Arabinda N. Chowdhury

Global, national, and local approaches to mental health: examples from India.

Neuropsychiatric disorders and suicide amount to 12.7% of the global burden of disease and related conditions (GBD) according to World Health Organization (WHO) estimates for 1999, and recognition of the enormous component of mental illness in the GBD has attracted unprecedented attention in the field of international health. Focusing on low‐ and middle‐income countries with high adult mortality, this article discusses essential functions of international agencies concerned with mental health. A review of the history and development of national mental health policy in India follows, and local case studies consider the approach to planning in a rural mental health programme in West Bengal and the experience in an established urban mental health programme in a low‐income community of Mumbai. Local programmes must be attentive to the needs of the communities they serve, and they require the support of global and national policy for resources and the conceptual tools to formulate strategies to meet those needs. National programmes retain major responsibilities for the health of their country’s population: they are the portals through which global and local interests, ideas, and policies formally interact. International priorities should be responsive to a wide range of national interests, which in turn should be sensitive to diverse local experiences. Mental health actions thereby benefit from the synergy of informed and effective policy at each level.

Community mental health and concepts of mental illness in the Sundarban Delta of West Bengal, India

The Sundarban Delta of West Bengal is a remote, rural region with poor infrastructure and until recently without designated mental health services or a community mental health programme. To inform development of such a programme for the region, and to complement epidemiological study of rates of suicide, nonfatal deliberate self-harm, and specific psychiatric disorders, cultural epidemiological research was undertaken. This research aimed to clarify the nature of broadly conceived mental health problems in the community (not just professionally defined psychiatric disorders) and local concepts of mental illness, clarifying specific features, perceived causes, and help seeking for these problems. Findings from ethnographic study of three villages of two Sundarban blocks (Sagar and Gosaba) are presented and discussed, focusing on particular stresses and supports in the community, local priority of mental health concerns, and concepts of mental illness. This first phase of research has been followed by a cultural epidemiological survey in phase 2, studying mental-illness-related experience, meaning, and behaviour among (1) patients coming for treatment with selected mental disorders, (2) patients admitted after surviving an episode of deliberate self-harm, (3) non-affected laypersons in the community, and (4) health care providers with diverse orientations and credentials serving the community. As important as they are, psychiatric epidemiological data alone are insufficient to clarify the nature of needs and to specify the character of services. This research shows how cultural epidemiology informs policy and action, and how similar research in other settings may contribute to the mental health of populations.

Deliberate self-harm and suicide by pesticide ingestion in the Sundarban region, India.

Objective  To examine the clinical epidemiology, including case fatality and determinants of self‐harm in six island blocks of the Sundarban region of West Bengal, India.

Pattern of domestic violence amongst non-fatal deliberate self-harm attempters: A study from primary care of West Bengal

Objective: Evaluation of various clinico-demographic variables and pattern of domestic violence in non-fatal deliberate self-harm (DSH) attempters admitted in 3 Block Primary Health Centers (BPHC) of Sundarban region of West Bengal, India in the year 2002. Materials and Methods: A prospective study of 89 DSH cases admitted at 3 Sundarban BPHCs by using a specially designed DSH register and a questionnaire on domestic violence in Bengali along with detail clinical interview. Results: Among the total of 89 DSH cases (23 male and 66 female), young (less than 30 years), female sex, low education and married status constituted major part of the sample. Pesticide poisoning was the commonest mode of DSH attempt. Typical stressors found were marital conflict or conflict with in-laws or guardian. A majority of DSH attempters (69.6%) experienced more than one form of domestic violence. Poverty and unemployment in the family were strongly associated with domestic violence. Among female DSH attempters, the most common perpetrator was husband (48.48%) followed by in-laws (16.67%) and parent (34.78%) was the most common perpetrator among males. Conclusion: Both DSH and domestic violence are serious socio-clinical issue of a major public health concern in the Sundarban region. Stressful life situations and various types of victimizations in the family intermixed with easy availability of lethal pesticides in this agriculture dependent community may facilitate the impulse of self-harm behavior, especially among the young housewives. Timely psychosocial intervention through community psychiatry program may mitigate the impact of psycho-cultural stressors and thus may help to reduce the morbidity and mortality from DSH.

Pesticide practices and suicide among farmers of the Sundarban region in India

Background Deliberate self-poisoning by ingesting pesticides is a serious health problem among farmers, especially in low- and middle-income countries. Preventing these suicides is a priority for a public mental health agenda. Objective To examine the role of pesticide poisoning in suicide and nonfatal deliberate self-harm, and clarify awareness of risks, safe practices concerning storage and use of pesticides, and associated self-injury, both unintentional and intentional, within farmer households of the Sundarban region, India. Methods Retrospective record review of adult cases of deliberate self-poisoning at the Block Primary Health Centres of 13 Sundarban Blocks was performed to analyze the relative roles of various methods of self-harm and their lethality. Focus group discussions, questionnaires, and in-depth interviews were undertaken in a community study of farmer households to examine pesticide-related views and practices, with particular attention to storage, use, and health impact. Results Pesticide poisoning was the most common method of deliberate self-harm in both men and women. Pesticide storage in most households was unsafe and knowledge was inadequate concerning adverse effects of pesticides on health, crops, and the environment. Conclusions An intersectoral approach linking the interests of public health, mental health, and agriculture is well suited to serve the collective interests of all three agendas better than each in isolation. Such an approach is needed to reduce morbidity and mortality from unintentional and intentional self-injury in low-income agricultural communities like those of the Sundarban region.

Eco-psychiatry and Environmental Conservation: Study from Sundarban Delta, India

Aims This study attempts to examine the extent and impact of human-animal conflicts visa-vis psychosocial stressors and mental health of affected people in two villages adjacent to Sundarban Reserve Forest (SRF) in the Gosaba Block, West Bengal, India. Methods Door to door household survey for incidents of human-animal conflicts, Focus Group Discussions, In-depth Interviews, Case studies, Community Mental health clinics and participatory observation. Results A total of 3084 households covering a population of 16,999 were surveyed. 32.8% people live on forest-based occupation. During the last 15 years 111 persons (male 83, female 28) became victims of animal attacks, viz, Tiger (82%), Crocodile (10.8%) and Shark (7.2%) of which 73.9% died. In 94.5% cases the conflict took place in and around the SRF during livelihood activities. Tracking of 66 widows, resulted from these conflicts, showed that majority of them (51.%) are either disabled or in a very poor health condition, 40.9% are in extreme economic stress and only 10.6% remarried. 1 widow committed suicide and 3 attempted suicide. A total of 178 persons (male 82, female 96) attended the community mental health clinics. Maximum cases were Major Depressive Disorder (14.6%), followed by Somatoform Pain Disorder (14.0%), Post Traumatic Stress Disorder-animal attack related (9.6%) and Adjustment Disorder (9%). 11.2% cases had history of deliberate self-harm attempt, of which 55% used pesticides. Conclusions Improvement of quality of life of this deltaic population by appropriate income generation and proper bio-forest management are the key factors to save their life as well as the mangrove environment of the Sundarban region.

Sociocultural Context of Suicidal Behaviour in the Sundarban Region of India

The role of mental illness in nonfatal deliberate self-harm (DSH) is controversial, especially in Asian countries. This prospective study examined the role of psychiatric disorders, underlying social and situational problems, and triggers of DSH in a sample of 89 patients hospitalised in primary care hospitals of the Sundarban Delta, India. Data were collected by using a specially designed DSH register, Explanatory Model Interview Catalogue (EMIC), and clinical interview. Psychiatric diagnosis was made following the DSM-IV guidelines. The majority of subjects were young females (74.2%) and married (65.2%). Most of them (69.7%) were uncertain about their “intention to die,” and pesticide poisoning was the commonest method (95.5%). Significant male-female differences were found with respect to education level, occupation, and venue of the DSH attempt. Typical stressors were conflict with spouse, guardians, or in-laws, extramarital affairs, chronic physical illness, and failed love affairs. The major depressive disorder (14.6%) was the commonest psychiatric diagnosis followed by adjustment disorder (6.7%); however 60.7% of the cases had no psychiatric illness. Stressful life situations coupled with easy access to lethal pesticides stood as the risk factor. The sociocultural dynamics behind suicidal behaviour and community-specific social stressors merit detailed assessment and timely psychosocial intervention. These findings will be helpful to design community-based mental health clinical services and community action in the region.

Participatory Research for Preventing Pesticide-Related DSH and Suicide in Sundarban, India: A Brief Report

Deliberate self-harm (DSH) is a major public health problem in the Sundarban region, India. This study is aimed to develop a DSH-suicide prevention programme based on the principles of community-based participatory research (CBPR). Perception and opinion of community about the problem of pesticide-related DSH and suicide were elicited in a series of facilitated focus group discussions in Namkhana block of Sundarban region. Based on their suggestion, a broad preventive programme was launched involving the development of information, education, and communication (IEC) and training modules and training of the stakeholders of the block. Most of the members of each target group found that the IEC materials were culture fair (message is acceptable, understandable, and meaningful in the local context) and very useful. Analysis of Dwariknagar BPHC, DSH admission data showed a definite reduction of DSH incidents after this CBPR approach to prevention was initiated. Similar model of DSH prevention in the other blocks of Sundarban region or in agricultural community may help to reduce the enormous mortality and morbidity from pesticide-related DSH and suicide.

Globalisation of Pesticide Ingestion in Suicides: An Overview from a Deltaic Region of a Middle-Income Nation, India

In many countries globally, intentional self-injury has become a frequent reaction to emotional distress, particularly among young adults. In high-income countries, the substances ingested are analgesics, antidepressants and sedatives, all of which are relatively harmless. However, the scenario is quite different in low- and middle-income countries (LMICs), especially in rural areas where agricultural pesticides are used to attempt self-harm. All across the world countries have accrued tremendous benefits from pesticide use. Pesticides have enhanced agricultural production dramatically in most countries thereby ensuring food for the increasing population. They have been instrumental in effectively controlling vector-borne diseases. In the 1950s and 1960s there was much glorification about the advantages of pesticides in reducing world hunger, increasing crop productivity, controlling pest infestation and crop damage and so on. However, recent evidence suggests that pesticides have considerable deleterious impact on the environment and human health. Moreover, accidental poisoning and pesticide-related self-harm/suicide is emerging as a grave public health issue in several nations, particularly in LMICs. The present chapter aims to highlight the issue of easy availability of pesticides in an agrarian region in India, the aggressive marketing by pesticide companies, the limited role of the local administration in the sale of pesticides, and specific sociocultural contexts such as dowry and domestic violence, in which pesticides are consumed.

Ecopsychosocial Aspects of Human–Tiger Conflict: An Ethnographic Study of Tiger Widows of Sundarban Delta, India

Aims Human–tiger conflict (HTC) is a serious public health issue in Sundarban Reserve Forest, India. HTC is a continued concern for the significant mortality and morbidity of both human and tiger population. This is the first comprehensive report on Sundarban tiger–human conflicts and its impact on widows whose husbands were killed by tigers. The study attempts to explore the situation analysis of HTC and the aftermath of the incident including bereavement and coping, the cultural stigma related to being killed by a tiger and the consequent discrimination, deprivation, and social rejection, and the impact on the mental health of the tiger-widows. Methods This is a three-phase ethnographic research with a mix of quantitative and qualitative methods. In the first phase, a door-to-door village survey (3,084 households) was carried out in two villages of Sundarban, which are adjacent to the Reserve Forest, in which the incidents of human-animal conflicts and the 65 tiger-widows identified were documented. In the second phase, the 65 tiger-widows were studied to explore the ecodemography of tiger attacks and tiger-widows alongside the stigma issue by using a stigma questionnaire (n = 49). The stigma burden was compared with normal widows (n = 21) and snake-bite widows (n = 18). In the third phase, the psychosocial and cultural dimensions related to tiger attacks were studied by using in-depth interviews (IDI) of the tiger-widows, focus-group discussions (FGD), and participatory mapping in the community. Clinical examinations of the mental health of the widows were also carried out in this phase. Results The mean age of the 65 widows was 43.49 ± 9.58 years. Of this, 12.3% of the widows had remarried and only 4.6% of the widows were literate. In all, 67.2% of all tiger attacks occurred as a result of illegal forest entry. The main livelihood of the former husbands of the widows were 43.8% wood cutting, 28.1% fishing, 10.9% crab catching, 9.4% tiger prawn seed (juvenile prawn), and 4.7% honey collection. The maximum number of attacks took place in the months of December (24.6%) and November (13.9%). The majority of incidences happened during the morning hours (47.7%) of the day. Of the cases, 86.1% were attacked while the person was engaged in livelihood activity. In all, 57.4% widows are recorded as living “below the poverty line”. Currently, 45.5% widows earn their living by laboring work followed by forest-based livelihood activities (30%) and begging (5.2%). Tiger-widows differed significantly (P < 0.001) from both normal and snake-bite widows on all stigma cluster scores and the total score. Of the tiger-widows, 44% were shown to be suffering from some designated mental illness. IDIs and FGDs helped to unfold the cultural construct of stigma related to tiger-killing. This can be seen in how the tiger-widows’ quality of life has been negatively impacted in the way their economic and social security, health, remarriage opportunities, and child upbringing is restricted, along with a multitude of posttrauma psychological scars, deprivation, abuse, and exploitation. Conclusions The study highlights the multitude of sufferings experienced by the tiger-widows including the issues of the gender aspect of HTC and the ecopsychiatric risk factors of tiger attacks combined with the background of local sociocultural beliefs and practices. It is well known that a similar problem also exists in Bangladesh Sundarban as well, in which case it may be that a strong and practical administrative strategy for sustainable alternative income generation and a balanced conservation policy with integrated participatory forest management may go to save both human and tiger. A community ecocultural mental health program involving all the stakeholders (community, gram panchayat, and forest department) and aiming to address and even eradicate the cultural stigma of tiger attack may help to reduce the stigma burden and socicultural discrimination currently experienced by the tiger-widows.