Haroon Reshi

Kashmir needs more professionals, institutional support to deal with increased incidence of mental health issues

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With available resources already overstretched, burnout is a consequence staring in the face of experts!

Five years have passed since Doctors Without Borders (Médecins Sans Frontières) and the Srinagar-based Institute of Mental Health and Neurosciences (IMHANS), after conducting a comprehensive survey, found that nearly 1.8 million adults (45 percent of the adult population) in Kashmir were experiencing some form of mental distress. A report titled “Kashmir Mental Health Survey 2015,” was released in May 2016. It confirmed that the distressed adult population was affected by probable depression, anxiety disorder, and post-traumatic stress disorder (PTSD).

Sadly, much has changed since then for the worst, which experts say has deteriorated the situation in terms of mental health in Kashmir further. For example, just two months after the survey report was released, civil unrest started in July 2016 in the Valley, causing deaths and injuries to many, mostly youngsters, and the Valley remained under strict and consecutive curfew for 53 days. Then, following the August 05, 2019 developments, a strict lockdown including a blanket ban on communication links was imposed here for months. Worst, the outbreak of global pandemic — COVID-19– like other parts of the world, hit all walks of life in Kashmir too.

All these mishaps, according to the experts, have taken a toll on the mental well-being of the people in Kashmir. They say that the OPD rush at the mental health centers across the Valley has risen up to 40 percent since the outbreak of the pandemic early last year.

This, eventually, has caused an overburden on medical professionals —psychiatrists, clinical psychologists, counsellors, psychiatric social workers, psychiatric nurses, et al. Some experts say that there is already a shortage of mental health professionals in Kashmir in terms of the doctor-population ratio. And on the other hand, conflict-ridden Kashmir has an alarming number of patients suffering mental illnesses, if compared to other regions of the country. The 2015 survey had estimated that 11.3 percent of the population had a mental health disorders in Kashmir – higher than the national prevalence of around seven percent.

These facts lead to some important questions: Are our mental health professionals, in given situation, themselves vulnerable to the emotional, physical, and mental exhaustion because of their workload? Do they have sufficient facilities available to ensure their own mental well-being? Do we have enough infrastructures available in the mental health sector here? And what needs to be done to ensure required mental health facilities are available in Kashmir, and mental health professionals are not overwhelmed, emotionally drained, and unable to meet constant demands.

To know the answers to all these questions, KASHMIR IMAGES spoke with some mental health professionals. They have shared their views on the present scenario related to the mental health sector. Here are the excerpts:

Dr. Mushtaq A. Margoob
Psychiatrist, former Professor & Head, Post Graduate Department of Psychiatry, Government Medical College, Srinagar

In general, people world-over live in an age of constant stress but the inherent nature of medical practice in which doctors are expected to function competently, work hard and relieve suffering and distress, imposes a heavy strain on them as well.

In most health institutions, the staff faces extreme stress in the form of excessive workload, poor staff strength, less than expected remuneration, inadequate security, and at times threat to life. Burnout is work-related mental health impairment, a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress. It occurs when you feel overwhelmed, emotionally drained, and unable to meet constant demands. The realities of on-the-job stressors are usually present in almost every occupation, but they can have a significant impact on how well mental health professionals are able to do their jobs. The individual characteristics that often attract professionals to the mental health field and make them well suited for the job are the same characteristics that make them vulnerable to burnout as well.

Individuals who are emotionally responsive, empathetic, and compassionate are often equipped to be strong clinicians, but they are also regularly exposed to the impact of the pain experienced by their patients. Secondary traumatic stress results when clinicians frequently hear about traumatic events from the lives of their help-seekers that strains the empathetic response natural for the helpers.

Given the nature of the work, mental health professionals do have this type of stress, also known as compassion fatigue, and it has become a significant topic in current research. Organizational bureaucracy, large demanding caseloads, and unsupportive work environments are examples of these conditions. Our earlier study published in 2006 and titled “A study of burnout among clinicians as caregivers in a chronic mass trauma situation” was quite reassuring indicating a low degree of burnout in the overall sample of clinicians which included 37.29 percent from primary care settings and 62.71 percent from secondary/tertiary health-care locations. However, the preliminary results of our current ongoing study during the COVID-19 pandemic period is perturbing as the data analysis pertaining to the first-wave period has clearly indicated that the prevalence of stress and burnout among healthcare workers working in Kashmir has been higher than their peers working in other parts of the country.

Unending tragic events as a consequence of multiple natural disasters superimposed on ongoing conflict/manmade disaster situation of more than three decades have resulted in perpetual, indescribable psychosocial stress which indirectly may also reflect the possible undesirable impact on mental wellbeing and peace of mind of the mental health-care providers in Kashmir, who have always been tirelessly trying their best to help the sufferers under very trying circumstances.

To achieve an ideal psychiatrist to population ratio of about one psychiatrist for eight to ten thousand individuals is right now obviously a distant dream like any other place in India or for that matter in South-Asia with a current ratio of about one psychiatrist for 1.25 lakh people in India. In fact, the WHO’s mental health atlas of 2017 stated that India has 0.29 psychiatrists for every one lakh individuals which has currently improved to 0.75 psychiatrists per lakh. That way we in Kashmir, as of today, are relatively better placed than many of the states with one psychiatrist for about 94,000 people though desirable would have been any number with three or above that number of psychiatrists per lakh population.

As explained above, to address the issue of fatigue, exhaustion, and burnout among mental health professionals, one of the most important measures would be task-sharing in the community mental health work for which there are evidence-based, scientifically validated and cost-effective models developed here, and adopted by even in the most developed country settings as well with great satisfaction in bridging the gap and decreasing the burden on expert mental health professionals. The infrastructure in public health institutions is currently being developed quite satisfactorily as last week only the process of inducting half-a-dozen faculty members in IMHANS-K has been completed and SKIMS Medical College has also approved for setting up of an Addiction Treatment Facility. But much more needs to be done in this direction particularly at the district and community level to share the burden and workload of mental health professionals working there.

Although now the patient-care burden at tertiary-care level institutions like at IMHANS-K, with adequate available mental health professional manpower, is being shared comfortably, but the situation at other institutions especially at district mental health-care levels institutions needs prioritized attention.

Over the decades’ mental health professionals have evolved some additional effective coping mechanisms besides other well-known steps like trying to maintain a healthy work-life balance; subscribe to a holistic self-care model that pays attention to aspects of physical, social, mental, emotional, spiritual, and vocational wellness as well as setting limits for themselves and knowing one’s boundaries, but at times all this doesn’t seem to work which should be a matter of concern for all. Because if the dedicated mental health professionals involved in solving other people’s emotional issues end to the extreme extent of professional fatigue and burnout who would look after the masses suffering from mental health problems in Kashmir.

Dr. Arshad Hussain
Neuro-psychiatrist and Professor in the Department of Psychiatry, Govt. Medical College Srinagar

We had a unique experience, in terms of our resilience after the outbreak of the pandemic early last year. Before Covid, we had our own mechanism of resilience that was developed over the years. But during the past almost two years, we had an entirely different experience. In the pandemic, we started seeing patients in both ways, physical sittings as well as online or telephonic consultations.

Prof Nand Kumar (Prof. in-charge of ICMR CARE in Neuromodulation for Mental Health, Department of Psychiatry, AIIMS, New Delhi), who was recently on a visit to the Institute of Mental Health and Neuroscience (IMHAMS) in Srinagar, was overwhelmed to know that the institute had seen around 77,000 patients in its OPD from March 21, 2000 (when the first Covid lockdown was started) to December 21, 2020. He said that the world needs to be told that there is a mental health institute in our country that has treated this much of patient inflow even in the pandemic lockdown. He was pleasantly surprised to see the record of our serves at IMHAMS.

When Covid started and hospitals stopped seeing patients other than the virus-infected ones, we at IMHAMS decided to continue our OPD, of course with extreme precautionary measures and SOPs. And we convinced the authorities for allowing us to do so. It was a time when our professionals could have gone to their homes and rest. But they choose to serve in these worst times. A month later, in April 2020, the principal medical college visited, and she was overwhelmed to see who we worked in those tough times when even hospitals like SMHS would wear a deserted look.

That said, I would not like to call it an overburden of work. Simply because this is our job and we are being paid for it. Additionally, seeing our patients and their kith and kin appreciating us for our services to them gives us immense pleasure. I was recently at a grocery shop in the city and I was surprised when the manager of the shop informed me that someone had paid for me. Then the person who had made payment for the things I had bought told me that I had treated his mother during the pandemic in the hospital. It is not a matter of few bucks, rather it shows the deep gratitude and appreciation from our patients and their families. And this is something much greater than monetary gains. I can show you my phone has hundreds of appreciating messages from my patients on it. This gratitude from the people gives us the strength to go on serving the help-seekers. Also, it helps us to cope with the negativity of burnout.

I agree that we have an overwhelming amount of patient inflow in Kashmir, but I don’t think we lack the infrastructure or manpower of professionals here, which was the case some two decades ago. You can google to find out the in the year 2000 a magazine published a story under the heading “Only 2-3 psychiatrists available for whole J&K”. And it was a reflection of the true state of affairs at that time.  But we have improved a lot over the years. Now we have a psychiatrist available in every district. Some districts have more than one; for example, Anantnag has five psychiatrists available. We have already as many as 70 psychiatrists in the Valley and every year they are added with eight more. We have also produced an ample number of clinical psychologists who graduated from INMHAS during the past five years.  And, this is not the case with other states of India. We also have District Mental Health programmes running in all districts.

That said, I would say that there is always a possibility of improvement. For example, we should have admitting facilities in every district, so that burden on our tertiary-care hospitals is reduced. We also need to equally distribute the counsellors across the Valley because most of them are deployed in tertiary-care hospitals.

Finally, talking about the mental health professionals in Kashmir, I think all of them are doing well to serve the people, and the same time, they manage to take care of their own physical and mental health. As far as my personal situation is concerned, my greatest source of self-care during the past 20 years has been my learning that I always need to be part of the solution and not the problem. Usually, most stressed people are those who become part of the problem and not part of the solution. I have started in a situation when we did not have even a chair to sit on in mental health centers in many rural areas. I am sure that we will continue to build infrastructure and manpower in the mental health sector in the coming days and years.

Prof (Dr) Yasir Hassan Rather
Department of Psychiatry, IMHANS, GMC, Srinagar

Mental health issues are rising in Kashmir. Covid-19 pandemic has affected mental health and varied aspects of life. The pandemic has led to emotional burnout in people.

In my practice these days, I often come across patients whose illness either started during the pandemic or because of the pandemic or got aggravated because of it. I would say as a mental health professional when you witness more patients than your acceptable capacity, it causes phases of burnout sometimes, but this is a difficult situation and we have to develop positive coping mechanisms to deal with our personal burnouts.

I have a hectic schedule, and the majority of my time goes with my work. However, I try to at least have one physical activity a day, mostly in the morning. I either go cycling or for a walk. And when I come back, I try to qualitatively spend time with my family. I engage in playful activities with my kin.

As far as the doctor-population ratio is concerned, the situation in Kashmir is not ideal but still better if you compare it with other states of India. We have a psychiatrist available in most district hospitals and we also have District Mental Health programme running in some of the District hospitals.

We are trying to create as many services as possible, we are trying to create a unified system where IMHANS ties up with different stakeholders — be it government departments, NGOs and other mental health setups to stay connected, create a better mental health network for people. I would say that we are trying to do more than our capacity.

Finally, I would say that in this situation where there is a surge of mental health situations and a lot of environmental factors that are detrimental for mental health, those people who are at the helm of affairs should be more open to mental health projects, where resources will be available for people. We have IMHANS-K in Srinagar, the only hospital for psychiatric services. More support should be provided to this institution so that we can create more manpower and better facilities for the patients.

Wasim Kakroo
Child and adolescent mental health therapist, CGWC, Institute of Mental Health and Neuro-Sciences

Workload beyond a certain limit always impacts the physical and mental health of a human-being, particularly if it is a matter of routine for him or her. As far as the mental health providers are concerned, they, in addition, have a burden to hear out the ordeals of the patients. Every day we have to listen from our patients the stories of suffering and torment; some of them very disturbing. Hearing our patients keenly and thoroughly is the first requirement of our professional responsibility. As clinical psychologists, we are supposed to develop enough empathy to be able to connect with our patients, and in order to have some positive effects on their minds.

Sadly, the pandemic has caused the rise in patients with various kinds of mental illnesses. So there is no denying the fact that this situation has increased pressure on mental health providers. We have to take online sessions with some patients as well, which was not the case before Covid started.

If I cite my personal experience, I would say that I am for about 12 hours seeing my patients in the hospital and at my clinic. Once a client asked me how I was able to take care of my own mental health while hearing so many trauma stories from patients every day. I responded by saying that I take care of my mental health by studying more and more about the trauma. And that is a fact. I study a lot and it helps me to take care of myself. Because when you understand more about trauma than you will have less impact of trauma on you.

Secondly, we professionals talk to each other about our patients to get ourselves de-stressed. Then we spend qualitative time with our family. These are our coping mechanisms to ensure our mental health is not harmed due to the nature of our job.

That said, I have to acknowledge the fact that in given circumstance there is a lot of pressure on mental health professional, particularly the mental health providers. Even before the pandemic, we had already a large number of people grappling with mental health issues in Kashmir. The pandemic has worsened the situation. This part of the land is vulnerable to psychosocial variables because of so many factors. In fact, Kashmir is a live laboratory of mental health issues.

But, unfortunately, we do not have sufficient professional manpower available to deal with the given situation. We lack manpower in the mental health field in Kashmir. For an example, there are as many as 12 positions for clinical psychologists available in the Government Medical College in Srinagar. Of them, only four are filled. They too are working on a contractual basis. We should have at least 2-3 registered clinical psychologists available at every district hospital for help-seekers.

If we have sufficient infrastructure and manpower available in all districts then there will be no unnecessary load on the tertiary-care hospitals, and also we will be able to ensure a strong referral system is in place. With a strong infrastructure and manpower, most of the patients can be dealt with at their native places.

For example, we are grappling with addiction problems on a large scale in Kashmir. This is a part of mental health issues and we should be able to deal with these cases at the local level. Tertiary-care hospitals should be only for patients who are battling grave mental health issues. Now, since the authorities have started focusing on district-level training programmes, I am sure such initiatives will be fruitful.


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