|Year : 2020 | Volume
| Issue : 5 | Page : 98-101
The impact of social inequities on mental ill-health: The banyan response
Rachel Mathew1, Preetha Krishnadas2, Smriti Vallath1, Vanitha Rajesh3, Joske G.F. Bunders4, Lakshmi Ravikanth5, Vandana Gopikumar6
1 The Banyan Academy of Leadership in Mental Health, Chennai, Tamil Nadu, India
2 Centre for Social Care and Livelihoods, The Banyan, Chennai, Tamil Nadu, India
3 Centre for Mental Health and Inclusive Development, The Banyan, Chennai, Tamil Nadu, India
4 Faculty of Science, Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands
5 Centre for Social Action and Research, The Banyan Academy of Leadership in Mental Health, Chennai, Tamil Nadu, India
6 The Banyan, The Banyan Academy of Leadership in Mental Health, Chennai, Tamil Nadu, India
|Date of Submission||11-Aug-2020|
|Date of Acceptance||11-Aug-2020|
|Date of Web Publication||02-Oct-2020|
Dr. Vandana Gopikumar
The Banyan, The Banyan Academy of Leadership in Mental Health, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mathew R, Krishnadas P, Vallath S, Rajesh V, Bunders JG, Ravikanth L, Gopikumar V. The impact of social inequities on mental ill-health: The banyan response. Indian J Soc Psychiatry 2020;36, Suppl S1:98-101
|How to cite this URL:|
Mathew R, Krishnadas P, Vallath S, Rajesh V, Bunders JG, Ravikanth L, Gopikumar V. The impact of social inequities on mental ill-health: The banyan response. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 28];36, Suppl S1:98-101. Available from: https://www.indjsp.org/text.asp?2020/36/5/98/297156
An estimated 197·3 million people in India live with mental illness and contribute to 14.5% of Years Lived with Disabilities. Evidence has consistently pointed toward a robust bidirectional link between poverty, homelessness, and mental illness, with many experiencing severe marginalization, isolation, and exploitation. Despite these vulnerabilities, on account of inaccessible care pathways, mental health gains are often not prioritized, impeding early identification, treatment, and recovery, and leading to increased disability, caregiver strain, and homelessness. India is home to 1.8 million homeless persons, of which an estimated 20%–25% live with a mental health concern.
These complexities are further amplified in the context of the COVID-19 pandemic. The country-wide 21-day lockdown was issued by the Indian government, as extended till June 8, 2020. The resulting impact on homelessness, poverty, and starvation has been immense. Ninety-three percent of Indian's migrant workforce, who have been displaced, are unable to fend for their basic and safety needs and find themselves in exacerbated states of mental flux., On the other hand, distress and unbearable suffering have led to a corresponding increase in rates of suicides and domestic violence, and other forms of disturbing social behaviors, and have had a disproportionate impact on women and children. The economic crisis that is expected to follow the lockdown will further increase vulnerabilities, especially among individuals from disadvantaged backgrounds. Distress that results from these circumstances of exacerbated poverty needs to be anticipated and addressed. Therefore, intersectoral collaborations, with emphasis on reframing the mental illness narrative to include mental health and well-being, are essential to appropriate and adequate mental health services.
This write-up gives a first indication of what these needs are by analyzing the challenges encountered and adaptations initiated at The Banyan in response to the pandemic. It places the services of The Banyan in the context of wider developments during these times. The hope, ultimately, is to arrive at tangible recommendations that may advise mental health professionals, service providers, and policymakers.
| Study Context|| |
The Banyan is a Chennai-based health-care nongovernment organization that caters to the needs of persons with severe mental illnesses, and with varied vulnerabilities, particularly homelessness. It provides inpatient care, long-term care, outpatient care, social care, crisis support, and continued care to clients who access its mental health services. The Banyan places special emphasis on user-centric services, developed collaboratively to enable individuals to harness their capabilities. In the face of limitations arising due to COVID-19, service delivery systems have been reformulated at The Banyan. In the following sections, we discuss some of these interventions.
| Inpatient and Long-Term Care: Adherence to Public Health Guidelines|| |
The Banyan assembled a rapid response team, detailing protocols on safety, preparedness, testing, isolation, supplies, human resources, etc., With inpatient service users at its Emergency Care and Recovery Centers, daily monitoring of all vitals, including oxygen saturation for 210 persons accessing inpatient services, was initiated; all medical care was provided on-site, limiting referrals to an already overburdened public health system. In its noncongregate housing-based long-term care option (Home Again) that services 250 persons, these restrictions have impinged minimally on the choice or rights of its residents, owing to personalized and smaller care units.
In addition, cognizant of the influence of stress sensitivities among persons with severe mental illnesses,, sessions with service users on COVID-19 lockdowns were initiated to ease anxieties regarding observable changes in structures and social milieus. This is particularly important given that social distancing has often resulted in exclusion, stigma, and discrimination of this group who continue to harbor feelings of abandonment and rejection. Transparent communication systems and health education have been pivot points for better health-care management through this period.
| Rapid Response and Social Needs Care|| |
Context appropriate responses that acknowledge and validate distress and address social concerns are an essential part of mental health responses in these times. A rapid needs assessment that was conducted (n = 1833) by The Banyan indicated that 50% had an average family size of 4 and lived on a monthly family income below INR 5000 (65$); 9.62% reported domestic violence; 13.42%, substance misuse; and 0.52%, sexual abuse. This indicates that psychological needs fueled by structural and systemic barriers require serious attention. In response, The Banyan's care coordinators and community-based NALAM (”well-being” in Tamil) mobilizers addressed issues arising from deprivation, ensuring continued access to social needs care, psychological services, and psychiatric care. In the absence of daily wages, many required immediate access to dry rations (22.80%), medication (16.04%), and financial support (26.46%).
| Use of Technology in Crisis Responses|| |
In the absence of transport and access mental health services, The Banyan initiated a helpline that catered specifically to marginalized populations, particularly its clinic-based service users. Preliminary results from the helpline showed that a greater number of women (52.9%) accessed support, with 29.4% belonging to the unorganized sector, and reporting multiple issues including interpersonal issues, violence, and economic concerns (41.2%). Distress counseling, problem-solving support, social care support, and when required, crisis support were offered to those who accessed this service. Crisis support was provided when clients experienced intimate partner violence and had to be rescued, or experienced abject poverty, helplessness, or starvation, and required urgent and immediate intervention.
| Recommendations|| |
Expanding the scope of mental health interventions
Mental health can no longer be viewed using an exclusive biomedical lens. It has become crucial to recognize that one's social context may result in mental health implications and that not all of these experiences can be pathologized. Especially in the context of a global health crisis, addressing the social determinants of mental ill-health assumes an importance like never before. As a consequence, mental health professionals should partner with community development practitioners, sociologists, and other social work practitioners, to develop policies and plans that integrate the needs of persons with psychosocial disabilities, across sectors. People with disabilities are over-represented among the poorest. Maybe it is time to pilot a “basic income” economic intervention or an out-of-job income among persons with severe mental health disorders and measure their impact on the individual and caregiver's quality of life and emotional health.
Role of the social work practitioner
COVID-19 has adverse economic and social impacts, especially on the poor (World Economic Forum, 2020). Enhancing support networks and outreach services are critical to preventing a descent into homelessness or abject poverty. In such circumstances, as The Banyan's efforts reveal, the role of social work practitioners, alongside health professionals, is critical to a crisis intervention team., Social workers are in a unique position to provide both clinical services and coordinate interdepartmental liaison work, all embedded in a collaborative, justice, and human rights framework. Care coordination and leadership of mental health programs can be driven by this cadre.
Technological advances have proven, especially serviceable during recent times, and have significantly enhanced outreach options. Crisis toll-free helpline services can reduce hospitalization, address distress immediately in the absence of in-person consultation and contact, and ensure adequate referral and escalation pathways, facilitating both psychiatric care and psychological counseling, as well as access to social entitlements and livelihoods.
Smaller, inclusive living models
Community care approaches such as The Banyan's Home Again Model ,, and housing first models ,, have shown to promote recovery, and facilitate a well-rounded development of an individual's capacities within the community, besides reducing costs of care substantially., There is an urgent need to revisit some of our mental hospitals and assess adequacy in adoption of public health guidelines and measures. A better mental health professional–client ratio is also necessary to ensure better social health for those accessing care, as well as for the care providers.
Tackling the current surge in mental health conditions will remain a priority in all societies for the foreseeable future. The circumstances brought about by COVID-19 will amplify hunger, extreme poverty, reduce access to education and health care and increase mortality. Consequently, impeding the targets of the millennial developmental goals. The aftermath will conceivably observe a rise in depression, anxiety, suicides, posttraumatic stress disorder, and other severe mental illnesses., The fall in gross domestic profits across the Asia-Pacific region warrants for systems to take policy measures that focus on sustainable initiatives in building resilient infrastructure, and strengthening social protection systems focused on crisis prevention and risk reduction. In addition, targeted activities to prevent homelessness, sustained engagement with at-risk populations  are critical to sustainable interventions. The need for intersectoral, collaborative work, targeting social and economic inequities by enabling access pathways through innovative strategies, is imperative in planning future mental health interventions.,
We would like to acknowledge all the members of the program implementation team at The Banyan, who had collected this valuable information from the clients, which has contributed immensely to this body of knowledge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
India State-Level Disease Burden Initiative Mental Disorders Collaborators. The burden of mental disorders across the states of India: The Global Burden of Disease Study 1990-2017. Lancet Psychiatry 2020;7:148-61.
Gopikumar V, Narasimhan L, Easwaran K, Bunders J, Parasuraman S. Persistent, complex and unresolved issues: Indian discourse on mental ill health and homelessness. Econ Polit Wkly 2015;50:42-51.
Srivastava K, Chatterjee K, Bhat PS. Mental health awareness: The Indian scenario. Ind Psychiatry J 2016;25:131-4.
] [Full text]
Gowda GS, Komal S, Sanjay TN, Mishra S, Kumar CN, Math SB. Sociodemographic, legal, and clinical profiles of female forensic inpatients in Karnataka: A retrospective study. Indian J Psychol Med 2019;41:138-43.
] [Full text]
Ministry of Finance. Economic Survey of India 2019-20. India Ministry of Finance; 2020. p. 1.
Sahoo S, Rani S, Parveen S, Pal Singh A, Mehra A, Chakrabarti S, et al
. Self-harm and COVID-19 Pandemic: An emerging concern-A report of 2 cases from India. Asian J Psychiatr 2020;51:102104.
Peterman A, Potts A, Donnell MO, Shah N, Oertelt-prigione S, Van GN, et al
. Working Paper 528 April 2020 pandemics and violence against women and children. Cent Glob Dev 2020;:43.
Tsai J, Wilson M. COVID-19: A potential public health problem for homeless populations. Lancet Public Health 2020;5:e186-7.
Cash R, Patel V. Has COVID-19 subverted global health? Lancet 2020;395:1687-8.
Narasimhan L, Gopikumar V, Jayakumar V, Bunders J, Regeer B. Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India. Int J Ment Health Syst 2019;13:54.
Reininghaus U, Kempton MJ, Valmaggia L, Craig TK, Garety P, Onyejiaka A, et al
. Stress sensitivity, aberrant salience, and threat anticipation in early psychosis: An experience sampling study. Schizophr Bull 2016;42:712-22.
Lataster T, Valmaggia L, Lardinois M, van Os J, Myin-Germeys I. Increased stress reactivity: A mechanism specifically associated with the positive symptoms of psychotic disorder. Psychol Med 2013;43:1389-400.
Kavoor AR. COVID-19 in People with Mental Illness: Challenges and Vulnerabilities. Asian J Psychiatr 2020;51:102051.
Thornicroft G, Tansella M. Balancing community-basedand hospital-based mental health care. World Psychiatry 2002;1:84-90.
Reza Iravani M, Majidi Parast S. Examine the role of social workers in crisis management. J Sociol Soc Work 2014;2:87-97.
Padmakar A, de Wit EE, Mary S, Regeer E, Bunders-Aelen J, Regeer B. Supported Housing as a recovery option for long-stay patients with severe mental illness in a psychiatric hospital in South India: Learning from an innovative de-hospitalization process. PLoS One 2020;15:e0230074.
Busch-Geertsema V. Housing First Europe : A “social experimentation project.” Eur J Homelessness 2011;5:209-11.
Stefancic A, Tsemberis S. Housing first for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. J Prim Prev 2007;28:265-79.
Bouras N, Ikkos G, Craig T. From community to meta-community mental health care. Int J Environ Res Public Health 2018;15:806.
Subhnij T, Hasannudin Z. Financing SDGs under a new normal: Challenges and response to COVID-19 pandemic | United Nations ESCAP. Un Escap 2020;7-9.
Tracy M, Norris FH, Galea S. Differences in the determinants of posttraumatic stress disorder and depression after a mass traumatic event. Depress Anxiety 2011;28:666-75.
Sood S. Psychological effects of the coronavirus disease-2019 pandemic. Res Humanit Med Educ 2020;7:23-6.
de Sousa A, Mohandas E, Javed A. Psychological interventions during COVID-19: Challenges for low and middle income countries. Asian J Psychiatr 2020;51:102128.