of his teachers reprimanded him in class, is his biggest problem in life. And, you know, from my perspective, I’m thinking about and going one teacher in eighth grade doesn’t make any difference. But for him at this point, it’s probably the most important aspect of his life. So one question I had for you, Dr Murthy is, knowing what we know now about this, how do we design health interventions in a way that is context-specific and life cycle-specific? And have you been able to see some good practices of how this is done? That will be great to hear as well.

PM: [00:13:41] I have two responses to what you said. The first thing you talked about is collectivism. And I think one of the wonderful things about Eastern societies has been ‘I am because we are’. And I think in general the focus in our societies has been a more collectivistic, “we” kind of situation. Whereas, you know, over time that has shifted to an “I and me and mine”. And therefore I think it is very important to consciously think about how it is that we can develop this sense of a collective consciousness. Because then I think that the drivers of such things are compassion, concern for others, making sure that I don’t grow at somebody else’s expense, you know, that we don’t create that kind of an individual competitiveness with others, but focus on one’s own ability to grow and thrive in a community. The second thing that you mentioned is I think we’ve always made the error of possibly believing that there is one size fits all as far as interventions are concerned and therefore, you know, just tweaking something for a child or, you know, making something a little different. So I think we need to understand the needs along a developmental continuum or the needs of different groups of people and make our responses important for those needs. I mean, typically, the example that you mentioned about your 13-year-old son, you know, what am I going to tell him? You know, if he’s anxious about that, I’m going to obviously, one of the things I would do is to really prepare him to be able to handle his day-to-day, you know, issues in class. I’m also going to tell him that, hey, if you do get reprimanded, it’s not the end of the world, because that’s the most important problem for him.

RB: [00:15:38] The point you made around how should hence I as a parent, respond to a child and the child’s specific context is one. I often ask myself, Dr Murthy, how do we design population-scale interventions that address some of these things? Because I think the challenge in some sense is its population-scale interventions largely are top down, hence miss a lot of nuances and don’t take into account the context effectively. One of the ideas is always been to say, how do we integrate the conversation of mental wellness into the institutions where the child is part of, so that it’s topdown? For example, how do we do it in schools or how do we do it in workplaces for adults,

colleges and so on? Have you actually seen best practices maybe in India or abroad where some of these things have been done well?

PM: [00:16:24] So I think there are occasional examples from different places. Because with population-based, strategies, there are some simple things like for example, you might introduce yoga in schools, which is an important strategy to kind of make sure that all kids have some basic way of looking after themselves, developing some degree of confidence and calmness in themselves. But it’s also important as a systemic kind of approach to recognise where you have kids with difficulties, perhaps even knowing when they come into school what is happening in their homes, engaging parents much more, because parents are also in a hugely difficult situation because you know, with the changing world, their ways, the ways they were brought up may not necessarily be the only ways which work for children. So really that kind of adaptation to see how best they can provide things. Parents are often very stressed because both father and mother are out at work. We do not have a support system which existed earlier. You know, I can always talk about the wonderful support system I’ve had in terms of both the grandparents on the maternal and paternal side being available to my children and therefore allowing me to be able to go and do the work that I can. Everybody doesn’t have the luxury to do that. And sometimes, even if they have this structure in place, they don’t foster this and they don’t kind of enrich it enough because of interpersonal difficulties. They don’t take the advantage of situations like that. So I always talk about needing to grow your roots to make sure you develop a lot of social connectedness.

You enrich those networks so that when you are in difficulty, you have a good network of family and friends to help you to deal with the kind of difficulties that you might have. So, therefore, parents need help. Teachers need to be empowered, not just to teach, but to be good communicators with the students and of course, be good mentors and role models for students, because a lot of that kind of idealisation actually occurs in school, doesn’t occur so much at home, but definitely occurs in school. So I think being able to be available for them. Also having some facilities where either the teachers or counsellors can actually be available to identify kids who have some difficulties and help them along so that if these things are caught early, they can be something that can be done remedially to make sure that the child manages to deal with a difficult situation. So I think these are all, for example, systemic changes that can occur in school. 

Now at a larger population level, we have a huge treatment gap when it comes to disorders. We talk about treatment gaps upwards of 75% to as much as 90%. So people need to be aware that they have a problem, that they need to seek help. But if they are aware and seek want to seek help and there is no help available, that’s a very difficult situation. Therefore, making help available is also very critical. Now, we do know that help is available usually in clinical care settings, and that’s not something that everybody may have access to, and therefore, you need to move help beyond institutional settings into community settings so that people know where to go. Now, if people are from very remote, underserved areas, even getting to a primary healthcare facility or getting to a healthcare provider might be very difficult. Therefore, the country has introduced something called Tele MANAS, which you call 14416 in most states and union territories, it’s now available. So that and one of the commonest things that people called in for, there have been three lakh calls in the last ten months. And one of the most important things people call was for sleep disturbance. What do I do that a simple strategies that we can do to make sure people sleep better because sleep is very restorative and regenerative. Similarly, a low mood, a relationship problem. Now, ideally, we also need to make sure that we have informal support networks around us. 

I mean, everything does not need to go to a professional. We need to have those informal networks. But equally enough, when there are severe problems, it’s very important not to delay access to care. So really that understanding in a community, having a set of different kinds of help arrangements to both provide informal help, and also provide professional help, if necessary, but equally in-patient care, medication, emergency help, particularly for people with severe mental disorders, which can be a huge crisis. Somebody feeling suicidal, somebody becoming psychotic, somebody being violent – these are all very important. In fact, it’s not just the people who are in these difficult circumstances who need help. A lot of the families are at a loose end. In fact, last week we had a programme for families who have had to deal with death by suicide in their near and dear ones. We don’t have mechanisms actually to support people like this because it can be devastating. Similarly, parents of children who have serious difficulties, and family members of people who have to deal with very severe illnesses like cancer, and other chronic diseases. We need to develop support systems for them. And I think these are all the gaps that we have. We are looking at the acute treatment of people, but we must remember that there’s a lot in terms of prevention, in terms of early intervention and of course rehabilitation and aftercare, particularly for people with severe mental illnesses so that they can be reintegrated to the extent possible in society, which means financial assistance, which means jobs, which means compensation for time people spent taking care of persons with special needs, which means rehabilitation facilities to help them to recover to the extent possible. So, I think looking from a policy point of view, all of these need attention. We’re doing we’re taking baby steps towards that. But I think a whole of societal approach and an intersectoral approach is what are going to be very important to be able to achieve this in any meaningful manner.

RB: [00:23:11] Thank you, Dr Murthy. Coming back to the life cycle aspect we mentioned earlier, one of the things I wanted to ask you was also not just by age, but there are specific life situations that we know are very stressful. For example, pregnancy and the entire early stage of a child, and you mentioned right in the beginning how that has a crucial impact on the child’s mental well-being itself. The second has been jails, for example. And you’ve talked about right in the beginning around substance abuse. Again, it’d be great to hear from you not just in contexts like school and workplace, but also contexts like these, which are life stages where the stress of mental health, the mental well-being is actually at risk. How do we look at models of integrating mental well-being effectively in some of these cases? I think that be great to hear as well.

PM: [00:23:56] As I mentioned earlier, in this life, developmental life cycle approach is very critical. So, when you talk about a mother and child, when you talk about pregnancy, we talk about perinatal mental health services. So just for example, as you go for antenatal check-ups to look at how the baby is physically growing in the womb, just like you have ultrasounds, it’s also very important to make sure that there is the good mental health care of the mother, which starts from good diet, which talks about sleep hygiene, which talks about preparing for the child coming in, which means support soon after childbirth, which also means safe childbirth, because we know if childbirths are not safe and there are minor injuries to the brain, they can be a lifelong disability to the child. It also means making sure that the early development of the child is also taken care of. So one thing that we have developed, for example, at NIMHANS is a perinatal mental health facility. We also know that postpartum depression, postpartum psychotic disorders are also well-recognised conditions. So, we need to make sure that families don’t dismiss them as some kind of a black magic or something like that that occurs. But these are actually clinical conditions that need treatment as well as further management. So, for example, women who have these problems are not just treated for the disorder, but are also supported in how to take care of the child, the families are spoken to. That’s very important. The other thing that has happened in Karnataka is the Mathru (Chaitanya) programme, which looks at integrating mental health along with physical health, so that, you know, this program is made available to women. The Thayi Bhagya scheme is another additional entry where mental health evaluations are also carried out. So, these are excellent models which can be used in other states as well to make sure that mental health components are addressed along with physical components.

RB: [00:26:06] I know both in the case of children and schools, there has been a growing recognition about the issue of stress. We’ve been reading about the Kota suicides and there has been a growing awareness on happiness curriculum, for example, mental health related support, both for parents and for children across states. Is that something that you are seeing as well and are there some good examples that you can highlight?

PM: [00:26:28] More than a couple of decades back, the World Health Organisation talked about life skills education in schools. So many schools have incorporated aspects of the life skills education in their programmes. Many schools, in fact, there is a mandate actually that every school should have counselling facilities for children. That’s another thing that can be done. The third thing is what teachers themselves can do to make sure that the curriculum extends to some of these elements of skill building in terms of their emotional skills, in terms of developing self-confidence amongst the children, and in terms of improving communication, particularly at the emotional level. So I think many of the strategies are being implemented in schools. Just recently I was reading about children taking an oath that they will look after themselves, that they will be kinder to themselves and it’s okay to reach out to an adult for help when they need to. So there are these kind of strategies. But I think perhaps a structured programme which looks at, and we were talking about an integrated approach to learning, so more structured programmes which also focus on developing well-being and resilience and a community sense of purpose. You mentioned that, to have a purpose. I think those are going to be critical. There is in at the national level too, RBSK programme, where certainly the components of mental health and well-being have also been integrated along with the other programmes. But we need to see the impact of this and then we’ll be able to scale up components of this much better. So, there are initiatives that are occurring both at a local level and at a national level, which can be further strengthened. 

Early childhood experiences can also influence the way we think, behave and feel. So, for example, there is enough research to suggest that if you have a lot of adverse childhood experiences, you are from a broken home, you witness a lot of domestic violence. You are exposed to a lot of deprivation or abuse in any fashion that can change the way you think and feel as adults. So one of the critical interventions is to ensure that people have childhoods where the children are properly looked after, not just for their physical needs, but their mental health needs as well, which means learning to teach the child self-confidence, acceptance, learning to teach child how to be resilient when there are disappointments, how to overcome such issues, how to communicate well, including how to communicate distress and accept that at times you can’t be on top of everything. How to cope with academic pressures, how to cope with peer pressures. This is particularly important for children who might have these difficult biological temperaments. I mean, for example, birth injury. We know that minor birth injury can produce changes in temperament we talk about neurodiversity, that everybody is not alike, and that some children may have some intellectual difficulties learning disabilities, and emotional dysregulation.

PM: [00:29:49] So if we know how to handle these children well, so that they are able to overcome such problems to an extent and that they learn to develop self-esteem and self-confidence, that translates into handling whatever disadvantages they have and being able to grow up. So similarly, I think especially during adolescence, we know that children go through a lot of changes. It’s not just physiological change, it’s also tremendous psychological changes that it’s a reality. At school, for example, some kids are very confident, some kids are very shy, and some kids are bullied in school. And all of these can also have repercussions. We place a huge amount of emphasis on academic development, but we equally need to foster the overall development of children, which includes developing life skills like good communication, how to be assertive, to have some degree of control over one’s emotional regulation and so on. How to interact with peers, how to make decisions, for example, with substance use, which is a common thing. And that’s an area of my interest. And very often it’s when children aren’t able to do this kind of critical thinking that they likely, if they also have temperamental difficulties and don’t have critical thinking and good judgement, they are more likely to turn to this kind of activity for enjoyment, for relaxation and so on. So as young people and adolescents, we also need to make sure people have avenues to relax, you know, what is it that gives them a buzz which is safe for them? Those are all very critically important.

And in fact, another very critical thing in children and adolescents is to develop a sense of community, is to foster a social connectedness. We don’t focus on our young people as important social capital for tomorrow’s well-being of the nation and therefore investing in young children in terms of making sure that their all-round development is done, along with, of course, their own professional growth for the future. That becomes very important. So that’s an important strategy that all of us need to focus on. Now, earlier I mentioned to you about the developmental perspective and how we need to look at interests and needs of people across the lifespan. So similarly, young adults, especially young adults who get into work, they have to balance a whole lot of things. I mean, it starts with expectations from themselves, from their parents, from society, their financial security, how they get on in the workplace, what are the norms that people judge them on. Nowadays, we know the important pressures that social media now exerts on people in terms of their own expectations. So young adults are also, you know, juggling around a lot of things, particularly at the workplace. So, for example, having good workplace interventions, which fosters a place where you can actually not just do your work, but enjoy the work that you do so that you contribute to the well-being of the workplace.

PM: [00:32:58] But at the same time there is an emphasis on personal growth. So that becomes very important for young people. It’s during this productive period that it also becomes very important to focus on diet. and like diet and exercise is something that we should begin to inculcate right from the beginning, maybe some kind of mindfulness. This mindfulness, of course, has become quite a jargon in today’s age. But mindfulness basically means a sense of awareness of yourself, about your environment and so on. So that becomes very critical. Good sleep. I mean, it’s amazing how little attention we give to the quality of sleep and the restorative capacities of sleep. And this is particularly important for students and young adults who might have pressures at, you know, in their studies and at work to make sure that that’s regulated well. And of course, resilience. How do you build up yourself? Because, you know, all of us know that life is not one smooth ride. It’s pretty much a roller coaster. And therefore, the ability to kind of be able to manage both the highs and lows of life is something that we need to also inculcate. Of course, as we grow older, there are other problems. There are so many other issues as well. It’s not just age that determines what we are and how we feel and what we kind of do.

Maybe at a more, you know, structural level, we perhaps need to look at our educational system and just see what kind of burden we place on children the while making them responsible and be able to, you know, meet the challenges of today’s world. We also need to make sure that the environment we teach children in helps them, motivates them and makes them excited about learning rather than make them fearful about the consequences of not performing. It also means that the expectations we have from our children needs to be congruent with their abilities and their strengths rather than, again, one size fits all. I spoke about neurodiversity earlier, so I think recognising the abilities of different people as being different and channelising those abilities. So I mean, one of the things we’ve always done is solely focussed only on academic kind of pathways. We now know that some children are more autistic, some children are more inclined to physical sports. How do we then recognise that and develop those things so that the kids can thrive in those spheres? In addition, of course, to meeting the needs in terms of employability and so on, or do they have careers that can be developed in their own areas, spheres of interest? I think these are all questions that we need to ask ourselves at a larger level.

RB: [00:36:01] The growing stress in workplace environments continued to be rising. There are so many stories we hear about 40-year-olds, 42-year-olds across various industries, you know, having breakdowns to a point of death, which is related directly to the level of stress they are facing at work. How do you see us integrating mental health into the context of workplace as well?

PM: [00:36:25] So just as I mentioned with younger people, adults in the workplace, problems can emerge out of their own individual characteristics, work-related characteristics and the environment of the world of work. I worked a lot with the International Labour Organisation and one phrase really stuck with me that it’s very rare that a worker leaves the problems of home behind when the worker enters the factory gate. So I think even though one is at work, there are lots of complexities which might be stress related to the workplace and the working conditions and the nature of work, as also the kind of problems and baggages that the person might be having in the community. So I think when you look at workplace interventions, you need to address all of these. You need to look at the characteristics of work, what kind of work the person is doing. So for example, workplaces which involve constant engagement with the public can be extremely stressful, especially when there are, you know, there are members of the public demanding certain things be fulfilled and there’s a single person there doing all that kind of work. Similarly, very monotonous work can lead to a complete loss of motivation and energy. Having too much work, which is very, very quick-paced without having control on it, can also be extremely stressful. So I think one needs to constantly look at the workplace and see how best the workplace can be conducive to making sure that the person gives their best and of course is not undergoing severe psychological distress.

PM: [00:38:04] Equally so, as I mentioned, if the person happens to develop a mental illness or is under tremendous pressure – and very often the pressures are related to having to take care of young children at work, elderly at work. So facilities like creches are all important, simple things that workplaces can also develop. And thirdly, of course, workplaces also need to develop a confidential counselling for people. Several workplaces, particularly in the corporate sector, have developed employee assistance programs, whether it’s for mental illness, for substance use, et cetera, where they provide confidential counselling or referral to other places. So having a network of places to refer to when the employee returns to work, making sure that they’re reintegrated, that, you know, some attention is paid to the kind of jobs that they need to be kind of eased into. These are some of the elements of employee assistance and what workplaces can do. 

Now the challenges come to unorganised workplaces, and that’s something I’m always concerned

about. Let’s take taxi drivers and auto drivers and people who run other kinds of public transportation, people who work in very, very small settings. Unfortunately, we don’t have enough schemes to do that. So I think we need to look at worker organisations to make sure that they incorporate also elements of mental health and well-being into their programmes. There are lots of training programmes that do occur for workers in different sectors and we need to make sure that we integrate this component. There are a few organisations which are doing that, but again I think that needs to be scaled up. 

You mentioned jails. Now jails again are a location where there can be significant mental health problems, substance use problems and so on. When we did a study in the Karnataka prison, we found that more than 60%, more than two thirds of the prisoners, both undertrials and convicts, had some form of mental disorder or substance use. And that might be responses, reactions to coming into prison, particularly among undertrials who have not been there before, are developing substance use in the prison because there was so much loneliness and despair and anxiety – developing new mental health problems within the prison system. So many of these things need attention. So what does that mean in a prison system, that in addition to doing a physical evaluation at the time of entry into a prison, the person is evaluated in terms of their mental state? There is a regular intervention that occurs to make sure that nobody decompensates while in prison, that they are given some degree of psychological support.

This is not just for people who come into prison as undertrials, but also as convicts, because what happens is a culture of maybe violence or unkindness or disregard for others which actually develops if the system does not pay attention to that. Equally, along with the prisoners, the staff themselves are under tremendous stress and therefore you need to have programmes which address the staff stress, teach them how to be able to deal with the prisoners in a less traumatic manner so that finally the environment is better for the prisoners as well as for the staff. One of the things that we commonly see in prisons is that the undertrial comes with one crime, which may be even a petty crime, but then might go out as a hardened criminal. If you don’t want to do that, you need to make sure that you have these preventive programmes in prison. Drug abuse in prison. It’s possible that a person who comes with a history of drug abuse, who is not recognised at the time of entry into prison, may actually have a very severe withdrawal. If it’s a severe alcohol-related withdrawal, the person may have seizures, may have deaths.

PM: [00:42:04] So it’s not good for the prison system not to be able to identify these problems and to have corrective action. So it makes a whole lot of sense. One of the things that we realised when working in prisons is that at the time of discharge from the prison or release from the prison, if you don’t prepare the prisoner to go back into the community life, there are so many problems, right from financial difficulties to access to medication. If they had a significant mental health problem. I remember the very poignant case in which a prisoner begged the prison authorities to let him back into the prison because he had no food outside and no access to medication. Therefore, that continuum of care, that inter-sectoral collaboration that I spoke of, because we all know that even if you have distress, it’s not just access to treatment that becomes important. It is also how you live, where you live. What kind of work will you have? What kind of stigma do you need to deal with? What kind of continuum of care will you have? So all of these need to pay attention. There are small projects here and there which are looking at these, but I think we need to do a scale up and make sure that these are available throughout the country.

RB: [00:43:20] This is very, very helpful, Dr Murthy, and one of the things I wanted to understand is, are there specific states where this has already been done effectively and would be great to see how it has been actually implemented and what have been some of the results?

PM: [00:43:33] Yeah, I think there are examples of how effectively you can carry out these. For example, in Karnataka having a psychiatrist service available in every prison offering counselling and psychotherapy is something that’s being done. In Punjab, handling drug abuse in the different prisons is something that’s being carried out. In Tamil Nadu, for example, all the police personnel are being trained by NIMHANS to not only take care of their own personal stress, but to be able to support one another. These are not just looking after prisoners, but, you know, in the general police force, we are aware that there is so much stress and strain. There have been courses and in fact, that’s been extended now into a certification course where some of the police personnel themselves are certified counsellor so that they can then expand this to other places. And you know, the similar things like Punjab, Sikkim, Delhi, these are some places where such experiences are there. I’m sure there are more such experiences, but this is a start to tell you that we need to think about it in a systematic, structured manner to be able to provide such counselling and care in prison settings.

RB: [00:44:54] I think there is a growing recognition around, you know, elderly as well. I think there is increasingly going to be the number of elderly in India are going to go up. And there is today both an opportunity conversation around how can we engage them better and a risk conversation. What do we have to take care of? How does mental well-being play in the context of elderly? And also, are there examples of good ideas and solutions that you see getting implemented?

PM: [00:45:18] Yeah. I mean, I think, again, we must commend the NGO sector for starting a lot of initiatives with the elderly. One example is day care for the elderly, so that when people go out to work, they are reasonably sure that elders have an environment where they can go to be safe and be productive. I mean, I think we forget that, you know, unless the person is so severely incapacitated, just age is not a determinant of not being able to thrive and be productive. So I think that’s one very important thing that we see happening. And in Bangalore, for example, Nightingales, is a very good example of such an initiative that was taken to for day care for the elderly. I know they’ve started off a similar one for the elderly from marginalised communities, so I think that’s a great initiative. Similarly, we heard about the Ratan Tata initiative where young people kind of got involved in doing little chores for the elderly, you know, spending time with the elderly, reading to the elderly. And I think that’s a fantastic model where young people can get involved and therefore, in that sense they also become aware and more compassionate towards the elderly. Of course, there are other facilities that the elderly need, particularly in dementia, where they may need support. So, for example, training people to provide compassionate support to the elderly in their homes. There are initiatives to do that as well. And of course, finally, I mean, the conventional model of having more residential care centres, I’ve seen the concept of dementia villages, in Taiwan and other places. And while they may be okay, I think I still think we should have good models where the elderly can be taken care at home if possible, with some support being provided so that they are in the context of their homes. But maybe, you know, concepts like day care where they can go out and socialise, but at the same time have the comfort of being with family members. So I think we constantly need to explore such programmes that we can take forward and strengthen. I don’t think it’s very easy to find faults with one particular programme, but I think every kind of programme has its strengths and limitations and therefore we need to look at a continuum of services, particularly for the elderly, as their social supports begin to dwindle. And I think that becomes a responsibility of both government as well as non-government players.

RB: [00:47:52] One of the points you had mentioned earlier, Dr Murthy, which I thought was very important, is how do we make care as easily accessible as possible and how do we bring care to the community. I remember Gandhi once talked about this ever-widening circles of compassion. How do you look at the family first and the community and then the facilities, et cetera? And the Tele MANAS as a telehealth facility is a great example. Do you also see interesting examples where mental health support has been integrated into the fabric of the community today, maybe by government, maybe by other organisations as well? Are there some good examples that you are seeing of?

PM: [00:48:28] So there are several NGOs who are working throughout the country. There are these kind of sporadic activities that occur in different groups. So remember a group of young people who had had experiences with attempting to take their lives, who actually came together and had a discussion on what circumstances led to that and how they were very grateful that this had not resulted in anything, you know, more morbid and how they had been able to pull themselves together and then make successes of themselves. So that’s a very powerful statement. I remember for tobacco cessation, one of the very powerful things is to have tobacco survivors who had cancer and have had a tracheostomy come and talk about the, you know, the hazards of tobacco smoking. That’s on the one hand. On the other hand, you have people with lived experience who talk about the kind of difficulties they’ve gone through and how they’ve been able to come around. That can be another very good example. The third can be having role models who come and talk. I mean, a typical example is Deepika Padukone who through her Live Love Laugh Foundation, has been able to publicise that you can talk about depression in a non-stigmatising manner and get help. So, there are several such organisations, particularly NGOs in the community who are working in the mental health space. Equally so, especially after the Covid pandemic, everybody seems to have got onto the bandwagon and you have so many apps, you have so many, you know, helplines, etcetera.

And that also while it’s welcome to have more facilities, that raises the concern of making sure that people who are appropriately trained and capacitated to provide these services, that must be that’s a very important thing and that people must not be exploited for commercial reasons. So that raises the issue of making sure that we have adequate, credible sources in the community and some form of accreditation so that we make sure that anybody, anywhere must get quality help in a supportive and non-exploitative manner. So that’s a challenge ahead for many of us. You spoke about community interventions. Now many of these community interventions have been around empowering people, particularly I’ll take the example of women. So there have been a lot of women’s groups which have empowered women around livelihood, around economics, about child care, and they also integrate components of mental health and well-being and how the women can look after it. There are one-stop counselling centres which address women who have been victims of domestic violence so that they can go to and help. Many police stations have such rescue lines or helplines or facilities where women can go and make complaints, particularly about domestic violence. So these are very good examples of what can actually be scaled up so that anybody anywhere knows that these facilities exist in the community. And I can turn to one of these for help.

RB: [00:51:41] Again, coming back to the population scale framing. As I listened to a lot of what you’re saying, it goes back to how do we design our cities? How do we design our communities? How do we design our schools? How do we look at our children holistically? And we have a public system where all of these responsibilities are divided. The same child for a health practitioner is different from an education practitioner to somebody who looks at protection, versus a city is today in the hands of a lot of administrators. Is there ways in which we can achieve a greater convergence across some of these departments while keeping them administratively of course, specifically focussed on the areas that they should focus on?

PM: [00:52:20] We teach our children that they must learn to communicate better, but our biggest barriers are the communication barriers. And this is true of public health policy administrators, the way we run programmes, perhaps even true of doctors and other medical professionals. So I think it’s very important to understand that when we talk about care, it is not just limited to health care, but there are several other pillars of support that we need to develop in the community. You talked about cities, so I think now there is a lot of attention to safe cities. There’s a lot of attention to having a green environment because we know that, you know, being in nature, having trees and plants around you, having flowing water can all be very soothing, Not just there are studies in the elderly which have suggested that having these actually improves a person’s sense and well-being. I know recently that there was a lot of concern about the elderly, for example, wandering away from home and getting lost. Who is responsible for them? So in starting with safe cities, smart cities, cities which make sure that the environment is conducive, having more playgrounds for children to play in so that they’re not always confined at home and not looking at digital devices all the time for entertainment.

Remember that playgrounds not only are an important thing from physical activity, it’s also to develop social connectedness, a sense of togetherness, team building, etcetera. So I think we’re looking at those kind of macro changes in cities. I know that there is, for example, another attempt to try and make cities smoke-free. How do you come together to make cities tobacco smoke-free so that younger people are not exposed to that? There are some valuable lessons. We know that through policy and through legislation, we’ve actually brought down tobacco use in this country by 7%. This is by the COTPA, the Cigarettes and Other Tobacco Products Act. But again, legislation without public engagement and awareness doesn’t work. And how do we do that? We do that by teaching people to look after their mental health, to make sure that they don’t get into situations where they can compromise their mental health and well-being. And as we spoke, also reducing stigma around these areas and making sure that services are available. I don’t think we can just wish all these problems away. I think there will always be situations where there will be people who can’t always rely on self-help or rely immediately on their family members and their social circles. So I think it’s important to really understand the whole of community and see look at the needs of the whole of community.

And obviously government alone cannot manage the entire problem. Given the complexity of the problem, given the magnitude of the problem, given the population of our country. And therefore having a stepped approach to care, having multiple partners being available, improving communication, figuring out the roles and responsibilities of each of us, having platforms to really discuss some of these issues so that there is an understanding and appreciation of what each group is doing. But at the same time, we cannot afford to duplicate the services because our resources are meagre. So how then do we have partnerships and collaborations to address different aspects of these? Maybe it’s public private partnerships, maybe government and NGO working together. I think that’s the only way as a whole of society approach that we can deal with these problems which are in some ways complex. But if they are broken down into elements which promote care and resilience elements, which reduce stigma, elements which provide better information, better and accurate information to people and elements of early intervention and care, elements of rehabilitation and reintegration. Then perhaps we can really look at a true whole of society approach that helps us to improve well-being and reduce the burden of care.

PM: [00:56:51] We should not forget our existing cultural mechanisms, which actually been fairly strong pillars. Of course, it would be wrong to say that everything that has been existing as a society is always very good. But I think there are strengths, for example, in family bonding, in family togetherness, that’s very important. As I mentioned earlier, systems like yoga, etcetera, can be very important to kind of build our resilience and our things. So I think we need to look at both existing systems of care and perhaps newer ways and newer and innovative ways, especially using technology to reach out to people in a meaningful manner so that we can make sure that even in remote and unreached parts of our country, we can make sure that some degree of mental health promotion, as well as prevention of disease and treatment of disease is ensured. 

One of the things that we have always believed to be our strengths is spirituality. And I think again, along with one’s developing one’s resilience, one’s ability to help one’s self, there are lots of people who do benefit from spirituality, and I think that’s, again, a strength that we can build upon at an individual level, maybe at a collective community level, towards helping one’s own mental health and well-being.

RB: [00:58:22] Throughout this conversation, you’ve given us such a broad canvas and highlighted many areas where we need to focus to be able to look at this problem holistically. One, of course, is how do we look at institutions that people are part of today and integrate a certain holistic thinking of well-being there? As we were talking, you talked about better ways of making access and help available for people. You talked about ensuring accreditation, for example, so that people are not, you know, manipulated or genuine concerns are not getting addressed. If you step back and sort of look at the, let’s say, the public policy landscape and philanthropy landscape, what are your top recommendations, Dr Murthy, on what on priority we should be focusing on right now?

PM: [00:59:06] I mean, I think it’s been wonderful to see philanthropy step in in a big way. And I am seeing that there has been a growing interest in mental health. I think one of the things, of course, is simply as a prevention principle. I mean, I’d love to use the ILO example of a traffic light. You have the green, the amber and the red zones. Traditionally we have focussed on the red zone, which is really dealing with people who have established problems. But that’s a necessity. And therefore even in our country, the gap for the treatment of persons with severe mental disorders like schizophrenia and bipolar mood disorders and so on is very, very high. The burden of these disorders, even though the prevalence may be low, is also very high. So I think we need to make sure that we have facilities for them, particularly as I mentioned, in terms of rehabilitation and reintegration, that there are there is a growing support for such initiatives both from the government as well as the philanthropic sector. So that’s very important. The second and most important thing, I think, is to make sure that people with certain vulnerabilities, those vulnerabilities are taken care of and expanded. So perhaps identifying high-risk individuals, people from marginalised groups, the people in settings where there is higher mental morbidity, I think having interventions there is very important. The third and most important thing is reducing stigma and particularly for many mental disorders. As I started off this conversation, I mentioned that biology is also a very critical element. So we know that there are brain changes in any kind of mental health disorder. So understanding in some ways mental health disorders, like we do physical disorders is going to be very important. And I think that kind of awareness and education to tell people that their minds are no different in some ways than the rest of their bodies, so that there is a sense of ownership, if you will, being able to be more open about it. Taking help becomes very important. And finally, the Green Zone is really about keeping the greens green. Many of us, most of the times enjoy good mental health, but how can we make sure we look after it, particularly among young people whose future is there ahead of them to make sure that they grow up with a sense of identity, a sense of purpose, a sense of self-confidence so that they can be important social capital for the future. So these are all the areas where I can see that we need to work with our institutions, with our schools and colleges, with other establishments, with government, with NGOs, and of course, with in partnership and collaboration from philanthropy. I think we can make a huge change in this whole dialogue which looks at mental health on a spectrum from well-being to recovery from illness.

RB: [01:02:15] Dr Murthy, I think you’ve summarised it extremely well. So I don’t want to add to that. It was a fascinating conversation, and for me, I think the enduring feeling I leave back with is really how do you live a good life? I think rather than asking ourselves, how do we have good mental health, I think the question of how do we live a good life? How do we stay connected to other people? How do we build better social networks? How do we build resilience? How do we accept the fact that life is going to be a combination of ups and downs rather than one way? And then how do we build a system that takes care of, as you rightly highlighted, the red, amber and the green, I think is going to be very, very important. Thank you so much for your time. I genuinely enjoyed our conversation. I’m sure everyone who’s listening to it is coming out of it wiser. So thanks so much for your time again.

PM: [01:02:57] Thank you so much.

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