Large swathes of cotton farms in central India have been the epicentre of the debt crisis that has gripped the rural population. For years now, it has driven thousands of farmers to commit suicide. These suicides are not merely a loss of human lives; they are debilitating scars on a nation’s development that can perpetuate a vicious cycle.
An intensive eighteen-month program in the affected region of Vidarbha, Maharashtra, has seen an effective reduction in suicidal behaviour while encouraging those affected to seek professional help for depression. The program deployed health workers from within the community. Conceived by Dr Vikram Patel, a Professor at the Public Health Foundation of India, VISHRAM was carried out in the Amravati district of Vidarbha by trained community health workers aided with mental health first-aid kits.
Patel uses community volunteers and trains them as mental health workers for his project. He runs focus groups to gauge community acceptance and conducts trial sessions to train new counsellors who impart enhanced traditional care. This includes diagnosis by a doctor or health worker at a primary health centre, medication if necessary, and sympathy from the staff.
According to Patel, mental health support workers can be trained at a low cost. In countries like India, where there is a shortage of trained doctors — especially in the field of psychiatry — community treatment by these workers can prove to be a successful alternative support system. Patel says, “We need to enhance skills in doctors working in primary care units to detect and treat mental health problems. There should be a direct link between the specialists teaching or practising in medical schools and district hospitals with basic medical facilities… This is the same model of care used for all chronic diseases, not only for mental disorders. In fact, in the long term, the most sustainable way to improve access to mental health care is to see mental disorders as a chronic disease similar to diabetes.”
As a part of VISHRAM, existing front-line workers such as Accredited Social Health Activists (ASHAs) worked at the community level to raise mental health literacy. They are provided with psychological first aid and treatment in community and primary health centres. Psychiatrists from the government’s District Mental Health Program and the private sector provided medication for serious mental disorders. Workers interacted directly with the rural population, talking about the “tension” they were experiencing. By raising awareness about stress episodes, they were able to guide farmers to help cope with their problems.
For many of them, sharing their toxic thoughts was cathartic. Since healthcare workers are drawn from the same community, they are familiar with the environment and are able to empathise with the farmers.
Patel feels that stigma of mental illness is a major challenge, and there is no simple solution here. What works is disclosure: people coming out and talking about their experience with depression. Mental health problems are still perceived by many as rich man’s diseases.
It is assumed that if you are poor, then the symptoms of depression are simply an expression of the misery of your life. Contrary to public belief, mental suffering is not a natural consequence of poverty and those who are poor and depressed deserve, if anything, even more attention than the rich.
VISHRAM has mobilised self-help groups and village leaders for early detection of mental disorders with a focus on affordable, home-based care. More than 1,000 small group meetings were held over the 18 months. First aid for mental health was provided to 1,441 individuals with psycho-social distress. More than half of these people (793) were referred to counsellors, while patients with severe mental illnesses like schizophrenia were referred to the local medical hospitals.
With trained counsellors working at a grass-root level, Patel and others are seeking to scale up the program, spreading it to other states of the country.
It is a cost effective and efficient model that can be implemented in different parts of the country with support from the government. To continue proactive policies, the government could integrate such programs into its National Mental Health Policy.
For every Indian farmer who takes his own life, a family is hounded by the debt he leaves behind, typically resulting in children dropping out of school to become farmhands.
The Indian government’s response to the crisis—largely in the form of limited debt relief and compensation programs has failed to address the magnitude of the problem or its underlying causes.
Farmers’ suicides must be tackled in various ways. Addressing mental health problems is just one of them, but it is certainly a major part of the solution.