By Mujtaba Hussain and Jitamanyu Sahoo*
The rising global burden of violence due to armed conflicts is increasingly recognised as a key to the rise of stress and anxieties of the population. Moreover, constant infliction of violence by the State has a direct association with mental health problems. Another, disturbing aspect of the conflict-related violence is the large-scale forced migrants externally displaced (across national boundaries) and internally displaced (within national borders) placing the forced migrants at a greater risk of developing mental disorders.
According to researchers working in conflict zones, there is still a serious dearth of systematic empirical information about the mental health status of the population. There is a need to broaden the evidence in conflict zones to examine all psychosocial dimensions of mental health. There are serious gaps in the research policies and State practices adopted in assessing the trauma, suffering and social functioning of an individual in the conflict zone. Moreover, the impact of resilience on the mental health of population in the conflict zones also needs to be assessed.
Survey of 2015
In 2015, Kashmir Mental Health Survey was conducted by Médecins Sans Frontières in collaboration with Institute of Mental Health and Neurosciences, Kashmir and Kashmir University in all districts of Kashmir Valley, emphasizing on the prevalent disorders like depression, anxiety disorders, and posttraumatic stress disorder (PTSD). The findings of the survey asserted glaring mental health situation in the valley, with mental disorders and distress reaching epidemic levels. With 37 percent of adult males and 50 percent of females suffering from probable depression; 21 percent of males and 36 percent of females from a probable anxiety related disorder and 18 percent men and 22 percent women suffering from probable PTSD the survey exposed the burden of mental health problems in Kashmir.
The Survey of 2015 revealed more disquieting and discomforting results. Around 1.8 million (45 percent) adults in the Kashmir Valley have significant symptoms of mental distress. Nearly 1.6 million adults (41 percent) in the valley are living with significant symptoms of depression, with 415,000 (10 percent) meeting all the diagnostic criteria for severe depression. Approximately 1 million adults (26 percent) in the valley are living with significant symptoms of an anxiety related disorder. The districts of Badgam and Baramulla reported the exorbitant rates of symptoms for all three mental disorders.
The Survey also revealed high rates of co-morbidity in the Kashmiri adult population, with nearly 90 percent of individuals identified as a probable case for PTSD and 88 percent of those identified as having a probable anxiety disorder, also screening positive for depression. Only 0.3% of Kashmiri adults have not experienced a traumatic event during their lifetime. The most frequently reported traumatic episodes mentioned were difficulty in experiencing, expressing and describing emotional responses, conflict-related crackdowns, raids and frisking.
The survey of 2015 provided, for the first time, an insight into the level of mental distress in all ten districts of Kashmir Valley. This evidence based approach indicated a relationship between traumatic events experienced and the symptoms of depression, anxiety and PTSD in Kashmir. The evidence based study also draws us to the fact that such interventions in conflict zones remain nascent.
However, in 1999, the National Mental Health Plan (NMHP) was initiated by the Indian Government with the intention of rolling out community-based mental health services in all Indian states. The programme commenced in Jammu and Kashmir in 2004-2005. Alongside the NMHP, each district developed its own mental health plans – District Mental Health Plan (DMHP) – which reflected the national goals and principles but is tailored to the local context. However, DMHP is barely functional and the Government of India pledged to ‘offer insights as well as pathways for change’ needs renewed commitment.
The Demographics of Mental Stress
The most distressing lifetime trauma related to violence is witnessing violence to another person, the death or disappearance of close relatives, living in a combat zone, and forced displacement. In relation to injury, frightening medical treatments and absence of adequate medical care are some of the reasons associated with significant rise of mental health problems in Kashmir. We are witnessing a changing narrative of how violence has destabilized the state of mental health in our valley.
The obstinacy of injustice related to the unbroken chain of human rights violations might be an important factor leading to mental disorders in Kashmir. The commonality of human rights traumas leading to a mounting sense of injustice because most of the perpetrators have not been brought to account have affected the state of mental health in Kashmir. Moreover, structured state interventions in curtailing the human rights and the impunity enjoyed by the officials add to the accumulated trauma.
Rise of Resilience
Resilience refers to good mental health and developmental outcomes, despite exposure to significant adversity. It has been established that many of those who experience conflict-driven, often highly-traumatic state do not develop mental disorders despite being at-risk. Individual resilience has been described as the ability of a person to successfully adapt to or recover from stressful and traumatic experiences. Factors such as individual and/or community resilience and social support have been highlighted as key potential mediators between conflicts and subsequent mental health impact.
Kashmiri resilience is conceptualised today as a construct of her/his social environments which is permeating with everyday violence. Kashmiris are altering their social process and paving way for the rise of resilience. Individual to community resilience is seen as the collective ability to adapt and recover from the adversity of imposed violence in the valley. What such resilience does it significantly contributes in providing protective measures and enhancing the mental health outcomes in the valley.
Response to the Mental Stress
Perhaps unsurprisingly, the evidence suggests that the prevalent of conflict has a powerful negative effect on the mental health of people in the valley. Despite the fact that the profile of the conflict in Kashmir would suggest a heavy toll on the mental health of the population, surprisingly little systematic work has aimed to characterise and quantify the impact on the population.
There is a need for a) Convergence of National Mental Health Programme/ District Mental Health Programme under National Rural Health Mission Programme and using existing PHCs and sub centres to provide mental health services; b) Capacity building of Rural/registered Medical Practitioners/Primary Health care doctors/ASHA workers/ teachers/Aanganwadi workers on tailor made modules; c) Advocacy through community,
social and other bodies and involvement of religious leaders, teachers, local community leaders with key stakeholders; d) Targeted awareness programme using available rural media; d) Provisioning social security to the mentally ill patients; f) Research in the areas of suicide and substance use, in addition to child and adolescent mental health and e) Training for caregivers and relatives. There is a need for greater push to advance the prevention and care of mental illnesses and the promotion of mental health.
*Human rights activists, currently studying the changing socio-political contexts of Jammu & Kashmir