On a September evening, a 27-year-old was among the patients waiting anxiously in the lounge of a private mental health clinic in South Kashmir’s Anantnag town.
“I have a phobia that I will have a heart attack,” said the 27-year-old, who has a postgraduate degree in botany and wrote the Union Public Services Commission entrance exam earlier this year.
Trouble had started about four years earlier, when he was living near a coaching centre in Greater Noida, on the outskirts of Delhi, preparing for a different entrance examination. Scrolling down his Facebook feed, he had stumbled on bad news from home – a young boy from a village near his had died of a sudden cardiac arrest.
The very same day, he had stomach trouble. Over the next two weeks, filled with “restlessness and fear”, he stopped attending classes. He went home, hoping to get better but got worse.
Three top cardiologists assured him he was fine. “But I wasn’t ok,” said the 27-year-old. “I couldn’t get this post off my mind. I lost a year trying to find a way out.”
He managed to write his UPSC exams this year but got only average marks. “I know I could have done better,” he said. But he had not been able to focus on preparing for the exams.
Eventually, it was a nudge from a general physician at a Srinagar hospital that made him realise he may need psychiatric help. “I Googled my symptoms and read about others facing similar problems,” he said.
A few more Google searches for private mental health facilities near him led him to the Anantnag clinic, about 20 kilometres away from his home in Kulgam district. The clinic in Anantnag town, packed with patients, was closer home than Srinagar.
“Had it been in Srinagar, I would have had to spend the whole day on travel,” he explained.
Sizing up the problem
For years, the Government Hospital for Psychiatric Diseases in Srinagar was the only address for those seeking help with mental health problems. However, a growing awareness about mental health has meant more patients are seeking help at the local level, in their home districts. Driving this phenomenon is the spread of public as well as private mental health care infrastructure across the Kashmir Valley.
Over the last decade, government hospitals in all 10 districts of Kashmir have set up mental health clinics. Districts like Baramulla, Kupwara, Kulgam and Budgam have clinics at the sub-district level as well. Kashmir also has mental health clinics in three jails, at Baramulla, Srinagar and Anantnag. Taken together, there are about 17 government-run mental health clinics across districts. The government medical colleges in Anantnag in South Kashmir and Baramulla in the North also have psychiatry departments.
According to psychiatrist Arshad Hussiain, Kashmir is an outlier when compared to states across India. “It would be a rarity in the whole of India that all district hospitals have psychiatrists available at OPDs [out patient departments],” he said.
While data for the number of private mental health clinics is not immediately available, psychiatrists believe they are a growing trend in Kashmir. But even these facilities may not be enough for Kashmir, where mental health problems are usually studied through the lens of conflict. Decades of violence have left deep scars among most denizens of the Valley.
A 2004-05 study on the prevalence of trauma had revealed that around 59% of 1,200 individuals surveyed across four districts had undergone a traumatic experience. The trauma of having experienced shooting or explosions was the most common.
In 2009, a study published by Qassim University’s International Journal of Health Sciences had surveyed 2,728 individuals in the Kashmir Valley. It found the prevalence of depression was highest (66.67%) in the 15-25 years age group, followed by 65.33% in the 26-35 years age group.
A 2015 study, conducted by Médecins Sans Frontières in collaboration with Kashmir University’s Department of Psychology and the Institute of Mental Health and Neuroscience in Srinagar, surveyed all 10 districts of the Valley. It seemed to suggest a problem of a staggering scale.
“The survey showed that nearly 1.8 million adults (45% of the adult population) in the Kashmir Valley are experiencing symptoms of mental distress, with 41% exhibiting signs of probable depression, 26% probable anxiety and 19% probable Post Traumatic Stress Disorder (PTSD),” it said.
But the next year, a joint study by Action Aid, a non-governmental organisation, and the Institute of Mental Health and Neuroscience at Srinagar came up with lower figures – 11.3% of the adult population in Kashmir suffered from mental illnesses, it concluded. This was still considerably higher than the national average of 7.3%.
What the Action Aid study also emphasised was that only 6.4% of those experiencing mental health issues had tried to get professional help. “The reasons for this low treatment level may be because of very high stigmatisation of these illnesses in the society, very low awareness about illness as well as about treatment, and inaccessible treatment at the community level, as most mental health services available in Kashmir are located in urban areas,” the study noted.
For instance, a 59-year-old woman from Anantnag district’s Brakpora village, who identified herself only as Bano, spent years being treated for various physical symptoms before doctors realised the problem might lie elsewhere.
After three years of being treated for back problems, Bano suddenly developed stomach trouble and palpitations this January. “She couldn’t sleep and her shoulders stiffened,” explained her daughter. “We took her to a physician who asked her to do some tests. The tests didn’t show any problem with her stomach or heart.”
The physician then put her on an antidepressant for three months, which helped. “We have a gynaecologist in our family. When she saw my mother, she suggested we see a psychiatrist,” said her daughter.
Early September, when Bano visited a psychiatrist at a clinic in Anantnag town, she was diagnosed with major depressive disorder. Two weeks after her first visit, she was doing relatively well. The medication had worked and she was able to sleep.
A slow change
However, mental health practitioners in Kashmir say that the trend is “definitively changing”.
“The increase in the number of people seeking help is both because of a rise in mental health problems and increased awareness, particularly in urban settings,” said Arshad Hussain, who led the Action Aid study in 2016.
One of the reasons driving that change, Hussain added, might be the growing number of mental healthcare professionals in the valley. “When I started in the early 2000s, there were only three to four psychiatrists in the entire Kashmir,” he said. “Today, that number is around 80 psychiatrists. Currently, we are producing eight psychiatrists per year, which will be rising to 12 from next year.”
As Mansoor Ahmad, assistant professor of psychiatry at Anantnag’s Government Medical College, explained: “Over the years, consistent efforts to educate people about mental health have played a role but more than that, it’s the development of human resources which has changed things drastically.”
For the first three months after he joined as a psychiatrist at the Anantnag medical college in February, 2019, Ahmad recalled, he would hardly get any patients. “I decided to conduct a programme at the hospital in which I sensitised the hospital faculty about depression,” he said. “We discussed how a depressed patient exhibits symptoms related to cardiac, orthopaedic or gastric problems. Within one week of that programme, I saw my non-psychiatry colleagues referring patients to me.”
These days, Ahmad says, a group of four psychiatrists at the Anantnag hospital treats 80-90 patients in a day. “In the last 44 months, 71,000 patients have visited the hospital to seek mental health [treatment],” Ahmad shared. This number, Ahmad said, reflected a “drastic change” in Kashmir. “Twenty years back, a person in Kashmir wouldn’t think of consulting a psychiatrist,” he said.
Just the presence of mental health professionals had helped draw more patients. “If you post a psychiatrist in any far-flung area, he will attract patients,” Ahmad said. “Even if he doesn’t get patients, the least he can do is he will sit with non-psychiatric doctors and sensitise them about mental health.”
The Covid boost
Waris Zargar, who started his practice as a psychiatrist in 2018, echoed this assessment. Once or twice a week, he would drive up to Kupwara in North Kashmir. But there were few patients.
“For a year, not more than five or six patients would come to consult me on a single day,” he said. “Today, I see nearly 50-60 patients on a single day at my clinic in Kupwara.”
It did not help that doctors treating physical illnesses in rural Kashmir often lacked awareness about mental health problems.
“They feel a headache can be treated by a physician while the patient may be experiencing that due to a trauma or mental health problems,” he said.
While there may still be a long way to go, an unexpected boost to awareness came in the form of the Covid-19 pandemic. Global health organisations had launched campaigns talking about the need to take of mental health as millions across the world struggled with the devastating effects of Covid-19 and the lockdowns it entailed.
Mansoor Ahmad took grim satisfaction in these campaigns, which went a long way in changing attitudes to mental health in Kashmir.
“People began to take mental health seriously,” he said. “It’s a beautiful thing when bodies like the United Nations and World Health Organisation are talking about mental health. It’s bound to have an impact.”