Abstract
The emergence of the COVID 19 pandemic has made the need to focus on mental health more evident than ever before. The increased levels of anxiety and fear associated with the virus has not only exacerbated mental health issues amongst people but also exposed the associated lack of awareness and resources when it comes to these illnesses. Even though this is a global challenge, the situation in India is dire.
With a young population and an extremely competitive job market, According to the World Health Organisation’s list of countries with the greatest burden of disease for mental and behavioral disorders, in 2018, India ranked 2nd amongst the most depressed countries in the world, placing second in Depression and Anxiety-related disorders, and third in Alcohol and drug use. It is thus crucial to look at the gaps which exist currently in the level of awareness as well as the redressal mechanisms in place to come up with lasting solutions for this ever growing issue. This paper attempts to understand the perception, awareness, and access to mental health and wellness among the Generation-Z and Millennial Population in urban India and provide useful recommendations.
1. What is Mental Health?
The World Health Organization (WHO) defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” . While mental health is a term used to describe either a level of cognitive or emotional well-being or an absence of a mental disorder, a mental disorder or mental illness is an involuntary psychological or behavioral pattern that occurs in an individual and is thought to cause distress or disability that is not expected as part of normal development or culture.
1 in 4 Indians is likely to have a mental health issue in our lifetime. 150 million Indians were in need of active interventions for mental health issues (one or more), but less than 30 million of them sought care.
2. Spectrum of Mental Health Challenges
It is harder to isolate and look out for mental health challenges because of the lack of awareness about signs and symptoms to look out for and the stigma associated with it. It is important to understand that symptoms and severity of mental health challenges can be varied and present differently in different individuals.
According to ‘Bridge the Care Gap’ India, “mental health as a spectrum, ranging from well-being to a common or severe mental health disorder. Mental health is important at every stage of life, from childhood through adulthood. Mental health can deeply affect daily life, relationships and physical health too”. Figure 1 describes the different conflicts and the mental health syndromes associated with it.
Fig.1 Source: Bridge The Care Gap Campaign, India
For the purpose of this paper, we have focused on the most commonly present mental health disorders among our target group, found to be anxiety, depression, eating disorders and body dysmorphia.
Fig 2. Common noticeable symptoms for anxiety, depression, eating disorders (like bulimia and anorexia) and body dysmorphia (Mayo Clinic)
2.1. ANXIETY
Anxiety is the response of our body to a perceived threat triggered by an individual’s beliefs, feelings, and thoughts. It is characterized by worried thoughts, tension, increased blood pressure, respiratory rate, pulse rate, swdgt mneating, difficulty of swallowing, dizziness, and chest pain.
2.2. DEPRESSION
Depression affects the way a person feels, thinks and acts. It is known to cause feelings of sadness and loss of interest in activities one once enjoyed. It can lead to a variety of emotional and physical problems and can decrease one's ability to function at work and at home.
2.3. EATING DISORDERS
Eating disorders are conditions related to persistent eating behaviors that negatively impact a person's health, emotions and ability to function in important areas of life. The most common eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder.
2.4. BODY DYSMORPHIA
Body dysmorphic disorder is a mental health disorder in which a person can't stop thinking about one or more perceived defects or flaws in your appearance. The flaw usually appears minor or absent to family and friends. People with body dysmorphia feel embarrassed, ashamed and anxious and avoid many social situations.
3. Mental Health: In Gen Zs and Millennials
“In a global primary survey conducted by Deloitte, a staggering 48% of Gen Zs, and 44% of millennials said that they feel anxious or stressed all or most of the time.”
Young people, especially Gen Zs and Millennials, face uncomfortably high levels of tension and unhappiness which are likely to be byproducts of uneasiness and pessimism, arising from various concerns that constantly surround them. In fact, 75% of all adult mental disorders begin before the age of 24 years.
We conducted a survey in the month of June 2021, to understand the awareness around mental health, and the prevalence, awareness and accessibility around mental health concerns amongst young people in India. The sample size of the population was 104, and a pre-tested questionnaire was administered to the respondents.
They belonged to the Generation-Z and Millennial Population, from urban Indian cities, predominantly aged 17-21 (41%) and 22-30 (59%), and 99% have attended at least college or vocational school. Most of the respondents were students (30%) or employed (70%).
3.1. Scale Of Issue
As per the National Mental Health Survey 2015-16, conducted by the National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru, under the purview of the Union Ministry of Health and Family Welfare, it was revealed that 9.8 million teenagers in the age group 13-17 years suffer depression and other mental health disorders and are “in need of active intervention”.
According to our primary research, stress has been experienced by nearly 83% Indian Gen Zs and Millennials, followed by anxiety (66.3%), body-image issues and associated concerns (44%) and depression (43%).
Fig.3 Source: Primary Research Survey
In fact, the individual challenges and personal sources of anxiety that Gen Zs are facing are on the rise. “In 2019, a survey by the Statista Research Department found that 71% of the youth respondents across India in 2019 agreed that young people suffered more health and mental issues than before.”
Even from an economic perspective, millennials and Gen Zs together account for most of the global workforce, and an incidence in their mental health issues presents a significant challenge for employers around the world. In 2016, a study published in The Lancet projected that in the world’s 36 largest countries, more than 12 billion days of lost productivity were attributable to depression and anxiety disorders every year at an estimated cost of US$925 billion— a figure that’s surely on the rise. Additionally, the WHO also estimates that, in India, the economic loss, due to mental health conditions, between 2012-2030, is 1.03 trillion of 2010 dollars; considering that a significantly large proportion of people facing these problems are young, their mental health concerns pose a glaring problem for the economy as well.
3.2. Key Drivers of Mental Health Concerns in the Generation-Z and Millennial Population
3.2.1. Career Prospects and Education
Our primary research found that almost 71% of the millennials and gen-zs experienced some form of stress, anxiety, or depression due to future job and career prospects making it the most cause for mental health concerns, trailed by education-related fears and problems within educational institutions, that were ascribed to as a cause by around 57% of the respondents.
In fact, around 78% of millennials and Gen Zs described their schools, colleges, or educational institutions as competitive, and that school environments had a bearing on their mental health. In this context, around 70% of these respondents said that they faced the pressure of appearing for competitive exams to get into top colleges and business schools.
Research shows that for many young adults, educational institutions may serve as potential spaces for emancipation and growth, especially for those who come from vulnerable backgrounds. Thus, it is critical for educational institutions to understand and prioritise the mental health needs of students.
In this context, lay counsellors have also been known to be used effectively in colleges and educational institutions with young adults to work on not just handling exam and career- related pressures but also navigate issues like bullying, violence, depressive symptoms, attitudes towards gender equity, and knowledge of reproductive and sexual health.
3.2.2. Poor Work-Life Balance
In India, approximately 3 in 4 millennials and Gen Zs felt that stress is a legitimate reason to take time off work, much higher than the global average. (Deloitte: 2020)
Furthermore, according to our primary research study, around 59% of the respondents said that their educational institution or place of work did not provide or recognise any breaks taken due to mental health concerns; while a little over 82% of them felt that companies and educational institutions should be legally required to provide a bare minimum number of mental health days every year.
During the pandemic, in India, more than three-quarters (77%) of millennials surveyed said stress is a legitimate reason to miss work, and people in India were most likely to take off work for that reason during the preceding 12 months (Deloitte: 2020). 61% of Indians are experiencing mental health-related issues during the lockdown: Gen-Z and millennials have been impacted the most with 27 % of Gen-Z and 19 % of millennials expressing that the crisis has taken a significant toll on their mental health.
About 93% of the respondents to our survey said that mental health had a significant impact on their productivity levels at work, which must serve as a reminder for all employer organisations to recognize the mental health needs and expectations of their employees and to empower their employees to be able to raise mental health concerns with their superiors.
About 3 in 4 large employers and half of small employers offer at least one mental health resource to complement their health care benefits. Furthermore, even when mental health resources are available, many employees are not aware of them.
Employee mental health and concerns need to become a priority for employers and employees must be able to raise any concerns around their mental health without the fear of stigma. Framing policies around mental health-related leaves to support their employees is one such example. The process to reform mental health access in an organisation is influenced by structural factors, including the support provided by coworkers, supervisors, teams, and institutions.
3.2.3. Social Media and Technology
Social media and technology are generally perceived to be a leading cause of mental health concerns like anxiety and depression among young individuals. This hypothesis was validated by our survey, which found social media to be the third most common cause for any stress, anxiety or depression experienced by the target group, only after career prospects (71%) and education-related factors (57%).
The need to feel validated on social media, especially when it comes to working relationships and professional accomplishments, is very prevalent among the members of the Gen-Z and millennial population. The digitisation of CVs and going to the world wide web for everything, has inadvertently put young people at the risk of feeling inadequate and surrounding them with the habitual need to constantly compare and contrast their achievements with those around them.
3.2.4. Body Image Issues
The primary survey conducted for the purpose of this paper found that women are disproportionately impacted by body image issues and associated disorders. While 40% of the female respondents said that they faced body image issues, the figure was 30% among the male respondents.
According to a survey conducted by Fortis Healthcare, in order to gain an insight into the attitudes and perceptions of women towards the concept of body image, as well as the impact that body shaming has on their psychological well-being and at times leading to stress, 47.5% women reported having experienced body shaming at their school or work place.
In fact, 62% women reported having felt anxious and nervous when people have commented on their looks and physical appearance and 67% women also reported feeling angry because of body shaming. More importantly, 97% women believed that the issue of body shaming needs to be addressed in educational institutions and their workplace. This implies that there is an essential need for employers as well as college administrations to consistently maintain a stronger stance and stricter policies against body shaming. Employers also need to adopt and push for body positivity campaigns, and implement them more realistically.
3.2.5. Climate change and Social Issues
Almost half (50%) of the respondents in Deloitte’s primary survey said they believe it’s too late to repair the damage caused by climate change. The causes for stress among these younger generations are varied. Many of the young respondents are frustrated and want access to a better and kinder world. Their only hope and optimism lies in the fact that some individuals take personal ownership and action over solving climate health and environmental challenges.
When all primary survey participants were asked, “There are many challenges facing societies around the world; which of the following are you personally concerned about?” all 20 potential concerns were selected by more than 60% of millennials as personal concerns. When required to narrow down their top concerns from the same list to just three, millennials and Gen Zs were troubled the most with climate change/protecting the environment.
According to the annual survey by Deloitte, at least 1 in 5 respondents globally said they feel personally discriminated against “all of the time” or frequently because of an aspect of their backgrounds. While India has made some progress, such systemic discrimination is still deeply rooted in society, and significantly impacts the mental health of young individuals, especially those belonging to vulnerable groups.
3.2.6. Lack of Financial stability
Our primary survey found that nearly 32% of millennials and Gen-Zs ascribed financial issues and barriers, as a cause for their mental unwellness. Furthermore, Millennials and Gen Zs in India were more stressed about their general financial situation than their counterparts among global respondents, a Deloitte survey said.
A number of studies have demonstrated a cyclical link between financial worries and mental health problems such as depression, anxiety, and substance abuse. Financial problems adversely impact your mental health. The stress of student debt or other financial issues leaves young individuals feeling depressed or anxious. When compounded with high levels of insecure employment, part-time working, lower-paying occupations and increasing house prices, this becomes a leading cause for mental health.
4. Young Women and Mental Health
The patterns concerning mental health and mental unwellness among women are different from those seen in men. More importantly, according to an article published by the Indian Journal of Psychiatry, gender differences occur particularly in the rates of common mental disorders wherein women predominate like anxiety and depression. Women's health within the policy domain is often restricted to the discourse around their reproductive health, but often ignores women's needs for information about, and control over, reproductive processes. There are many systemic factors that disproportionately impact women’s mental health, with some glaring effects seen among Gen-Z and Millennial women.
According to a study by the Lancet, suicide deaths ranked first among all causes of death in women aged 15-29 years in 26 of the 31 states, and in women aged 15-39 years in 24 states in the country, projecting upon the excessive burden that mental health problems exert specifically on women.
Some of the largest barriers are increased strains on mental health — particularly increased levels of anxiety, stress, and grief. In fact, even during the pandemic, young women have been critically impacted with about 42% of female respondents between the ages of 18 and 25 years of age stating that their well-being was strongly affected at that time, according to a survey by Statista Research Department.
Key Insights:
● In the Indian context, it is not surprising that safety proved to be a leading factor in generating mental health concerns among women.
● According to our research study, over 40% of women agreed to having faced additional stress and pressure to prove themselves at their college/workplace as a direct result of their gender. In fact, millennial and Gen-Z women were significantly less likely than their male counterparts to tell their employers when they take a stress-related leave. This also shows why most women believed that the barriers in access to opportunities, was a major cause for their mental health concerns.
● Body image issues affect women disproportionately, followed by other causes including reproductive health and household responsibilities.
5. Government Policies, Interventions and Mental Health Resources
5.1. Overview of the current policy landscape
● The severity of the mental health wellbeing of Indians as compared to citizens of other lower middle-income countries (LMICs) is much greater, with suicide mortality rate (per 100,000), 16.3 and the disease burden measure, disability - adjusted life years (per 100,000), 2,443.41.
● The country also has a void with respect to the human resources available to take control of the situation. Multiple other LMICs harbour a better human resource structure to deal with the rising number of persons with mental illness. WHO Mental Health Atlas 2017, estimates India to have 1.93 total mental health workers (per 100,000 population) and approximately 0.3 Psychiatrists (per 100,000). Albeit, the desirable number is anywhere close to 3 psychiatrists per 100,000.
● As estimated by researchers from MIMHNS, there are 9000 and counting number of psychiatrists and our country falls short of 27,000 doctors, which is a deficit, requiring a long time to fill. Long term goal to sustainably solve the problem would definitely have to include steps to increase specialised health workers.
● Govt. of India has allocated close to INR 600 Cr under the Union Budget 2021-2022, for mental health programs and institutes, however a 90% of it has been allocated to institutes and the remaining amount will financially support National Mental Health Program, which has been working towards increasing access of psychiatry aspect of mental health services, including medicines.
● The National Mental Health Program has covered just one third number of districts in the country (241 out of 718 districts) and with the current resource allocation, it is difficult to look forward to a financially accelerated increase in availability of basic mental health resources.
● The District Mental Health Program (DMHP) was launched under NMHP in 1996. The program includes, early detection and treatment, imparting short term training to general physicians, public awareness generation and better record keeping.
● Coverage of DMHP still remains low- In NMHS states, the numbers are low. Only 1/3rd of the surveyed states had more than 50% of the population covered by the DMHP. Though there has been an improvement since 2012, the reach is still limited.
Fig.4 Mental Health Resources in LMICs
Fig.5 DALY(Disability-Adjusted Life Years in LMICs)
Fig.6 Suicide mortality in LMICs
5.2. Gaps Identified In The Mental Health Policies Currently In Place
5.2.1.Mental Health Programmes & Initiatives in India are a low priority on the public health agenda-
In a majority of the surveyed states, mental health programmes and activities were fragmented and had a low priority during implementation. It is important for all states to have a policy as seen in other health and non-health programmes as it sets a vision, mission and direction for future activities.
The National Mental Health Survey conducted in 2015-2016 found that state budgets allocated less than 1% towards mental health. Most states did not even have separate budget health for mental health, making it impossible to decipher if any money was spent at all.
5.2.2. Need for a multi-pronged approach
A large number of private health care institutions and professionals were available in general and specialised care; however, their numbers, quality and activities are unclear and the role they could play is yet to be delineated. Practitioners also say that the government urgently needs to set up bodies that recognise NGOs and community level organisations working in the mental health space and perhaps look at funding them so that they can continue their work.
Limitations faced by MHNGOs(mental health non govt organization) primarily are-sustainability, accountability and scope. Possible solutions include-
Clear planning and execution models need to be prepared for all associated NGO’s to avoid duplicacy of work. These volunteers should work hand in hand with the officials of NMHP , Government and psychiatric stakeholder representation. These can take up roles of workforce building and monitoring rights.
NGOs developing specific community based services including day care centers and residential facilities for disabled patients, help lines for distressed & suicidal patients, facilitating user and family support groups and assisting with livelihoods and employment generation and so on.
NGO deployment should become necessary for psychiatric training for doctors and nurses whose current training programs are mainly hospital based, thereby missing out on the entire range of community-based and PSR experiences.
5.2.3. Importance of non-specialist professionals in mental health care delivery-
With grass root level health functionaries like ASHA / USHA, ANM and health workers contributing significantly to the workforce density, there is a need to involve them in mental health programmes through the development of skill enhancing programmes.
For the non-specialists professionals, the Atmiyata approach that was introduced in the state of Maharashtra, is a distinct approach from the health sector approach but complementary, as it is a community led innovation for the detection, support and referral for persons with common and severe mental disorders. This created an impact by allowing 14000 population screened with 7,600 reach of the programme.1350 people with mental health issues helped with mental health care and 1350 people helped with social benefit. There was a 27.5% reduction in the proportion of cases. 80% improved wellbeing outcome after intervention.
5.2.4. Maintenance of mental health service records-
The data regarding the number of registered mental health professionals in the country including psychiatrists working in government and private sectors is not maintained centrally. With a view to augment the availability of qualified manpower in the field of mental health, the government, under the National Mental Health Programme, is implementing manpower development schemes for establishment of centres of excellence and strengthening/ establishment of post-graduate departments in mental health specialties.
Such lack of data exists despite the Mental Health Act of 2017, setting down provisions for a central authority to “ maintain a national register of clinical psychologists, mental health nurses and psychiatric social workers based on information provided by all state authorities of persons registered to work as mental health professionals for the purpose of this act and publish the list (including online on the internet) of such registered mental health professionals.
5.2.4. Financing needs to be modernized and streamlined-
In 2021-2022, only seven percent of the mental health budget has been allocated for the NMHP; while a majority of it has been set aside for two institutions: Rs 500 crore for Bengaluru based National Institute of Mental Health and Sciences (NIMHANS) and Rs 57 crore for Lokpriya Gopinath Bordoloi Regional Institute of Mental Health in Tezpur. The budgetary support for mental well being related activities lacked a dearth in activity specification, timely allocation and problems in even utilising the available budget amidst human resource constraints. Experts say that proposing only Rs 40 crore for NMHP will leave India unprepared and unable to deal with the requirements of the population, especially with the added mental health impact and fallouts of the COVID-19 pandemic.
In addition to this, allocating funds only to state recognized solutions to dealing with mental health problems gets recognition. Only practitioners subscribing to these state recognized practices will be attracted to this system thereby leaving the other solutions and practitioners under funded.
5.2.5. Quality Control implementation
Initiatives to monitor the quality of mental health care available through pre-existing programs is imperative. An example of this which currently exists is a project by the government of Gujarat that uses the WHO’s innovative QualityRights framework and Tool Kit to scale up innovative solutions to tackle interventions in mental health facilities. The project impacted 49,500 people with mental disorders per year who were exposed to the innovative service model and accessed better mental health services. People with mental disorders at the 6 intervention mental health facilities experienced a 20% reduction in disability and improvement in functioning by the end of the project.
5.2.6. Information, Education & Communication (IEC) based interventions to take frontfoot measures
As WHO pointed out, stigma prevailing in the community and the perceived stigma of persons affected with mental illness are greatest hindrances for the delay in treatment-seeking, treatment continuing and reintegration to the society. Persons affected with mental illness who are progressing toward recovery should have the feeling of hope, de-stigmatization, empowerment, self-acceptance, insight, awareness, collaboration with professionals, sense of autonomy and self-control. Stigma is an interruption for treatment seeking and recovery as well.
There were many attempts made by mental health professionals to reduce the social stigma against persons affected with mental illness (PAMI). Community based work-place education for community people, PAMIs and their caregivers found to be effective in reducing stigma related knowledge and attitudes of the participants. Anti-stigma education programmes for police personnel brought changes in their changing attitudes, mental health literacy and intentional behaviour. A systematic review stated that classroom based interventions are effective in correcting stigma related beliefs of children and adolescents.
6. Academic Institutions based mental health and justice program for youth in India
Priorities and preferences for academic institutions-based mental health services in India: a multi-stakeholder study with adolescents, parents, administration staff, and mental health providers. This includes:
● Evidence-based promotive, preventive, and therapeutic interventions;
● A stepped approach that organizes interventions according to different levels of need and resource constraints;
● Involvement of gate-keepers such as administration, parents, and teachers in the development and delivery of the interventions;
● Partnerships with local healthcare agencies for treatment of severe cases
● Role of passionate volunteers instead of just academic oriented staff
7. Current Methods for mental wellness
A person’s well-being is more than just a state of mind, it is a habit, it is the lifestyle. While it is possible for people in general to foster a strong mental well-being by following the commonly accepted routine that includes mindfulness, meditation, setting realistic goals, healthy diet, adequate sleep, exercise, quiet mind, valuing yourself, surrounding yourself with good people, gratitude, avoiding alcohol and drugs and breaking the monotony; people oftentimes need professional help to construct the way to their own mental well-being.
The most commonly practised professional techniques for mental well-being are:
i. Psychotherapy
ii. Medication
iii. Recreational Therapy
7.1. Psychotherapy
Often referred to as Talk Therapy, Psychotherapy - said to have been practised through the ages by medics, philosophers and spiritual practitioners - is the use of psychological techniques based on regular interaction in order to help a person change behaviour and overcome problems in desired ways. It is a healing relationship involving persuasion and rhetoric. Psychotherapy is a way to help people help themselves.
The American Psychological Association (APA) has adopted the following definition of psychotherapy: “Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable.”
Psychotherapy is used for a psychological illness as well as solving day to day problems.
7.1.1. Challenges of psychotherapy:
● Finding the right therapist is like ‘hit and miss’. A strong psychotherapeutic relationship is a must for progress.
● Psychotherapy is a paradoxical dichotomy since it is a professional relationship for the therapist, but extremely personal for the candidate.
● There is a possibility that the candidate will form emotional attachment with the therapist, and this can be harmful because at some point therapy ends and the therapist leaves.
● It is usually 50 minutes a week. Increasing sessions can be expensive.
● Sometimes, therapists can be just as crazy as the patients. Therapists are also in need of therapy.
● Sometimes people like therapists who speak their mother tongues.
● Feelings, fears, traumas, pains can be complex, and a candidate might not always find the right words and ways to convey them.
7.2. Medication
Medication is more of a way to cure mental illness rather than to enforce mental wellness.
Psychotropics include a broad category of drugs that treat a variety of classes and conditions. They work by adjusting levels of neurotransmitters, such as dopamine, gamma aminobutyric acid , norepinephrine, glutamate, and serotonin. The risk of a dangerous adverse reaction must be weighed over its benefits before use.
There are five major classes of legal psychotropic medications:
● Anti-anxiety agents
● Antidepressants
● Antipsychotics
● Mood Stabilisers
● Stimulants
7.2.1. Challenges of medication:
● Psychotropics can cause very serious side effects ranging from low blood pressure, dizziness, vomiting, weight gain, weight loss to tremors, muscle stiffness, muscle spasm, memory problems, increased possibility of diabetes and heart diseases.
● Some drugs can cause even more severe disorders. For example, Antidepressants can worsen suicidal thoughts and behavior in children and adolescents. SSRI antidepressants can cause sexual disorders.
● Many drugs cannot be taken by people with heart problems, diabetes, glaucoma, thyroid etc.
● Medication has special strict monitoring requirements by healthcare providers.
● Stimulant drugs may cause dependence and addiction.
● In order to achieve the best effect from medication for young people, thus supporting emotional wellbeing, it is important to consider different aspects of medication use that potentially enhance or undermine its benefits.
● The burden of illness and the efficacy of the medication must be balanced against the potential adverse effects and the burden of treatment.
7.3. Recreational Therapy
Words can be overwhelming. People tend to cling to words. People may not always find the right words. So, there can be better ways of expression - ways consisting of expressing oneself in something that already gravitates the person. It can be dance/movements, rhythm/music, visual art, drama, yoga, meditation, sports. Words are restrictive, medication is inhibitive. Art is free, art is liberating. With art, people can let go. Though recreational therapy can be used systematically for mental illness, even a person without any mental illness can employ such recreational aspects for better mental health. Recreational therapies overcome most of the challenges of psychotherapy and medication.
According to the American Therapeutic Recreation Association (ATRA), recreational therapy or therapeutic recreation (TR) is a systematic process that utilizes recreation (leisure) and other activities as interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, as a means to psychological and physical health, recovery and well-being.[1] Recreational therapy may also be simply referred to as recreation therapy, in short it is the utilization and enhancement of leisure.
Recreational therapy can take place in a variety of settings such as schools, colleges, hospitals, company offices, nursing facilities, sporting programmes, community centres, assisted living facilities, community centres, substance use programmes, mental health facilities etc.
Recreational Therapy creates interest, increases self-esteem, strengthens social connections, positive improvement by endorphin, boosts cognitive ability, increases strength and physical fitness (if sports, yoga are practised) and relieves anxiety.
8. Alternative Interventions To Work On One’s Mental Wellbeing
Professional services provided by psychiatrists and psychologists, in the form of counselling, therapies and medical intervention, support people diagnosed with mental illness and provide emotional assistance. Physical counselling and visits through a brick-and-mortar model are present moderately around in urban areas, although COVID-19 have increased hurdles for accessing such services due to constraint on movement and meeting in closed spaces.
Other interventions which a person struggling with mental wellness can utilize include, telehealth services, emotional support applications and software, peer support groups and helplines and government initiatives.
Fig 7. Source: Internal Analysis
8.1. Telehealth based services:
● Function: connecting professionals including counsellors or doctors to the patients virtually. These platforms offer services directly to consumers, in forms of single or multiple sessions, along with predetermined models pertaining to the problem the user is facing, including depression, anxiety, relationship troubles, financial crisis etc.
● Benefit: Users can go through the profiles of professionals in partnership with the firm and can book a session with them. Users do get the flexibility to choose language in which they would like to obtain the service. Ease of connecting with a professional at a relatively cheaper price, complemented with the flexibility to connect with a professional with no geographical restrictions.
● Headroom for improvement: However, the platforms do have the potential to scale up and partner with more professionals to provide users with an expanded set of alternatives with respect to language, as currently the number of professionals is limited, offering a limited set of polyglot professionals.
8.2. Emotional support applications and software
● Function: focus towards empowering individuals by assisting them with enhanced mental wellbeing. They give access to guided therapies and methods for meditation, soporific sound effects and distracting activities, helping individuals deal with stress and anxiety.
● Benefit: Users gain self control over their mental wellbeing, with steps that can be taken at individual level to work regularly over improving one's situation.
● Headroom for improvement: Primary research survey indicated users do not find these alternatives extremely effective, on a scale of 1 to 5, the interventions received 2 and 3. It was also indicated that users did not find solutions effective and hence didn't use them for long term. Feedback on user experience could give insights.
8.3. Peer support groups
● Function: offer safe space for people to openly discuss their issues with similar age groups. The portals provide an outlet for people to seek emotional support from strangers.
● Benefit: Such community-based initiatives can further push access to mental health, by leveraging peer support and trained supervisors, as indicated a better user experience and effectiveness with a score 3, as compared to mental wellbeing applications.
8.4. Government Interventions
Government Interventions are psychiatry focused but also newly launched kiran, Mental Health Rehabilitation Helpline launched by govt. in September 2020, is one step further increasing access to mental health services pan India. The service connects professionals and patients over phone, it is accessible 24*7 and in 13 languages. Awareness and trust on these affordable and free services are low among the generation Z and urban cohort.
Mental health solutions in the sector are picking up pace as well and multifold increases in customer base have been reported by companies in the segment post pandemic. Investors have financially backed multiple such home-grown organisations, recently Now&Me raised USD 1 million seed funding. The gap between the human resources can however be brought down with use of the above mentioned telehealth based interventions, emotional support groups and services provided leveraging technology.
9. User Experience Based Issues
The regulatory requirements and guidelines are conducive for such applications however, barriers at consumer end have been inferred from primary research.- Lack of confidence in the professionals, low awareness among consumers - regarding available alternatives, stigma/ apprehension towards mental health and affordability of these interventions.
Individuals expressed opinions regarding not having confidence in the professionals in order to feel comfortable opening up to them. Awareness among the consumers regarding these alternatives is low and has potential to further expand. Nearly 64% of our primary research cohort indicated not using any external mental health services from various providers, while only 20% had utilised face-to-face therapy sessions, less than 10% had accessed any kind of digital intervention, including telehealth solutions, emotional support applications or virtual support groups. Around half of the cohort depends on self-coping mechanisms, however 44% people expressed need of external help to deal with stress or anxiety, when given an option 30% people expressed comfort seeking help from a therapist. Primary research also indicated that people do not find currently available solutions much effective hence, providing a headroom to transform these solutions to provide better care.
Fig 8. Insights from Primary Research Survey
10. Recommendations
Few employees today feel comfortable sharing their mental health concerns with their superiors. Many people believe mental health remains stigmatized in the workplace, but it also means that employers are probably underestimating the impact of poor mental health on their productivity because they lack an accurate picture of the problem. Employee mental health must become a priority for employers, and employers must make an effort to regularly understand the mental health concerns specific to their employees and devise organisation-wide plans based on their learnings. It is also important for supervisors and team leaders in teams to regularly check-up on their team members and make sure they are doing well.
Companies and educational institutions should have an on-site and/or on-call therapist mandatorily to better understand the mental health care needs of employees and students respectively and to conduct awareness sessions periodically to help them better understand and detect the signs of mental health challenges.
With the rising discourse about mental health, corporates and companies need to reevaluate their stance on issues like body shaming and existence of conventional beauty norms, since they directly impact the mental health of many Gen Zs and millennials. Thus there is a need for them to actively oppose campaigns and media portrayals that create unfair expectations on young individuals and to support campaigns that are making an attempt to empower young individuals with narratives around body positivity.
Mental Health service providers can work on raising awareness regarding easy accessibility and effectiveness of solutions like therapy and help in reducing stigma surrounding the subject through campaigns.
Government based programs including Kiran and esanjeevani, teleconsultation services are free of cost, however do not enjoy significant awareness among the young urban population. Teleconsultation services offer confidentiality and a way to escape judgmental attitude surrounding seeking psychiatric help. Hence, by raising awareness about such interventions can help the population facing the affordability barrier.
Inclusion of professionals speaking local languages on multiple internet and tele-platforms - Offering flexibility along with ease for patients. Currently the number of professionals on online counselling platforms are low and service can further be augmented by inclusion of professionals comfortable in multiple languages.
Community based programs dedicated for a younger cohort, at district and community level can be helpful, as espoused by multiple professionals in secondary research. Primary research points towards the confidence people have on friends and family members and higher comfort while seeking support, which can be utilized in community based monitored and guided programs carried by non-specialist professionals.
In the long term, the NMHP along with the DMHP needs radical strengthening through addition of resources, mental health professionals and some basic codified norms followed across states. The funding needs to be streamlined with tough mechanisms for efficient executions. A frameworkwith definable and actionable processes should be put to place at national, state and district levels. Further, the NGOs, the education sector, civil society organisations and other private sector interventions are required at the community level.
A research wing concerning mental health issues should be set up with timely finance and logistics available for the correct understanding of the needs and requirements of different groups and communities. Researchers have, for long, advocated for an umbrella administrative body to monitor and undertake mental health initiatives in the country.
International benchmarking and gaining insights from policies which have been implemented in other developing nations - Luxembourg has been rated highly for its mental wellness system. The country executes the Positive Education Model, bridging the gap between academic skills and mental wellness skills for achievements among the school going population. The model entrenches self-motivation, happiness and optimism among the students.
Trials conducted testing these principles on middle school students showed optimistic results, where in, at the start of study, 25% of cohort undergoing this model showed moderate to severe symptoms of depression as compared to 23% of the control group, after 2 years 22% of the preventive cohort showed symptoms, whereas 44% of the control group (World Government Summit - The State of Positive Education Report). In India, the model has been successful in lower income areas as well, CorStone, a nonprofit organisation, has deployed the model among young girls from slums, teaching positive psychology along with other health related topics. Girls First program is a data backed program, 33% increase in emotional resilience was observed in the trial conducted, indicating potential scalability of such community based programs even in low income areas.
Norway is another leading country with a comprehensive mental health care system. In Norway casualty clinic doctors are responsible for 38-63% of acute referrals to psychiatric wards. Norway has a strict two-tiered healthcare system. A patient cannot directly go to a hospital. General practitioners (GPs) serve as gatekeepers for all secondary care, including psychiatric specialist care. A patient can get voluntary or involuntary psychiatric care at a hospital through the referral of a GP. Norway has many Psychiatric Casualty Clinics that are staffed with GPs. This has equipped Norway with a systematic infrastructure. India can equip itself with such a system if it has sufficient numbers of colleges to train the required number of professionals and doctors.
Additionally, in 2017, Norway announced the trailblazing Medication Free Treatment, which is a system for psychiatric patients who do not want to take psychiatric medication, underlining the right of autonomy over oneself and the freedom of choice of treatment. This is a paradigm shift from the situation where once a hospital brands a person needing psychiatric medication that person entirely loses his say in it. It rethinks psychiatric care and the merits of medication.
Meet The Thought Leaders
Shatakshi Sharma has been a management consultant with BCG and is Co- Founder of Global Governance Initiative with national facilitation of award- Economic Times The Most Promising Women Leader Award, 2021 and Linkedin Top Voice, 2021.
Prior to graduate school at ISB, she was Strategic Advisor with the Government of India where she drove good governance initiatives. She was also felicitated with a National Young Achiever Award for Nation Building. She is a part time blogger on her famous series-MBA in 2 minutes.
Naman Shrivastava is the Co-Founder of Global Governance Initiative. He has previously worked as a Strategy Consultant in the Government of India and is working at the United Nations - Office of Internal Oversight Services. Naman is also a recipient of the prestigious Harry Ratliffe Memorial Prize - awarded by the Fletcher Alumni of Color Executive Board. He has been part of speaking engagements at International forums such as the World Economic Forum, UN South-South Cooperation etc. His experience has been at the intersection of Management Consulting, Political Consulting, and Social entrepreneurship
Pratham Mehta is an undergraduate from IIT Delhi. He is correctly employed with Boston Consulting Group as a part of India consulting team. He has also interned in Bobble.ai, Snapdeal and Deloitte giving him a plethora of experience in the corporate world. He also started his own venture in service industry. Pratham is an avid dancer and finance enthusiast when not at work.
Meet The Authors (GGI Fellows)
Gursimar Kaur is a commerce graduate from Hansraj College, University of Delhi. She currently works as a Business Analyst at MXV Consulting, a boutique management consulting firm based
out of Delhi and Bangalore. An avid debater, she has been the president of her college’s English debating society and has won numerous accolades at debating tournaments across India. She is passionate about social impact and creating discourse around feminism and inclusion.
Shivani Batra is a Biotechnology Engineer from Vellore Institute of Technology. She works as an Analyst in the Healthcare advisory arm of Sathguru Management Consultants. She aims to direct her work in the intersection of technology, life science and impact, towards expanded access and
inclusion.
Rajeshwari Kannan is a 2019 graduate in Computer Science from Vellore Institute of Technology. She works as a technology graduate in Deutsche Bank. She is an avid singer with a diploma in hindustani classical music.
Mallika Rahane is a graduate from St. Xavier’s College, Mumbai in Economics-Statistics. Mallika is currently working
as an Analyst in KPMG Global Services. She is devoted to Kathak Classical Dance since the last 16 years and is on graduation level in Kathak too. She has performed at various events and won distinction at all levels. In 2018, Mallika was the winner of Miss. Kshitij in Mumbai. Mallika is vastly passionate about performing arts. She is an avid public speaker and a vehement theatre aficionado. She has written, directed and organised theatre originals. She is very fond of post-colonial literature, classic literature and drama, especially Shakespearean drama.
Ritul Jha is currently pursuing her graduation in commerce from Hansraj College, University of Delhi. She has interned across different profiles ranging from Entrepreneur-In-Residence to research projects. From a personal standpoint, she is interested in gardening and is an observer of the
political discourse.
If you are interested to apply to GGI Impact Fellowship, you can access our application link here.
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