The State should specifically support, tailor and prioritise the mental health care needs of the vulnerable sections of the society.
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THE recent death by suicide of a second-year undergraduate law student belonging to the Scheduled Tribe [ST] community at National Law University, Orissa is another stark reminder of the increase in the number of student suicides and the consequent inadequate state of basic mental healthcare in the country. As per data shared on suicide by the Union Education Minister on December 20 last year in Lok Sabha, out of the 122 students from union government-run higher education institutions, including the Indian Institutes of Technology and Indian Institutes of Management, that committed suicide between 2014 and 2021, half belonged to marginalised castes or tribes.
The fundamental point which cannot be lost sight of is that death by suicide cannot be generically addressed as a mental health issue without specifically acknowledging socio-economic factors, and the discrimination one faces by virtue of belonging to a marginalised section of the society.
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The myth of depression being a rich person's problem has been long busted. Indian research psychiatrist Vikram Patel, in his research on low- and middle-income countries, establishes this correlation between poverty and mental health. The effect of socio-economic factors on mental health was also a central focus in the first National Mental Health Policy of India published in 2014. It provided for prioritisation of the mental health of persons living in poverty, persons inside custodial institutions, orphaned persons with mental illness, homeless persons, persons affected by disasters and emergencies, children of persons with mental health problems, internally displaced persons as well as other marginalised populations.
“Death by suicide cannot be generically addressed as a mental health issue without specifically acknowledging socio-economic factors, and the discrimination one faces by virtue of belonging to a marginalised section of the society.
Similarly, the Mental Healthcare Act, 2017 [MHA] has been hailed as a rights-based progressive legislation even though both the policy and legislation remain largely unimplemented. Several public interest litigations have been filed at different courts for the implementation of the provisions of the MHA. The Patna High Court as recently as April 1, in a strongly worded order, remarked that "it was saddening to see that the State of Bihar, even after the passing of more than four and half years, had not taken adequate steps in line with the intention of the Parliament."
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Incidentally, the progressive provisions of MHA were also considered by the Supreme Court in its landmark judgemnt in Navtej Singh Johar vs. Union of India (2018) to decriminalise homosexuality in India. The concurring judgment by Justice Indu Malhotra stated that "Sections 18(1) and (2) read with 21(1)(a) of the Mental Healthcare Act, 2017 provide for the right to access mental healthcare and equal treatment of people with physical and mental illnesses without discrimination, inter alia, on the basis of 'sexual orientation'".
It is essential to note that the Justice D.Y. Chandrachud, in his concurring opinion, also considered the mental health concerns of the LGBTQIA+ community and stated that the "repercussions of prejudice, stigma and discrimination continue to impact the psychological well-being of individuals impacted by Section 377 [of the Indian Penal Code]". The Supreme Court considered global psychiatric scholarship which showed that there is a clear correlation between the political and social environments, and the mental health of an individual – and that persecutory laws against LGBTQIA+ individuals lead to greater levels of depression, anxiety, self-harm and suicide.
Justice Malhotra also noted that "LGBT persons are seriously disadvantaged and prejudiced when it comes to access to health-care facilities. This results in serious health issues, including depression and suicidal tendencies amongst members of this community."
“There is a clear correlation between the political and social environments, and the mental health of an individual – and persecutory laws against LGBTQIA+ individuals lead to greater levels of depression, anxiety, self-harm and suicide.
Recognising the need for LGBT-friendly counselling, Justice Chandrachud stated that "[t]here is not only a need for special skills of counsellors but also heightened sensitivity and understanding of LGBT lives. The medical practice must share the responsibility to help individuals, families, workplaces and educational and other institutions to understand sexuality completely in order to facilitate the creation of a society free from discrimination…"
Thus, the Supreme Court reaffirmed that homosexuality is not an illness; rather it is homophobia that, in fact, leads to mental health issues in LGBTQIA+ persons. However, the LGBTQIA+ community continues to face discrimination and the recent death by suicide of a dyslexic gay teenager due to constant bullying shows that inclusive mental health care remains a distant reality.
Similarly, it is structural discrimination on account of casteism, ableism and Islamophobia that in turn impacts the mental health of a person belonging to marginalised sections of the society. The death of Payal Tadvi, a doctor belonging to ST community, and Rohith Vemula, a Dalit Ph.D. scholar, were caused by institutional discrimination which resulted in suicide.
The framework of intersectionality, a term coined by American civil rights activist and critical race theory scholar Kimberlé Crenshaw, was recognized by the Supreme Court in Patan Jamal Vali vs. The State of Andhra Pradesh (2021) where in the case of rape of a blind Dalit woman, it was specifically noted that "when the identity of a woman intersects with, inter alia, her caste, class, religion, disability and sexual orientation, she may face violence and discrimination due to two or more grounds. Transwomen may face violence on account of their heterodox gender identity. In such a situation, it becomes imperative to use an intersectional lens to evaluate how multiple sources of oppression operate cumulatively to produce a specific experience of subordination for a blind Scheduled Caste woman."
Thus, a transgender Dalit woman faces greater discrimination in comparison to an upper caste heterosexual woman. There are ample studies that suggest that this intersectional discrimination leads to a disproportionate effect on mental health.
Another factor that adds to intersectional discrimination is the stigma of 'mental illness' itself. As per a 2018 survey by the Live Love Laugh Foundation, 87 percent of the respondents, based across eight Indian cities, called mental illness a disorder, and about 47 per cent used terms like 'retard', 'crazy', 'stupid' and 'mad' to describe those suffering from mental illness. Section 30(b) of MHA specifically provides for the government to take all measures to ensure that "programmes to reduce stigma associated with mental illness are planned, designed, funded and implemented in an effective manner" even though the ground reality suggests otherwise.
In an abetment to suicide case, the Karnataka High Court in a 2020 judgment noted that the deceased who died by suicide did not behave like a depressed person and went on to even use the word 'weakling' for him. On appeal to the Supreme Court, it was categorically noted by the division bench comprising Justices Chandrachud and B.V. Nagarathna in its judgment delivered last year that terms such as 'weakling' and "observations describing the manner in which a depressed person ought to have behaved deeply diminishes the gravity attached to mental health issues".
Similarly, in Ravinder Kumar Dhariwal vs. The Union of India (2021), the Supreme Court, while holding that initiation of disciplinary proceedings against persons with mental disabilities is a facet of indirect discrimination, addressed the extreme importance of removing the stigma associated with mental health and noted that "[t]he World Health Organisation and the World Psychiatric Association identify stigma as a major cause of discrimination against persons with mental health disorders."
The impact of interpersonal, institutional and structural discrimination on mental health of marginalised communities cannot be ignored and this reality should be acknowledged instead of seeing the issue from a generic lens. For example, Section 30(c) of MHA provides for periodic sensitisation and training of police officers and government officials on mental health issues. However, unless the sensitisation is LGBTQI+- friendly while also recognising the intersectional issues of caste, religion, gender and disability, the true purpose of MHA would not be served.
“The impact of interpersonal, institutional and structural discrimination on mental health of marginalised communities cannot be ignored and this reality should be acknowledged instead of seeing the issue from a generic lens.
Several grassroots organisations show us the way, such as journalist Divya Kundukuri's Blue Dawn, which supports and facilitates accessible mental healthcare services for marginalized communities. However, unless the MHA is implemented and the State specifically supports, tailors and prioritises the mental health care needs of the vulnerable sections of the society, the mental health crisis in the country would not be resolved.