Mind the Treatment Gap

KIRAN DHILLON30 June 2020

One in every ten Indians suffers from a mental-health disorder, but the country has fewer than four thousand psychiatrists. As a result, 83 percent of people with mental-health disorders do not get treatment.

THE 18-YEAR-OLD felt an indescribable sense of peace and comfort as he sat in a bus for hours at a time. The chaotic traffic mirrored the barrage of thoughts in his head. Every once in a while, the incessant honking would jolt him back to reality, but, often, aimlessly circling the streets of Delhi was a more attractive proposition than getting off at his university bus stop.

It was around this time, in 2004, that his mother began noticing changes in his behaviour. The once ambitious and studious young man had grown increasingly distracted while he was still in high school, and his downward spiral accelerated once he started university. He began withdrawing from daily activities and was uninterested in spending time with family and friends. Sometimes unable to sleep, he would climb to the roof of his parents’ tiny home and spend hours panicking about his lacklustre academic performance. The only thing that seemed to settle his nerves was running through the city streets at night.

By 2008, having watched his behaviour deteriorate and unsure what she could do to help, his mother decided it was time to get him professional help. She did not know exactly what was wrong, but each time he had what seemed to be a depressive episode or a prolonged bout of restlessness—a few times a year—she would take him to a hospital or a local doctor. “I kept taking him to different hospitals, different doctors, trying to get help,” she told me in March 2019. “Some would tell me, ‘Go here.’ Others would say, ‘Go there.’ We were running in circles. I felt my mind was going to explode.”

Over six years, she said, the family went to six general physicians, and even visited faith healers. No one could tell them what was wrong. In the absence of a diagnosis, the family chalked up his behaviour to stress. His life had always been difficult—they were poor, his father was abusive—and the trauma from his childhood was likely catching up to him.

The endless search for help only worsened his restlessness and depression. His illness caused frequent breaks in his education, and he twice dropped out of college to work in his father’s grocery shop. In 2014, at the age of 28, he suffered a panic attack. His heart was racing, and once the doctor treating him ascertained that he did not have a heart disease, he was finally referred to a psychiatrist. He was admitted to the Vidyasagar Institute of Mental Health, Neuro and Applied Sciences, or VIMHANS, a non-profit Delhi hospital. Nearly a dozen years after his symptoms first appeared, he was diagnosed with bipolar affective disorder.

His mother was relieved. “No one could tell me what was wrong with my son,” she said. “How were we then expected to know? But at least now there was something.”

What happened to the young man is not unlike the stories of many others in India. In his 2017 commencement address at the National Institute of Mental Health and Neurosciences, or NIMHANS, in Bengaluru, President Ramnath Kovind declared that the country was suffering from a possible mental-health epidemic. Dozens of professionals say we are already there. The National Mental Health Survey, commissioned by the health ministry and conducted by NIMHANS, between 2014 and 2016, found that 10.6 percent of Indian adults—nearly 150 million people—suffered from a mental-health disorder, and estimated that 83 percent of people with such disorders did not receive treatment. Meanwhile, a 2017 survey by the World Health Organization found that India had the highest number of people with depression in the world, and the second-highest number of people with anxiety, after China.

With growing urbanisation bringing fast-paced lifestyles, high costs of living and distance from support systems, the prevalence of mental illness in India will only increase over time. The country’s mental-health infrastructure is ill-equipped to cope. According to the WHO’s 2017 Mental Health Atlas, mental health made up just 1.3 percent of the government’s total health expenditure—amounting to four rupees per citizen. India had 1.93 mental-health workers for every 100,000 people. (The global average is nine, while higher-income countries average close to seventy, with some countries having as many as four hundred.) Counting both the public and private sectors, there were just 25,312 mental-health professionals in India. There were fewer than four thousand psychiatrists in the country, and the total number of child psychiatrists was 49.

The impact of the mental-health crisis is astronomical. Between 2012 and 2030, the WHO estimates, it will cost India over a trillion dollars in lost productivity. “Right now, the people of this country are suffering,” Dr Soumitra Pathare, a psychiatrist who helped write the Mental Healthcare Act, 2017, told me. “We need to get Indians healthy, so they can reach their full potential and the country can thrive. The economic loss is one thing, but the loss to humanity if the situation does not improve is worse.”

THE FIRST MAJOR mental-health initiativein independent India, the National Mental Health Programme, was launched in 1982. Building on multinational deliberations at the WHO over the past decade as well as the findings of numerous committees set up by the government since 1944, the NMHP had three objectives: ensuring availability of care to all citizens “in the foreseeable future,” encouraging the application of knowledge about mental health in general healthcare and building community participation in providing services. It sought to set up specialised hospitals, as well as to integrate the mental-health infrastructure with the overall health system.

Five years later, the Mental Health Act replaced the Indian Lunacy Act of 1912, which had largely focused on custodial care and “protecting” the public from patients. Under the new act, patients could be treated at general hospitals. In 1996, the NMHP was expanded to the district level. The new District Mental Health Programme was supposed to install a team of mental-health professionals to run outpatient services and manage a ten-bed inpatient facility in each of India’s 630 districts by 2025.

But the DMHP has faced several challenges. Because healthcare is the responsibility of individual state governments, the quality of DMHP facilities vary from state to state. By 2016, according to government statistics, only 241 districts had been covered under the scheme. Each district is supposed to receive up to Rs 83.2 lakh per year for mental-health services. According to the health ministry’s response to a question raised in the Lok Sabha, on 20 March this year, it released Rs 105.27 crore—enough to fully fund the DMHP in just 126 districts—under the scheme in 2018–19, of which only Rs 47.56 crore was spent.

In an effort to address some of these shortfalls, the government formulated its first ever Mental Health Policy in 2014. The goal of the policy was to increase funding in order to create universal access to mental healthcare. It also aimed to increase the number of mental-health professionals in the country, build community awareness, ensure support for families and caregivers of patients, and address discriminatory policies.

Perhaps the most significant breakthrough was the passage of the Mental Healthcare Act, which wrote into law the rights of patients. The legislation, introduced in the Rajya Sabha in 2013, updated the Mental Health Act in line with the United Nations Convention on the Rights of People with Disabilities, which India ratified in 2008. “It became quickly clear to us that the 1987 act needed a lot of updating and so, over time, we decided to create a new act altogether,” Keshav Desiraju, the former health secretary who helped ensure passage of the legislation, told me. “It took years to finish, but we finally got the new act.”

The Mental Healthcare Act mandated that every citizen has the right to access adequate services, regardless of income, race, religion or caste. It introduced advance directives—allowing any adult to put down in writing how they wish to be treated for a mental illness as well as how they do not wish to be treated, and whom they would like to represent them if they are unable to communicate their wishes—and also decriminalised suicide. It also specified that insurance companies should cover mental-health expenses.

While the act was revolutionary in its ambition, some health experts have called it more aspirational than realistic, given that the government is yet to set aside funding for its provisions. “A person can now decide what they want in terms of treatment, but what if they don’t know?” Pragya Lodha, a clinical psychologist and the head of the Mumbai programme of the Minds Foundation, a non-profit dedicated to providing mental-health care in rural India, said. “Additionally, people are now supposed to have their insurance cover mental-health treatments, but the government has provided no details on how that will happen.”

“I have no hope for this legislation,” Dr Avinash De Sousa, a co-founder of the Mumbai-based De Sousa Foundation, which spreads awareness about mental health, told me. “It will cause more problems. The government cannot afford to increase healthcare the way it has outlined. There needs to be more emphasis on public-private partnerships and joint collaborations for these healthcare initiatives to be achieved.”

Pathare, however, defended the legislation. “It is not up to an act to create a budget or deliverables,” he said. “The job of the act is to create a standard of care. It’s up to us to apply pressure on the government to set aside the funding and resources to see it through. This is a patient-centric legislation. Now that we understand what is possible for patients, it becomes our duty to make sure India looks in these directions in the future.”

Desiraju agreed. “It won’t happen overnight, or even in a few years,” he said. “But this is a step in the right direction.”

Pathare and Desiraju argued that despite many issues with India’s mental-health infrastructure, the government has made great strides in improving the system. He added that the government cannot fix things on its own, especially given the country’s vast and diverse population. A crucial role must be played by the hundreds of private groups, volunteers and NGOs working to bridge the treatment gap, especially in rural India.

IN THE VILLAGE OF MANAMATHY, about sixty kilometres south of Chennai, a 32-year-old woman used her light pink sari to wipe her eyes as she completed the hour-long bus journey from her rural home in Arungundram. Her eyes had become so sore from crying that her eyesight was now incredibly weak.

She had been depressed for several years and had arrived for treatment at a monthly clinic run by a local mental-health organisation called The Banyan. “I’ve thought about killing myself many times,” she told me. “Just thinking about what to do next drives me crazy. The medicine helps, but my situation is so bad, the drugs can only do so much.”

The woman lives with her husband and brother, both of whom have severe intellectual disabilities. Neither of them can work. They survive on around a thousand rupees a month, depending on donations from neighbours, rice from The Banyan and whatever they can earn from selling the milk of the one cow they own. She tries to get some work as an agricultural labourer, but leaving the men home alone is dangerous. Being stuck at home, and inside a cycle of poverty from which there seemed no escape, had deepened her depression. According to the NMHS, social issues such as extreme poverty, lack of education and limited employment opportunities can cause or exacerbate mental disorders, while also inhibiting recovery.

Her monthly visits to The Banyan, however, offered her a sliver of hope. She had been visiting for three years, ever since a local community-health worker for the organisation suggested she seek help there. After arriving at the isolated makeshift clinic, she and her brother joined dozens of people sitting on the floor, patiently waiting for their turn with the doctor. The consultation and medicines are free, but the wait can be long due to a shortage in trained personnel.

On that day in March 2019, Dr Shyam Ravilla was the only psychiatrist working. “On average, in a four-hour period, I see between twenty-five and fifty patients on an outpatient day,” he told me. “I can usually spend five minutes with each patient, otherwise I wouldn’t be able to get to everyone.” Ideally, he said, he would like to spend at least half an hour with each patient.

Mental-health facilities are usually out of reach for rural patients. According to the NMHS, patients travel between twenty and forty kilometres on average to access mental-health treatment, and the median out-of-pocket monthly expenditure on medicine and travel is around a thousand rupees. The long distances and lengthy waitlists at government facilities play a role in causing rural patients to either give up seeking treatment or turn to private providers. “If someone must travel to a government facility, that often requires taking time away from work,” Ravilla said. “Then there’s transportation and food costs, accommodations and the cost of the treatment, follow-up care and any medication one might require. It’s not something the average Indian can afford.”

Ravilla said that these factors contribute to him staying on at The Banyan, despite the onerous workload. “For so many patients in India, their mental illnesses are exacerbated by a complex mix of psychosocial issues. When a patient sits in front of me and I don’t have the time to listen to them, to talk them through things, and I can only address the biomedical aspects of the illness and give them medicine, those are the moments I feel the most overwhelmed.”

FOR INDIAN WOMEN, the effect of psychosocial issues on mental illness that Ravilla spoke about seems especially pronounced. Women are more likely than men to suffer many common mental illnesses, such as mood, neurotic and stress disorders. Across all diagnostic categories, the NMHS found, the “male to female ratio of mental disorders is 1:1.8.”

“Though it is changing, India is a patriarchal country at its core,” Dr Geetha Desai, a Bengaluru-based expert on women’s mental health, told me. “Cultural pressures such as gender inequality, marital rape, forced marriages, sex-selective abortions, domestic violence and dowries can all play a role in exacerbating mental illness.”

It is important to point out that there are many countries where rates of mental illness among women are higher despite lower levels of gender inequality, but Desai said there is no denying that Indian women face unique challenges in accessing care. “If anyone finds out the woman is mentally ill, who will want to marry her? Where will she go? In India, a woman’s worth is connected to her ability to get married, to have children. If she cannot do these things, she becomes a burden on her parents.” Some families conceal mental illness while marrying off their daughters, she added, “but that can lead to her abandonment down the road.”

A 30-year-old woman at The Banyan’s group home in Kovalam, a fishing village near Chennai, knows this all too well. The former teacher was diagnosed with bipolar affective disorder in October 2018, soon after entering an arranged marriage with a man from a nearby village. Three days after their wedding, she told me, she walked in on her husband having an intimate moment with his brother’s wife. Devastated, she begged him to move out of their joint family house with her. He refused and viciously beat her, before taking her to a temple to have her “cleansed” of the spirit he claimed possessed her and then dropped her off at her parents’ house.

Her family did not want her back. Even her four younger sisters turned against her, she said. “They told me I was bringing shame to the family, that if anyone found out I was ‘possessed,’ or that I was separated, no one would want to marry them.” She rolled up her sleeves. Her arms were covered in welts and bruises. “These are from when my sister tried to kill me,” she said. “She took a stick from our dosa maker and used it to burn me repeatedly.” Forced out of her home and having difficulty finding a job, she ended up at The Banyan, where she now lives indefinitely. She told me she had tried to kill herself several times. “I don’t know what my life has become. I went from having a great career to this.”

At NIMHANS, a 35-year-old woman had similar scars. The skinny, soft-spoken woman draped in a blue sari was finishing a computer lesson at the institute’s rehabilitation centre, where she had been living for over a year. She had just completed her postgraduate degree, ten years before, when her symptoms first presented themselves. Her mother took her to a hospital, where she was diagnosed with bipolar affective disorder. When they returned home, her mother forbade her from taking the pills she had been prescribed. “She said there was no reason for me to take any medication, that I should pray to god to be healed,” the woman told me. “She said if anyone found out about my diagnosis, or that I was taking medication, no one would want to marry me.”

She showed me the scars on her wrist, where her mother had tightly wound a rope. “After my second episode, my mom found me in the street and took me home,” she said. “She tied me up in a room and left me there for one week. She didn’t give me any food. She beat me with a stick.” The woman had had eight episodes in total, each triggered by her mother hiding her medication. After the most recent incident, her mother dropped her off at NIMHANS for good.

In the mother–baby ward at NIMHANS, a 29-year-old woman was spending her third day there, having arrived from the industrial city of Bhadravati, two hundred and fifty kilometres away. She sat quietly on a single bed, rocking a wooden crib that held her eight-month-old daughter. “I have been angry, manic, suicidal, violent, with everyone, including my four children,” she told me. “I’ve been violent after every one of my children was born, but nothing like this.”

She had completed her bachelor’s degree, she said, before marrying a timber merchant who had studied until the fourth standard. She loved him dearly but hated their life. They lived with his brother and mother. She detested her mother-in-law. “I am not allowed to do anything for myself,” she said. “I cannot leave the house or talk to anyone. I’m expected to stay in, clean, take care of the kids and the house. That’s the only thing I’m allowed to do. I could not take it anymore.”

Returning to the family home was not an option. “I will not go back to that house,” she told me.

She might not have to. Right before he dropped her off at NIMHANS, she said, her husband agreed that they would move into their own home once she was discharged. While many patients are abandoned, many others have family willing to support them through their illness.

THE YOUNG MAN’S FAMILY was deeply committed to helping him through his illness, whether they understood what it was or not. When he was admitted at VIMHANS, hospital policy required his mother stay with him for the entire two-month stay. She did not mind. During their time at the facility, they were educated about mental illnesses and encouraged to participate in cooking, art, gym and dance classes. The hospital charges patients on a sliding scale, depending on family income. For those like him who could not afford the treatment, the cost was waived.

His time at the hospital was largely positive. He filled his days with activities, staying busy to keep his mind on his recovery. He started participating in art therapy. It also provided him an opportunity to learn more about his illness and begin his journey toward forgiving the many professionals who had not been able to diagnose him for so many years.

The doctors had likely been unaware of bipolar affective disorder themselves. At medical schools and internships, primary-care doctors receive limited psychiatric training. According to a 2018 report in the Indian Journal of Psychiatry, when it comes to common mental disorders including depression and anxiety, Indian primary-care physicians fail to diagnose between half and three quarters of cases.

It is not just doctors who are unaware. Most people have difficulty recognising mental illnesses. While public-awareness campaigns surrounding mental health have increased in the past few years, most campaigns take place in big cities rather than rural areas. The NMHS found that mental-health education activities were “isolated, sporadic and invisible in nature,” lacking “focus and direction.” It observed that most people with mental-health issues delayed seeking help, and sought unnecessary treatments such as faith healing, “because of the community’s perception about a person with a mental health problem.” For serious disorders, such as schizophrenia and bipolar affective disorder, families are often left in a cycle of misunderstanding that can last years.

“Especially in rural areas, people do not grow up talking about mental illnesses,” Dr SN Chaudhry, the vice chair in charge of academics at VIMHANS, told me. “It is not something that is socially understood, taught in school or at work. It’s not a surprise many Indians are not educated on the topic.”

In the absence of education, movies and media reports, which often portray people with mental illness as violent or aggressive, as well as prevalent superstitions create a stigma. A 2018 survey by the Live Love Laugh Foundation foundthat 71 percent of the respondents reported stigmatising patients with mental illnesses. The NMHS found that such patients are often socially ostracised, and face discrimination in accessing education and employment opportunities.

As a result, the young man’s family kept his institutionalisation a secret. “He would have been labelled as ‘mental,’ so we couldn’t tell anyone,” his mother said. “There are so many stereotypes. No one will understand his depression. They would call him names; people would talk negatively. As a mother, that would hurt my heart.”

The fact that he could not share his journey with anyone often led to feelings of overwhelming claustrophobia. Nevertheless, his two months at the hospital helped him immensely, and he attempted to get back to life as usual after being discharged. At first, things went well. His father had stopped drinking and beating his mother. He resumed working at his father’s shop and found solace in spending time with his two younger siblings. But his old symptoms soon returned. He started having trouble sleeping again, and often felt depressed or anxious. It especially frustrated him that he could not contribute to the family’s finances.

One afternoon, eight months after being discharged from VIMHANS, he locked himself in the tiny attic he shared with his brother. He was tired of his constant struggles, of keeping his illness a secret, of the depressive feelings he could not erase. His heart racing, he became consumed with thoughts of ending his life. He swallowed a handful of the pills he had been prescribed.

THE LEVEL OF CARE the young man received at VIMHANS is not always available to Indian patients. One morning in March last year, six hundred people waited in line at the state-run Calcutta Pavlov Hospital’s outpatient department. For many, the journey to see a doctor had started hours before sunrise, with some travelling overnight to secure their place in line. Despite waiting hours, most got barely ninety seconds with the psychiatrist.

Dr Debananda Saha had already seen around two hundred and fifty patients over seven hours when we met. The 55-year-old appeared worn out, but insisted he was not. “I am here to serve the patients,” he told me. “It’s my responsibility.”

The workload, Saha said, was typical of most government hospitals in India. Besides the new patients, he also spent inpatient shifts treating over a hundred patients already admitted into the hospital. The underfunded hospital was also overflowing with patients, with some six hundred and fifty people in wards meant to house 250 patients in total. The hospital employs only 15 doctors and 35 nurses, less than a third of the number of personnel required for such a high patient load. Like Ravilla, Saha wished he could spend more time with each patient, but knew he would not be able to get through them all if he did.

A 47-year-old patient in the women’s ward told me she had been living on and off at the Pavlov Hospital for the past twenty years. She did not know her exact diagnosis, but said she suffered from dissociation and violent behaviour. She described being abandoned by her husband and daughter after becoming ill. Her parents, she added, had ridiculed and beaten her for her illness. She had been admitted at the hospital for good after her parents died eight years before.

The hospital food is deplorable, she said. “We eat vegetables floating in water. The food has no salt or seasoning.” The hygiene is worse. “We live with lice and ticks,” she added. “There are bedbugs.”

Dr Ganesh Prasad, the hospital superintendent, blamed the overflow of patients for the condition of the facility. The food quality is reviewed by a dietician every few months, he said, and pest control occurs on a regular basis. “We spray for pests, but with so many people coming into the hospital, it’s very hard to control,” he told me.

Prasad added that the hospital admits patients free of charge, which causes the overflow. “Patients are admitted off the streets, sometimes five or six a day,” he said. “We are doing our best. The government is, too.” Saha agreed, adding that many admitted patients never leave. “When a patient becomes mentally ill, some families do not want to keep them,” he told me. “They are poor, so leaving the patient in the hospital reduces their burden. Some give false names and addresses for their family members, leaving the hospital with no way of returning the patient home.”

Saha conceded that the conditions at the hospital were not conducive to recovery. A person’s mental health can deteriorate in a negative living environment, he explained. I asked him how the situation could be improved. He sighed. “In a country with such poor economic conditions, such a large population and a humongous treatment gap, it’s difficult to solve this problem,” he said.

WHILE OTHER COUNTRIES are making headway in this sphere, Dr Vikram Patel, a professor of global health at Harvard Medical School who has spent the last two decades working on reducing the treatment gap for mental disorders in low-income countries, believes India still has much to do. “India’s immense population and its cultural diversity, and the country’s lower socioeconomic level, limit its comparability with any other country,” he told me. “The fact that there is now a Mental Healthcare Bill and remarkable community-based interventions in the country give me hope that we will find appropriate strategies to scale up mental-health care.”

Most experts agree that, while the government needs to invest more, scale up existing facilities, incentivise doctors to work in rural areas and create additional psychiatry jobs, it will not be able to close the mental-health treatment gap on its own. That is why hundreds of groups around the country are experimenting with different ways to ease the burden on psychiatrists.

A 2018 report by The Lancet Commission on Global Mental Health and Sustainable Development recommended using technology to build a network of mental-health providers in rural and underserved areas. In Bengaluru, NIMHANS is doing just that. “Even in the next several decades, India will never be able to train enough psychiatrists, so we must find other, innovative ways to address the treatment gap,” Dr Nishanth KN, an assistant professor at NIMHANS, told me.

Nishanth is part of the institute’s primary-care psychiatry programme, which uses video conferences to train doctors in general psychiatry, including how to identify and treat patients with mental illnesses. The goal of the programme is to reach doctors in rural areas who would not otherwise have access to such training. In 2018, NIMHANS also launched a digital academy, in which psychiatrists from the hospital conduct patient-specific discussions over video conferences with primary-care physicians, social workers and nurses. Nearly three hundred professionals completed the digital-academy course in its first year.

In addition to such technical initiatives, grassroots organisations, such as Sangath in Goa, Mata Jai Kaur in Rajasthan and Anjali in West Bengal, are using lay counsellors and community health workers to reach underserved populations. The workers are members of local communities who are trained in general mental-health care. They identify those who may be ill and direct them to available resources, while also conducting awareness campaigns and regular home visits.

“Many patients do not need a psychiatrist or medication,” Dr Naveen Kumar Channaveerachari, who oversees the lay-counsellor curriculum at NIMHANS, told me. “Sometimes people just need support, someone to listen to them, a safe space. Beyond that, if there are more serious issues, the counsellors will refer the patients to doctors.”

Sumathi K, the local community-health worker from The Banyan who had convinced the 32-year-old woman from Arungundram to visit its monthly clinic at Manamathy, visits the woman every month at her home, providing her with therapy and support. She told me that such visits are important because they create a continuum of care. “There are so many things you see on home visits,” Sumathi said. “Some people take all their medication but are not aware of it. Or they stop coming to outpatient services. I can make sure they’re okay, remind them to come.”

The woman said the counselling has changed her life. “If I didn’t have her to talk to, I’d have nothing else. When Sumathi comes, I can vent and express my sadness and frustrations. I feel much better when she’s around.”

The lay-counsellor model has been used to supplement mental-health services in India for years, but the NMHS recommends integrating it with other health programmes so that they also include screening for common mental disorders. It also recommends mental-health initiatives in workplaces, educational institutions and the prison system, to ensure patients get help as soon as possible.

“Mental illnesses are toxic to the brain,” Dr Shivani Aggarwal, a child psychiatrist at VIMHANS, told me. “Over time, and if left untreated, they can become destructive to the mind. While patients can make full recoveries from disorders, the severity of their illnesses can depend on whether they received early intervention.”

WHEN HE opened his eyes after his overdose, the young man’s first thought was of regret. “I thought it would have been better if I died,” he told me.

His mother had saved him. She found him unconscious in his room and rushed him to a nearby hospital. After two days, he was sent home. “I knew I wasn’t okay and I needed more help, so I chose to be readmitted to VIMHANS,” he said. He spent another two months in the hospital, only to return eight months later, following another suicide attempt. “I felt so hopeless and sad,” he told me. “I really felt I had no other choice.” 

The most recent stay lasted several months but, as of last spring, he had been out of the hospital for three years, the longest he has been discharged since first being admitted in 2014.  His recovery has been challenging, he told me, and some days are better than others.

Despite his progress, the ghosts of his past were still visible in his slumped shoulders and sad eyes. His recovery had been challenging, he told me, and some days were better than others. He still lived in his family home. He was searching for a job, he said, after having lost his previous job as a telemarketer upon revealing his history of mental illness to his employer. Nevertheless, he was committed to his recovery. He attended regular counselling sessions, had become increasingly spiritual and was learning to play the guitar, a hobby he embraced while in treatment. He also dreamed of returning to university one day. His new goal was to become a sound engineer.

Gratitude has helped him through difficult moments. He was lucky to have the level of care he did, to have a mother who stayed by his side, to be male in a patriarchal society, to live in a city where help was readily available free of cost. “I know even just healthcare is a privilege for many people in this country, so mental-health care is a luxury,” he told me. “I know it could have been much worse for me.”

Going forward, he has one hope for India’s mental health care system. “There needs to be more awareness, so people know they can get help,” he said. “Because the help I got saved my life.” 

courtesy The Caravan