Year : 2016 | Volume
: 32 | Issue : 3 | Page : 227--237
How are social changes in the twenty first century relevant to mental health?
Krishna M Prasad, Hareesh Angothu, Manila M Mathews, Santosh K Chaturvedi
Psychiatric Rehabilitation Services, National Institute of Mental Health and Neurosciences, Bangalore, India
Professor Santosh K Chaturvedi
Dean, Behavioural Sciences, Head, Department of Mental Health Education, Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore
Mental health problems occur in a psychosocial context. Social dimensions significantly impact psychiatric practice and research. The twenty first century has seen dramatic urbanization, globalization, rapid advances in technology, and communications. These among several other social changes, such as nature and shift in family systems, newer patterns of relationships, migration, and social mobility will bring about novel challenges for diagnosing and managing mental health problems; nevertheless this may at the same time throw newer means and opportunities to intervene, particularly with the advancements in technology. There is likely to be greater awareness about mental health problems. The rights based and recovery oriented approaches will change the way psychiatry is practiced. Many of these changes will positively impact policies of the government and access to care. This article focuses on the social changes in the twenty first century and the impact this has had and will have on mental health, especially in India.
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Prasad KM, Angothu H, Mathews MM, Chaturvedi SK. How are social changes in the twenty first century relevant to mental health?.Indian J Soc Psychiatry 2016;32:227-237
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Prasad KM, Angothu H, Mathews MM, Chaturvedi SK. How are social changes in the twenty first century relevant to mental health?. Indian J Soc Psychiatry [serial online] 2016 [cited 2022 Jun 28 ];32:227-237
Available from: https://www.indjsp.org/text.asp?2016/32/3/227/193195
The role of social factors in the causation or maintenance of emotional disorders has been identified since time immemorial. Social factors play a significant role in the development, evaluation, and management of mental illnesses. Even in an era of biological psychiatry it is not possible to imagine psychiatric practice or research that is not influenced by social dimensions. Therefore, social changes will undoubtedly influence the social determinants, imagination, and responses to mental disorders. Twenty first century has seen a flurry of changes globally in the social sphere and very visibly so, such as urbanization, globalization, and rapid technological advances. The global demographics and distribution of population is also constantly changing as a consequence of universal phenomena such as migration and advances in transport and communication. India is not immune to all these changes in the background of the radical economic policy changes initiated since early 1990s. The effect of these social changes on the mental health scene in India will be reviewed in the current article with focus on the various social determinants that will likely influence mental health.
Demographic changes, religion, sex ratio, and aging
Rapid changes in population indices in the twenty first century are a cause for concern, as they imply significant changes in the needs that should be addressed by the governments and societies. World population was about 6 billion during the year 2000 and has reached 7.2 billion in 2015. Globally, men are higher in number before the age of 50 but after 50 years age women outnumber the men, which indicates that geriatric population consists of significantly higher women than men (http://www.census.gov/population/international/data/worldpop/tool_population.php last accessed on 6th May 2016). As per the census India 2011, among the 1.2 billion population 79.8% are Hindus, 14.2% are Muslims, 2.3% are Christians, and the rest of 3.7% are Buddhists, Jains, Sikhs, and others (http://www.census2011.co.in/religion.php last accessed on 6th May 2016). As per the census 2011, 30% of the total Indian population are under 14 years, 65% are aged from 15 to 59 and 12.7% are aged above 60 years. Also as per this census, 5.2 % of the total population in India is either widowed or divorced or separated and living alone in comparison to 3.3 % of such population of 2001 (http://www.censusindia.gov.in/vital_statistics/srs_report/9chap%202%20-%202011.pdf last accessed on May 6th 2016). As per the census 2001, 35.3% are under 14 years of age, 59.4% are aged from 1 to 64, and only about 5% were above 64 (http://censusindia.gov.in/Census_And_You/age_structure_and_marital_status.aspx last accessed on 6th May 2016). This data indicates that more and more Indians in the year 2011 are single and or elderly than compared with 2001. Life expectancy of women in India is 69.6 compared with 67.3 during 2010–2015 compared with life expectancy of 65.6 and 63.1, respectively (http://mospi.nic.in/Mospi_New/upload/India_in_figures-2015.pdf last accessed on May 9th, 2016).
These changes can be due to multiple reasons like advances in health care systems, which have prolonged the average life span of individuals, slightly decreased birth rate reflected by decreased population under the age of 14 years, increased divorce rates could be reflected by larger number of single persons, which suggests a significant social and demographic change in the Indian society during the first decade of the twenty first century that needs to be taken in to consideration, while considering health plans at macro level. Because of a consistent and significant rise in geriatric population there is a greater need for emphasis on evolving care models for elderly persons both for their physical health needs, as well as for mental illnesses. Traditionally, elderly population is dependent on their children for their support. Changes in current social economic situation with migration of working age group population to urban cities are leading to a situation where, in many villages only elderly population are residing at homes. In India, there are an estimated 3.7 millions of persons with dementia with an expected societal cost of about 14,700 Crore rupees. Persons with dementia are expected to be doubled by 2030 with an expected three times increase in societal costs.
Sex issues and equity
Indian society has undoubtedly had significant transformations and developments in the twenty first century as evidenced by globalization, urbanization, technological advancements, and improvements in education and health care systems. Contemporary India as portrayed today displays modernization and attempts to negotiate with traditional underpinnings. Sex equality, an integral dimension of social stratification, is one such cause that has been a forerunner in attempting to change its functioning in the traditional Indian society. Realistically, however, educated women seen to occupy even high professional and political positions in India are a minority, around 5% as per Gallop Poll from 2009–2012 who reside in the more economically advanced areas, in the South, like Kerala and more industrialized and urbanized areas such as Pondicherry (with a value of 4.04% sex gap being the lowest in the country as per the Census of India 2011). Most women, hence, continue to be employed in agricultural activities, domestic housework, and occasional employment.
Indian society being largely patriarchal in nature subscribes to a very hierarchical structure within which a woman’s role and position in this hierarchy is often determined by her age, being the daughter-in-law or by the status of her husband and his hierarchical position, lending to a subordinate position more often than not for the female sex. India ranks 105th out of 135 nations according to the Global Gender Gap Reporter 2012, published by the World Economic Forum, which monitors the extent of sex inequality on the basis of criteria relating to access to financial resources, education, and health. Condorelli in an interesting study using national and international data on women including the census data from 1901 to 2011, data on dowry deaths and female infanticide comments that new values and structures have not led to disappearance of the traditional values; rather they have learned to coexist. Relationships between traditional and modern models need not necessarily be mutually exclusive or dichotomous rather they may exist in manifold combinations or newer forms. For example, modernization and increased involvement of women in the workforce has not resulted in decline of the practice of dowry. Rather, the materialistic culture of the current times has well adapted this tradition to serve as a means to fulfil the needs of certain consumer needs.On the contrary, women engaged in fulltime occupations in addition also continue to fulfil roles of caretaking, which is seen to add to stress experienced, as well as reduce quality time with children.
Sex differences occur particularly in the rates of common mental disorders: depression, anxiety, and somatic complaints wherein women predominate. Women appear to be predisposed to psychiatric illness both due to biological, as well as environmental vulnerabilities. Biologically, she is vulnerable to depression on account of hormonal factors related to the reproductive cycle. However, sex disadvantage itself may pose an environmental vulnerability. The vulnerabilities often take shape in the form of excessive partner alcohol use, sexual, and physical violence by the husband, being widowed or separated, having low autonomy in decision making, and having low levels of support from one’s family, lesser educational opportunities, and employment., Violence toward women is displayed through means of female feticide, domestic violence, dowry death or harassment, mental and physical torture, sexual trafficking, and sexual coercion. Sexβ€'based violence can result in long standing emotional distress, posttraumatic stress disorder, and poor reproductive health. Battered women are much more likely to require psychiatric treatment and are much more likely to attempt suicide than nonbattered women. According to the National Crime Record Bureau, reports of rape, molestation, dowry death rose by 6.4 percent in 2012 from the previous year, with the highest number of rapes recorded in the capital city (http://ncrb.nic.in/(Last accessed on 5/6/16)). Although more women, nowadays, denounce violence, the figures indicate a general rise of sex-related violence in India.
Stigma toward women with psychiatric illness further magnifies the existing problem of sex inequality. Malhotra and Shah also comment in their study that women are expected to be primary caregivers for husbands with psychiatric illness; however, if a woman were to have a psychiatric illness, her role as caretaker would still be expected. Under-utilization of health care by women with mental illness conveys the stigma attached to health seeking or to the lowered importance of their health in general.
Sex equality and women empowerment is one of the Millennium Development Goals of United Nations, 2015. Through empowerment of women, it is intended that she must be free to make a choice from alternatives that are available in reality and not only perceived, in a manner that those alternatives chosen are accessible to her regardless of any opposition. Further, empowerment provides the women resources through which her agency can be exercised, with opportunities for success. Attempts to make this possible have been directed through access to education and to paid work.
Educated women were seen to be able to make informed decision on health and family planning, increased access to resources and economic decision making were better equipped to handle violent husbands and were better able to challenge male prerogative as seen in antiliquor movement by the Mahila Samakya in Andhra Pradesh, a literacy programme for women that fuelled collective action against alcoholism in husbands. The flipside is, however, it is also observed that in societies in which women’s role is purely defined for reproductive purposes, education itself becomes a means to get suitable husband or to become better homemakers further subjugating them to patriarchal structures and subordination. Other limitation to education at the macro level include the fact that curriculum itself often breed stereotypes toward men and women that reinforce the existing notions of the male–female role divide, whereas poorly acknowledging the foray of women into workplace, their contributions to household income, and the emergence of female headed families. At the micro level this results in women succumbing to poor salaries, casual forms of work and struggling to meet roles of earning member and the caretaker as seen in many dual-earner families.
Access to paid work increases women’s agency in several ways. Determining women’s status in social hierarchy and influencing wide spheres of social action in private and public life is closely connected to the degree of female participation in economic activity and their economic contribution. Without any education and self sustenance, they are subject to the decisions made by their respective husbands. Within the patriarchal system, they are often invisible and a social burden, more than a value for society. Several practices such as female infanticides, arranged child marriages, traditional dowry practices, and dowry deaths are reflections of this belief. Studies of the impact of microcredit in societies found that women's access to credit led to a number of positive changes in women's own perceptions of themselves, and their role in household decision making and reduced the incidence of domestic violence even if these were home based. Studies conducted on Microfinance organizations in India and Bangladesh suggested that association of women with such organizations in the long run led to increased autonomy and self confidence in women. Earning power could be used to renegotiate their relations within marriage, to leave abusive marriages, to help ageing parents, to postpone early marriage, and to challenge the practice of dowry.
Family: nature and shift, nuclear, extended and joint, single parents, live in relationships
Indian family lies at the heart of all cultural values and traditions. As an interdependent society, a lot of importance and values are attached to family ties through all stages of life. Traditionally, the Indian family system is patriarchal in nature and hierarchical system based on the norms of the dominant Hindu culture whereby men are seen to take part in decision making and planning for the entire family based on seniority of age. The wife of the eldest member is likely to take responsibility of management of all household chores. By structure, the tradition Indian family is joint and essentially the socializing agent for children and gives much importance to the roles played by the elderly. Women were also seen to be the less active members in decision making.
In the twenty first century, owing to host of changes in society as an outcome of urbanization, globalization, modernization, increased opportunity for education, increased employment opportunities, migration, and technological advancement, newer family systems in terms of structure and functioning are now apparent. Sooryamoorthy noted that the family in India is as diverse as country's demography, culture, and religion. Although there appears to be a surge of nuclear families, D’Cruz and Bharat note that the family is merely changing into an adaptive extended family and not nuclear. Alternate patterns of the family are found mostly in urban areas and metropolitan cities such as single-parent, female-headed, or supplemented nuclear families supported by relatives of the spouses. These families emerge from personal circumstances such as death of a partner or divorce or migration of the husband for work purpose.
Changes in nature such as assertion of women rights and protection of the girl child, resulting in softening of the patriarchal system within the family system have been because of transformation of the labour market and its association with female education, advancements in family planning, development of feminism, and globalization. Sense of equality in the family, role expectations, and selection of partners have been influenced by spread of western culture. The above developments are suggestive of better well-being of women, improvement in family life, increased agency of the wife, resulting in higher quality of family life and gradually improving acts of violence and oppression against women. Dual earner families have become child centered with the above noted changes, however, this has resulted in the neglect of the elderly, resulting in the sprouting of several old age homes across the country.
Dual earner couples are increasingly common these days. With work pressure and long working hours, parents often find it difficult to engage adequately with children. Natrajan and Thomas in their study on the need for family therapy in middle class families found themes of underinvolvement of husbands, reduced time spent with children, increased pressure on children to perform academically well, and generational gap with children owing to rapid changes in society. Stress arose from lack of role clarity, nuclear units no longer had the comfort of falling back on elders present in joint set up and lack of knowledge of availability of therapeutic services to address the same.
Single parents are often the outcome of circumstances such as death, separation, or divorce. Available literature primarily focuses largely on the role of a woman as a single parent with dependent children. Many of these women are poorly educated, low skilled, engage in agriculture, and low-paid jobs and are sole earners constitute the poorest of the community with inadequate family and social support. Indian society looks rather differently at a divorcee and a widow. Although the widow and her children may be looked upon with sympathy, a divorcee is often shunned in the Indian society. The restrictions are placed on a divorcee and poor acceptance both by her own family and society at large render her prone to anxiety and depression. She may prefer to live on her own with lesser resources. The divorced mother is the new trend emerging in India and needs supports such as creche, day care, low-interest loans, cheap housing, hostels to stay with children, social security, sponsorship for children, changes in property law, right to ancestral property, creation of community property, and so on are also required. Centres to help, guide, and counsel women, allow them to mourn the loss of the relationship and involve parental family in her recuperation are needed.
Female headed families are a term used for families in which the husband has likely migrated to another state or country. Male migration could result in ill-equipped partner who perhaps has been dependent on her husband previously and may have implications for children as well. However, it is also suggested that women may become more independent and self-confident.
The need for family therapy or individual therapy services in which required point in the direction of Indianizing therapy in the context of the changing society, negotiation of roles, rapid advancements of society, and its relation to intergenerational differences and strained yet cherished ties with the joint family that are integral to the family set up.
Economic changes: poverty, employment, and displacement
Technological advances although have reduced certain barriers for growth and economic development of India in the twenty first century leading up to India being one of the top 15 countries to have most number of Billionaires, but still on average per capita income of the Indian population in the year 2014 is 6 times lower than world average as per the International Monetary Fund data.
Per capita income of Indian population is $ 1471 in the year 2015 compared with $ 460 in the year 2000. Over the last few years, there is a slow but consistent increase in the number employees in the private sector. As 1.78 Crore Indians are in some form of Government employment during 2010 compared with 1.76 Crore during 2012. At the same time 1.08 Crore Indian were in some form of Private sector employment during 2010 compared with 1.19 Crore during 2012. Private sector is less likely to provide a secure job than a government job and often the private jobs being performance and target based there is higher chances of such private employees to work under continued stress. Probably, these private sector employees are more vulnerable to develop stress-related disorders (http://mospi.nic.in/Mospi_New/upload/India_in_figures-2015.pdf last accessed on May 9th, 2016).
Urbanization and globalization
Following economic liberalization and globalization policy of 1991 in India, urbanization has gained momentum with nearly 160 million added in 20 years, by 2011 nearly 31.16% living in urban areas. New employment, better education, and movement of the earning member of the family are the reasons for the migration of about 85% of male population from rural to urban in India, as per the report released in 2008. There are significant differences between the reasons for migration between women and men. In women, it was the marriage or movement of earning member, which were the major reasons for migration either rural to rural or rural to urban compared to men.
Geographic mobility: migration outside India, migration within India
Migration is the process of social change whereby an individual moves from one cultural setting to another for the purposes of settling down either permanently or for a prolonged period. Migration may be internal migration, which may be from rural to urban or from urban to rural, intrastate or interstate, or may be to another country. This gained momentum due to better financial options, better livelihood, and education or for reason such as marriage. It is pertinent to consider the timing of migration with reference to biographic and historical transitions such as childhood versus adulthood, first or second-generation migrants with special emphasis in determination of the socialization process.
Problems such as loneliness, helplessness, frustration, increased household, and social burdening are common among the migrants. The various stressors faced by a migrant are determined by several factors. These include age, sex, forced, or voluntary migration, vast differences of the host state/country in climate, language, food, culture, interdependent versus individualistic societies, whether one has migrated alone or with others. Distance from native place was found to be a factor impeding adjustment, as it determined frequency with which one could return to their hometown. However, technological advancements allow faster contact with family via various modalities, which may help alleviate difficulties in reaching families prior to these advancements. Bhugra also suggests that migration and its effects on mental health must be evaluated based on the phase of migration as individual is in.
The two points in migration associated with psychopathology are immediately after arrival when adjustment is difficult and several years after settling down when one is disheartened by the lack of achievement they had anticipated. This disappointment may result in lower self esteem increasing susceptibility to depression or other psychiatric disorders.
Rural to rural migration has been decreasing and rural to urban and urban to urban migrations have been increasing , the goal or main reason behind changing the residence would be improving their living conditions or to escape from debts and poverty. There are some special groups such as women, children, elderly, lesbian, gay, bisexual, and transgender individuals, who are more prone to certain mental health issues during the migration process. Studies suggest that unhealthy lifestyles may be resorted to after immigration due to difficulty in maintaining healthy lifestyle as an outcome of complications of the migration process. Migrants from developing countries who moved to developed countries are considered to be a high-risk group for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). This may be an outcome of social exclusion and cultural and language barriers in offering and accessing the health and other services at the place of destination.
Banal et al. in a study on Kashmiri migrants in Jammu describe that psychiatric morbidity was found to be more in migrant population than in controls. The most prevalent disorders were found to be posttraumatic stress disorder, depression, and other mental health problems. Similarly, in a sample of slum residents in New Delhi, migrated from other states were found to be more at risk for mental illness as an outcome of poor social support, relationship problems with other members of the family, increased worry about health, easily getting angry and irritated, lack of satisfaction about the living condition.,
Evaluation of psychiatric illnesses and treatment for migratory populations would do well to keep in mind the complex processes involved in the surfacing of mental health issues in this population.
Social mobility and caste system
A significant factor for huge discrepancies for lack of the uniform economic and social growth in India is the existing caste system. Culturally for hundreds of years certain segment of population was oppressed and refused equal opportunities for education and employment. After independence, affirmative action and a system of fixed reservation for Scheduled Castes and Scheduled Tribes at educational institutions, jobs and at legislature houses has lead to significant changes in their social mobility within the Indian society. Household surveys during 1983–2005 are suggestive of significant intergenerational changes of education and employment among the Scheduled Castes and Scheduled Tribes in comparison with nonscheduled castes and scheduled tribes’ population of India and almost convergent rates between these two groups. Some have observed more social mobility among the scheduled castes, which were considered as untouchable in comparison to Scheduled Tribes. Relative geographical isolation was postulated as one of the reasons for this observed difference.
However, some strongly disagree that the quota system or positive discrimination has been effective in bringing the much anticipated social mobility within society. According to Gregory Clarke, despite extensive social engineering, India is unusually immobile society, which he hypothesized that it could be due to strong marital endogamy. Endogamous marriages within the same caste or subcaste leads to greater chances of inheriting recessive disorders, as well as schizophrenia.
Effect of Technology, internet, telephones, media, and cinema
The twenty first century has seen a rapid influx of technological innovations with newer, more efficient, sophisticated, and more recently pocket friendly varieties of technology emerging every day. Use of smart phones and easy access to the internet may have earlier been seen as luxuries reserved for a more economically well off strata of society. What once may have been a luxury is now gradually emerging a “necessity”, as a large part of the Indian society now has access to these technological advancements. On the contrary, media and cinema, mediums that already had a comfortable dedicated social audience recently have reinvented themselves to be a bolder, unapologetic, often sensational means of being a reflection of Indian society. The joining of hands between the internet, telephones, media, and cinema has resulted in the best depiction of the concept of a “global village”.
Changes in technology have resulted in more transient, private and atomized local communities, and broader social networks consisting of complex, diverse, and international networks of individuals. The networks can be seen first at a local level, wherein the contact may be more physical and solid and face to face, and then at a cyber level wherein the contact may be fluid and anonymous. Various easy methods of communicating and sharing information including chat rooms, user groups, web forums, virtual reality worlds, and sites specifically dedicated to ‘social networking’ are available. Some of the advantages of internet-based social networks mentioned in this article include ease of being in touch, bringing disparate groups together, act as a support group online, provide anonymity and hence safety from being judged, thereby elimination of prejudice is possible. One of the biggest advantages online social communities provide to those handicapped by class, sexuality, disability is that it allows one to overcome the many barriers they are likely to face when they meet someone in person.
There are, however, several challenges to online social networks as well. Psychological effects of reduced face-to-face time are being debated now. Anonymity may also come at a cost as evidenced from the growing number of cyber crimes. Cyberbullying is another growing trend seen among children in schools and colleges wherein the perpetrator bullies another on online social networking sites. Compulsive gaming online is a manifestation of excessive use of video game on users' in the form of truancy from school to play, losing academic grades at school, decreased social activities, irritability if unable to play longer period of time, or advised to stop, an increase in expression of aggression, wrist pain and neck pain.
Internet addiction as a diagnosis is still at the crossroads with questions such as on whether one would consider it an addiction or behavior on a continuum of usage versus being classified as a case of poor impulse control. Studies conducted in viewing the same as an addiction have found that those found dependent on the internet were found to delay other work to spend time online, lose sleep due to late-night logons, and feel life would be boring without the Internet. The hours spent on the Internet by those who are addicted to it was greater than those nonaddicted to the Internet They also experienced higher loneliness in comparison with those who were categorized as nonaddicted.,
Another study suggested that sex (male), daily time spent on Internet use, reward seeking, and connecting and social influence gratifications dichotomize the Internet addict and nonaddict cohorts. ,
Technology has also had its implication on work life balance of individuals. In a study Rao and Indla , discuss why having access to all three aspects of life has become but a distant dream. Technology has made it possible to do tasks from everywhere blurring lines between work and home. It has also increased expectations of speedy work and replies increasing longer hours spent at work and greater stress experienced.
On a positive note, several social networking sites, newspapers, and news channels have tried to increase awareness of mental illness such a depression, bipolar affective disorder, and anorexia nervosa to name a few via public disclosures of famous celebrities in an attempt to normalize, garner support and reduce stigma faced by many others who may be suffering from the similar psychiatric illness. A study assessing two major Indian dailies over the course of 3 months reported that media plays a significant role in educating the public about psychiatric illness and often joins hands with professionals in taking expert opinions on issues related to news. Further, the Indian Psychiatric Society has also suggested guidelines for reporting news of suicide, a growing problem in a nonsensational, discrete, sensitive, and neutral manner so that media may be used as a tool for change to reduce the stigma surrounding mental illnesses. In the past, cinema has been guilty of a portrayal of mental illness that is often inaccurate and exaggerated, however, as political and economic stabilization are slowly being achieved, attitudes are changing once again with recent movies display more understanding toward characters with mental illness. Cinema has also taken a positive turn toward the trend of female–centered movies with various themes evoking the current social changes.
War, terrorism, and disasters
A wide variety of psychiatric morbidity is reported as a result of conflict situations that includes adjustment disorders, posttraumatic stress disorder, depression, panic disorder, and substance use disorders nevertheless nearly half of the population are also resilient. In the twenty first century, India is witnessing low-intensity conflicts in several regions across the country including those related to terrorism, religious extremism, regionalism, and Naxalism. The mental health consequences of these conflicts can include those directly related to violence and also because of stressful social and material conditions such as unemployment, poverty, malnutrition, and so on. Low-intensity conflict zones like Kashmir have seen an increase in psychiatric morbidity and a recent study among noncombatant civilians documented the prevalence of depression to be 55.72% with the prevalence in the youth (15–25 yrs) being even higher at 66.67%. There is a need to be prepared for a surge of newer forms of conflicts such as cyber warfare, bioterrorism, and their mental health consequences.
There is an increase in the number of disasters both natural and manmade globally; the consequences on mental health of survivors could be immense. The naturalness of several so called natural disasters is questionable – pressure on environment, growing population, intensification of economic activity in vulnerable areas could contribute to their more frequent occurrence. In a study among children and adolescents in the Andaman and Nicobar islands following a Tsunami triggered by an earthquake in 2004, children from the tribal communities who had joint families were more resilient and had less psychiatric morbidity. It has been argued, on the contrary, that the loss of a family member in a primarily family-oriented culture and belief in fatalism could predict poor psychological outcomes in primary survivors, as was reported following the Uttarakand floods and landslides of 2013. Mass accidents during religious congregations and festivals have been reported in the last decade; the mental health consequences are not yet reported.
With growing urbanization and industrialization, there is a need to learn from previous experiences of industrial disasters such as the Bhopal gas (methyl isocyanate) tragedy in 1984. General population “longitudinal epidemiological study of mental health effects” was initiated by the Indian Council of Medical Research (ICMR), New Delhi, but unfortunately the findings of the study were not reflected in the mental health care of the population.
Social changes and psychosis
Urbanization is associated with a two-fold increased risk of psychosis. There are speculations that this may be due to loss of social capital and social fragmentation. Rates of schizophrenia and other psychoses are elevated in migrant and minority ethnic populations particularly in second-generation migrants from developing countries. The initial findings from the large scale epidemiological studies about prognosis being better in developing countries including India may have changed. Even the earlier studies by ICMR indicated that urban centers had better prognosis. Improved maternal and child care may herald the birth of cohorts with poor prognosis due to survival into adolescence, which would have otherwise been eliminated. The large scale migration of refugees due to wars may lead to an increase in experience of adversity, which is a risk factor for development of psychosis. ‘Nuclearization’ of families and change in family structure may reduce social support for patients with psychosis.
Social changes and depression/mood disorders
The estimate of the global burden of disease predicts that depression, estimated to be the fourth leading cause of disability worldwide, will be the second leading cause of disability worldwide by 2020 as per the World Health Organization. As a part of the World Mental Health Survey Initiative by the WHO, a cross-national study on the epidemiology of depression in 2011 revealed that the percentage of the screen-positive respondents who had lifetime major depressive episode (MDE) was highest in India with a percentage of 39.5%. The study also indicates that other factors associated with depression include being of female sex and lesser number of years of education. However, young age was associated with less risk in India in comparison with other countries.
Associated Chamber of Commerce and Industry of India, in a recent study conducted across 150 companies across 18 broad sectors like media, telecom, and knowledge processing outsourcing and so on found that 42.5% of employees in private sectors are seen to have depression or anxiety disorder, compared with government employees with lesser levels of psychological demand at work. Increasingly demanding schedules and high stress were seen to be determining factors causing depression and anxiety and further also causing daytime fatigue, physical discomfort, performance deterioration, low pain threshold, and increased absenteeism.
Depression over the past decade has also focused on depression at age extremities including adolescent and elderly populations. Assessment for mood disorders among south Indian adolescents observed that 37.1% were mildly, 19.4% were moderately, and 4.3% were severely depressed. In addition, depression and stress were found to be significantly associated with a number of adverse events over the course of time, poor academic functioning, and suicidal behavior. Among the elderly, the suicide rate in the population above 55 years of age is 189/100,000 and about one in five of all successful suicides are committed by individuals above the age of 65 with implicated factors including social isolation, financial difficulties, physical comorbidities, and psychiatric illness.
The WHO World Mental Health survey initiative for bipolar disorder indicated that the aggregate lifetime prevalence of BP-I disorder was 0.6%, BP-II was 0.4%, subthreshold BP was 1.4%, and Bipolar Spectrum (BPS) was 2.4%, whereas less than half of those with lifetime BPS received mental health treatment, particularly in low-income countries wherein only 25% reported contact with the mental health system. India was seen to have the lowest lifetime prevalence of BPS.
Suicide, including farmers’ suicide
Majority of suicides in India have socioeconomic reasons as precipitating or triggering factors particularly in farmers. Certain states have very higher rates of suicide, that is, 40 per one lakh population in Puducherry and 26 per one lakh population in Telangana compared with Indian average of suicide of 10.6 per one lakh population. Indebtedness, inadequate crop production leading to economic difficulties, family problems, and substance-related problems were described as the main reasons from suicides of farmers in India. Climatic changes with reduced rain fall for many years in association with reduced availability of ground water and water mismanagement might have contributed significantly to the crop-related indebtedness in farmers.
Social changes and diet, lifestyle, eating disorders
The urbanization of India in the current century might see a further reduction in physical activity, which is associated with agrarian rural societies. The changes in dietary habits from the traditional lacto-vegetarianism in many societies to consumption of a more western diet coupled with sedentary lifestyle will invariably reflect in the growing obesity and metabolic disorders epidemic in India. Traditional sociocultural views in India regarding commensality have associated being “full bodied” with being healthy and also with psychological wellbeing. There is a growing rise in eating disorders as has been an increasing emphasis on thinness and fat phobia particularly among women. Two thirds of psychiatrists in Bangalore reported seeing at least one case of eating disorder indicating that these are not uncommon in urban India. The changing concepts of body image among men might also be reflected in reporting of bigorexia cases in India.
Social changes and common mental disorders
Despite the high economic growth rates, there is a problem with the redistribution of incomes in India with consequent income disparity and inequality (https://www.imf.org/external/pubs/ft/sdn/2015/sdn1513.pdf). This coupled with other factors due to rapid social changes such as the experience of insecurity and hopelessness, the risks of violence and physical ill-health may make the poor vulnerable to common mental disorders. The direct and indirect costs of mental ill-health worsen the economic condition, setting up a vicious cycle of poverty and mental disorder. The policy makers will need to focus on including common mental disorders among other diseases associated with poverty and low education. The ongoing national mental health survey may provide an accurate picture of the magnitude of the problem and the underlying social underpinnings.
Social changes and extremes of age
The changing styles of parenting and school environment, family discord, single parenting, risk of abuse, and early exposure to technology may shape the presentation and prognosis of several childhood mental disorders. The demographic dividend provided by the current generation in India may become a problem as this generation ages. Poor availability of social support may affect mental health in both the extremes of age.
Social changes and substance use
Age at having first alcoholic drink has lowered over the past few decades. In 2012, a survey conducted by Community against Drunk Driving in association with National Crime Records Bureau and Delhi Police revealed that, approximately, 90 % of men, 65% of women who consume alcohol, admitted consuming alcohol before their age was 18. These Social changes can pose significant problems for the general health of community in terms increased Road Traffic Accidents and related morbidity. Also mental disorders like alcohol dependence and related disorders can have more morbidity when the age of first use is lower. Significant drop in age at first consumption of alcohol has also been found by other researchers. Such early age of onset of substance usage can pose significant burden on society both directly affecting the health conditions of the individuals using substances and indirectly by affecting the productivity of those consuming.
Social changes and interventions in psychiatry
The various social changes discussed calls a clear understanding on the part of the therapist regarding, whether the current manifestations of symptoms or psychological distress may be influenced by social changes. Understanding of technological advancements, work-related policies, government policies, and some knowledge or curiosity of the cultural background of the client may help in addressing the challenges faced. Formulating therapy strategies that understand the contemporary fabric of Indian society and their needs is crucial at this point as tradition models of psychotherapy maybe be rooted in concepts from a western societal perspective. History taking must include a cultural formulation.
The modality of therapy itself has in the event of technological advancements begun to include mode of therapy including telepsychology, synchronous communication via online chat or asynchronous via emails, and so on, text based or non-text based. Various applications on smart phones also assist therapy, as well as e-therapy to keep track of therapy homework progress, track mood changes keeping in mind the feasibility and suitability of the client for the same, as well as ensuring appropriate protocols for ethical practice of the same.
With the rapid strides in pharmacology and genetics there is likelihood to see more personalized medical management. Mental health care will become more accessible (the costs have to be borne by governments), as also the scope for rehabilitation than ever before. All of this, however, augurs well overall for mental health.
Awareness, help seeking, Stigma, and discrimination
Stigma affects persons with psychiatric disorder in that they are ostracized leading to self-stigma, social exclusion and poor social supports, denied equal opportunities, reducing help seeking behavior further reducing access to mental health care, and delaying the process of recovery.
Stigma can often be a rather strongly held belief rendering it difficult to dismiss. Working against stigma has to be done both from the grass root level up to governmental structures and vice versa. Community mental health programmes and School mental health programmes are the need of the hour. India is rooted in values of interdependence and communal ties and bonds. Using our strength, which is the family system, community level projects to dilute, and eradicate existing misconceptions, care of mentally ill must be taken to the community level. We must also consider easily accessible lowβ€'cost mental health services need to be organized in the community that should also address the issue of cost of accessing the services. Introduction of syllabus on mental health in schools and colleges should also be considered to tackle stigma at its roots.
Sarkar and Punnoose suggest that training among medical, nursing, and other health profession is important to ensure adequate referral for patients, who might need psychiatric services.
In recent years, several celebrities have publically disclosed their experience of having suffered psychiatric illness and treatment outcomes. It is yet to be seen how far these messages might have reached out to the public and the outcome of the same. Mental health professionals should also liaison with media and engage in disseminating information to the public through interviews or articles so as to promote talk about mental health and increase awareness among the general public.
Social changes and mental health Policy
As the concept of what is mental disorder can change over time social changes all over the world can have a significant impact in the mental health policy. Technological advances can also lead to variety of new mental health diagnosis such as internet, smart phone, and online gambling addictions. A recent Indian metaanalysis found that smart phone addiction in Indian adolescents ranges from 39 to 44%. Rapidly changing socioeconomic and demographic circumstances and increasingly accepted rights-based approach for persons with mental illness has lead to several changes in the mental health legislations. India has initiated the process of changing its existing mental health legislation, that is, Mental Health Act 1987 and has created a new legislation Mental Health Care Bill 2013, which unfortunately has not got the executive approval.
Changes in conceptual understanding about the importance of mental health, the burden mental disorders can pose on society, many countries have considered changes in their mental health policies. In the United Kingdom “No health without Mental Health” slogan was considered in the year 2011 and several steps are being taken to achieve an overall better mental health.
Recognizing the importance of lack of national level mental health policy, government of India has released one in 2014. This is the first ever mental health policy for India, which itself is an indication that government of India is committed toward assessing and emerging new mental health needs of Indian population. The strategic areas identified in this policy and action are promotion of mental health, prevention of mental disorders and suicide, universal access to mental health care, enhanced availability of human resources for mental health, community participation, research, monitoring, and evaluation.
The future of psychiatric practice in relation to newer social factors like, virtual reality, technology, and gadgets is likely to change with advances in technology and their usage. One would have to examine ‘loss of touch with virtual reality’ and probe stress related to technology to understand the distress of the individuals. Workplace is being replaced by computer laptops and notebooks. People accustomed to these run their office from anywhere and everywhere. There will be a need to redefine ‘work place’ as ‘where ever the laptop is’ and identify newer and variable mobile work place related stress disorders. Other demographic changes in India such as an increase in the aging population will call for health services and policy to be geared to handle public health problems such as dementia. There will be a greater need to evolve services and treatment strategies that take into account sex issues and rights of the underprivileged. The newer technologies will help improve systems of mental health care delivery but at the same time there will be a need to tackle issues emerging from technology addiction. Urban migration, ‘nuclearization’ of families, greater caste mobility will complexly influence mental health problems. Broader lifestyle changes will not only impact mental health as also physical health. Awareness, help-seeking and access to care will certainly improve as a result of the various social changes. Many of these positive developments along with an increasing focus on a rights based approach should hopefully create more services that are recovery oriented.
Financial support and sponsorship
Conflict of interest
There are no conflicts of interest.
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