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159]

Review Article

How are Social Changes in the Twenty First Century Relevant

to Mental Health?

Abstract Krishna M. Prasad,

Mental health problems occur in a psychosocial context. Social dimensions significantly impact Hareesh Angothu,
psychiatric practice and research. The twenty first century has seen dramatic urbanization,
globalization, rapid advances in technology, and communications. These among several other social Manila M. Mathews,
changes, such as nature and shift in family systems, newer patterns of relationships, migration, Santosh K Chaturvedi
and social mobility will bring about novel challenges for diagnosing and managing mental health Psychiatric Rehabilitation Services,
problems; nevertheless this may at the same time throw newer means and opportunities to intervene, National Institute of Mental Health
particularly with the advancements in technology. There is likely to be greater awareness about and Neurosciences, Bangalore, India
mental health problems. The rights based and recovery oriented approaches will change the way
psychiatry is practiced. Many of these changes will positively impact policies of the government
and access to care. This article focuses on the social changes in the twenty first century and the
impact this has had and will have on mental health, especially in India.

Key Words: Social changes, globalization, mental health, twenty first century, India

Introduction Demographic changes, religion,

The role of social factors in the causation or maintenance
of emotional disorders has been identified since time
immemorial. Social factors play a significant role in the
development, evaluation, and management of mental
illnesses. Even in an era of biological psychiatry it is
not possible to imagine psychiatric practice or research
that is not influenced by social dimensions. Therefore,
social changes will undoubtedly influence the social
determinants, imagination, and responses to mental
disorders.[1] Twenty first century has seen a flurry of
changes globally in the social sphere and very visibly
so, such as urbanization, globalization, and rapid
technological advances. The global demographics and
distribution of population is also constantly changing as
a consequence of universal phenomena such as migration
and advances in transport and communication. India is
not immune to all these changes in the background of
the radical economic policy changes initiated since early
1990s.[2] The effect of these social changes on the mental
health scene in India will be reviewed in the current
article with focus on the various social determinants that
will likely influence mental health.
Corresponding Author: Professor Santosh K. Chaturvedi, Dean,
Behavioural Sciences, Head, Department of Mental Health Education,
Professor, Department of Psychiatry, National Institute of Mental Health
and Neurosciences, Bangalore, India. Email: skchatur@gmail.com
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sex ratio, and aging
Rapid changes in population indices in the twenty first
century are a cause for concern, as they imply significant
changes in the needs that should be addressed by the
governments and societies. World population was about 6
billion during the year 2000 and has reached 7.2 billion
in 2015. Globally, men are higher in number before the
age of 50 but after 50 years age women outnumber the
men, which indicates that geriatric population consists of
significantly higher women than men (http://www.census.
gov/population/international/data/worldpop/tool_population.
php last accessed on 6th May 2016). As per the census
India 2011, among the 1.2 billion population 79.8% are
Hindus, 14.2% are Muslims, 2.3% are Christians, and the
rest of 3.7% are Buddhists, Jains, Sikhs, and others (http://
www.census2011.co.in/religion.php last accessed on 6th
May 2016). As per the census 2011, 30% of the total Indian
population are under 14 years, 65% are aged from 15 to 59
and 12.7% are aged above 60 years. Also as per this census,
5.2 % of the total population in India is either widowed or
divorced or separated and living alone in comparison to 3.3
% of such population of 2001 (http://www.censusindia.gov.
in/vital_statistics/srs_report/9chap%202%20-%202011.pdf
last accessed on May 6th 2016). As per the census 2001,
This is an open access article distributed under the terms of the Creative Commons
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DOI: 10.4103/0971-9962.193195
How to cite this article: Prasad KM, Angothu H, Mathews MM,
Chaturvedi SK. How are social changes in the twenty first century relevant
to mental health?. Indian J Soc Psychiatry 2016;32:227-37.

© 2016 Indian Journal of Social Psychiatry | Published by Wolters Kluwer - Medknow 227
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Chaturvedi, et al.: How are social changes in the twenty first century relevant to mental health?
35.3% are under 14 years of age, 59.4% are aged from 1 to
64, and only about 5% were above 64 (http://censusindia.
gov.in/Census_And_You/age_structure_and_marital_status.
aspx last accessed on 6th May 2016). This data indicates
that more and more Indians in the year 2011 are single
and or elderly than compared with 2001. Life expectancy
of women in India is 69.6 compared with 67.3 during
2010–2015 compared with life expectancy of 65.6 and
63.1, respectively (http://mospi.nic.in/Mospi_New/upload/
India_in_figures-2015.pdf last accessed on May 9th, 2016).
These changes can be due to multiple reasons like
advances in health care systems, which have prolonged the
average life span of individuals, slightly decreased birth
rate reflected by decreased population under the age of 14
years, increased divorce rates could be reflected by larger
number of single persons, which suggests a significant
social and demographic change in the Indian society during
the first decade of the twenty first century that needs to be
taken in to consideration, while considering health plans
at macro level. Because of a consistent and significant
rise in geriatric population there is a greater need for
emphasis on evolving care models for elderly persons
both for their physical health needs, as well as for mental
illnesses. Traditionally, elderly population is dependent on
their children for their support. Changes in current social
economic situation with migration of working age group
population to urban cities are leading to a situation where,
in many villages only elderly population are residing at
homes. In India, there are an estimated 3.7 millions of
persons with dementia with an expected societal cost of
about 14,700 Crore rupees.[3] Persons with dementia are
expected to be doubled by 2030 with an expected three
times increase in societal costs.[3]
Sex issues and equity
Indian society has undoubtedly had significant
transformations and developments in the twenty first
century as evidenced by globalization, urbanization,
technological advancements, and improvements in
education and health care systems. Contemporary India
as portrayed today displays modernization and attempts
to negotiate with traditional underpinnings. Sex equality,
an integral dimension of social stratification, is one such
cause that has been a forerunner in attempting to change its
functioning in the traditional Indian society. Realistically,
however, educated women seen to occupy even high
professional and political positions in India are a minority,
around 5% as per Gallop Poll from 2009–2012 who
reside in the more economically advanced areas, in the
South, like Kerala and more industrialized and urbanized
areas such as Pondicherry (with a value of 4.04% sex gap
being the lowest in the country as per the Census of India
2011).[4] Most women, hence, continue to be employed in
agricultural activities, domestic housework, and occasional
employment.
228
Indian society being largely patriarchal in nature subscribes
to a very hierarchical structure within which a woman’s role
and position in this hierarchy is often determined by her age,
being the daughter-in-law or by the status of her husband and
his hierarchical position[5,6] lending to a subordinate position
more often than not for the female sex. India ranks 105th
out of 135 nations according to the Global Gender Gap
Reporter 2012[7], published by the World Economic Forum,
which monitors the extent of sex inequality on the basis of
criteria relating to access to financial resources, education, and
health. Condorelli[4] in an interesting study using national and
international data on women including the census data from
1901 to 2011, data on dowry deaths and female infanticide
comments that new values and structures have not led to
disappearance of the traditional values; rather they have
learned to coexist. Relationships between traditional and
modern models need not necessarily be mutually exclusive or
dichotomous rather they may exist in manifold combinations
or newer forms.[4] For example, modernization and increased
involvement of women in the workforce has not resulted
in decline of the practice of dowry. Rather, the materialistic
culture of the current times has well adapted this tradition to
serve as a means to fulfil the needs of certain consumer needs.[8]
On the contrary, women engaged in fulltime occupations in
addition also continue to fulfil roles of caretaking, which is
seen to add to stress experienced, as well as reduce quality
time with children.
Sex differences occur particularly in the rates of common
mental disorders: depression, anxiety, and somatic
complaints wherein women predominate.[9] Women
appear to be predisposed to psychiatric illness both due
to biological, as well as environmental vulnerabilities.
Biologically, she is vulnerable to depression on account
of hormonal factors related to the reproductive cycle.[9]
However, sex disadvantage itself may pose an environmental
vulnerability. The vulnerabilities often take shape in the
form of excessive partner alcohol use, sexual, and physical
violence by the husband, being widowed or separated,
having low autonomy in decision making, and having low
levels of support from one’s family, lesser educational
opportunities, and employment.[10-11] Violence toward women
is displayed through means of female feticide, domestic
violence, dowry death or harassment, mental and physical
torture, sexual trafficking, and sexual coercion. Sex‑based
violence can result in long standing emotional distress,
posttraumatic stress disorder, and poor reproductive health.
Battered women are much more likely to require psychiatric
treatment and are much more likely to attempt suicide than
nonbattered women.[14] According to the National Crime
Record Bureau, reports of rape, molestation, dowry death
rose by 6.4 percent in 2012 from the previous year, with
the highest number of rapes recorded in the capital city
(http://ncrb.nic.in/(Last accessed on 5/6/16)). Although more
women, nowadays, denounce violence, the figures indicate a
general rise of sex-related violence in India.[4]
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Stigma toward women with psychiatric illness further
magnifies the existing problem of sex inequality. Malhotra
and Shah[9] also comment in their study that women are
expected to be primary caregivers for husbands with
psychiatric illness; however, if a woman were to have
a psychiatric illness, her role as caretaker would still be
expected. Under-utilization of health care by women with
mental illness conveys the stigma attached to health seeking
or to the lowered importance of their health in general.
Sex equality and women empowerment is one of the
Millennium Development Goals of United Nations, 2015.[12]
Through empowerment of women, it is intended that she
must be free to make a choice from alternatives that are
available in reality and not only perceived, in a manner that
those alternatives chosen are accessible to her regardless of
any opposition. Further, empowerment provides the women
resources through which her agency can be exercised, with
opportunities for success. Attempts to make this possible
have been directed through access to education and to paid
work.[13]
Educated women were seen to be able to make informed
decision on health and family planning, increased access
to resources and economic decision making were better
equipped to handle violent husbands[14] and were better
able to challenge male prerogative as seen in antiliquor
movement by the Mahila Samakya in Andhra Pradesh,
a literacy programme for women that fuelled collective
action against alcoholism in husbands.[15] The flipside
is, however, it is also observed that in societies in which
women’s role is purely defined for reproductive purposes,
education itself becomes a means to get suitable husband
or to become better homemakers further subjugating
them to patriarchal structures and subordination.[13] Other
limitation to education at the macro level include the fact
that curriculum itself often breed stereotypes toward men
and women that reinforce the existing notions of the male–
female role divide, whereas poorly acknowledging the foray
of women into workplace, their contributions to household
income, and the emergence of female headed families. At
the micro level this results in women succumbing to poor
salaries, casual forms of work[13] and struggling to meet
roles of earning member and the caretaker as seen in many
dual-earner families.[16]
Access to paid work increases women’s agency in several
ways. Determining women’s status in social hierarchy and
influencing wide spheres of social action in private and
public life is closely connected to the degree of female
participation in economic activity and their economic
contribution. Without any education and self sustenance,
they are subject to the decisions made by their respective
husbands. Within the patriarchal system, they are often
invisible and a social burden, more than a value for society.
Several practices such as female infanticides, arranged
child marriages, traditional dowry practices, and dowry
deaths are reflections of this belief.[4] Studies of the impact
Indian Journal of Social Psychiatry | July-September 2016 | Volume 32 | Issue 3
of microcredit in societies found that women's access to
credit led to a number of positive changes in women's
own perceptions of themselves, and their role in household
decision making and reduced the incidence of domestic
violence[13] even if these were home based. Studies
conducted on Microfinance organizations in India and
Bangladesh suggested that association of women with such
organizations in the long run led to increased autonomy
and self confidence in women.[13] Earning power could be
used to renegotiate their relations within marriage, to leave
abusive marriages, to help ageing parents, to postpone early
marriage, and to challenge the practice of dowry.[13]
Family: nature and shift, nuclear, extended and
joint, single parents, live in relationships
Indian family lies at the heart of all cultural values and
traditions. As an interdependent society, a lot of importance
and values are attached to family ties through all stages of
life. Traditionally, the Indian family system is patriarchal in
nature and hierarchical system based on the norms of the
dominant Hindu culture whereby men are seen to take part
in decision making and planning for the entire family based
on seniority of age.[17] The wife of the eldest member is
likely to take responsibility of management of all household
chores. By structure, the tradition Indian family is joint
and essentially the socializing agent for children and gives
much importance to the roles played by the elderly. Women
were also seen to be the less active members in decision
making.
In the twenty first century, owing to host of changes in
society as an outcome of urbanization, globalization,
modernization, increased opportunity for education,
increased employment opportunities, migration, and
technological advancement, newer family systems in
terms of structure and functioning are now apparent.
Sooryamoorthy[18] noted that the family in India is as
diverse as country's demography, culture, and religion.
Although there appears to be a surge of nuclear families,
D’Cruz and Bharat[19] note that the family is merely
changing into an adaptive extended family and not nuclear.
Alternate patterns of the family are found mostly in urban
areas and metropolitan cities such as single-parent, female-
headed, or supplemented nuclear families supported by
relatives of the spouses.[20] These families emerge from
personal circumstances such as death of a partner or
divorce or migration of the husband for work purpose.[19]
Changes in nature such as assertion of women rights and
protection of the girl child, resulting in softening of the
patriarchal system within the family system have been
because of transformation of the labour market and its
association with female education, advancements in family
planning, development of feminism, and globalization.[24]
Sense of equality in the family, role expectations, and
selection of partners have been influenced by spread of
western culture.[18] The above developments are suggestive
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Chaturvedi, et al.: How are social changes in the twenty first century relevant to mental health?
of better well-being of women, improvement in family life,
increased agency of the wife, resulting in higher quality of
family life and gradually improving acts of violence and
oppression against women.[24] Dual earner families have
become child centered[21] with the above noted changes,
however, this has resulted in the neglect of the elderly,
resulting in the sprouting of several old age homes across
the country.
Dual earner couples are increasingly common these days.
With work pressure and long working hours, parents often
find it difficult to engage adequately with children. Natrajan
and Thomas[22] in their study on the need for family therapy
in middle class families found themes of underinvolvement
of husbands, reduced time spent with children, increased
pressure on children to perform academically well, and
generational gap with children owing to rapid changes in
society. Stress arose from lack of role clarity, nuclear units
no longer had the comfort of falling back on elders present
in joint set up and lack of knowledge of availability of
therapeutic services to address the same.
Single parents are often the outcome of circumstances
such as death, separation, or divorce. Available literature
primarily focuses largely on the role of a woman as a single
parent with dependent children. Many of these women
are poorly educated, low skilled, engage in agriculture,
and low-paid jobs and are sole earners[17] constitute the
poorest of the community with inadequate family and
social support. Indian society looks rather differently at
a divorcee and a widow. Although the widow and her
children may be looked upon with sympathy, a divorcee
is often shunned in the Indian society. The restrictions are
placed on a divorcee and poor acceptance both by her own
family and society at large render her prone to anxiety and
depression. She may prefer to live on her own with lesser
resources. The divorced mother is the new trend emerging
in India and needs supports such as creche, day care,
low-interest loans, cheap housing, hostels to stay with
children, social security, sponsorship for children, changes
in property law, right to ancestral property, creation of
community property, and so on are also required. Centres
to help, guide, and counsel women, allow them to mourn
the loss of the relationship and involve parental family in
her recuperation are needed.[23]
Female headed families are a term used for families in
which the husband has likely migrated to another state
or country. Male migration could result in ill-equipped
partner who perhaps has been dependent on her husband
previously and may have implications for children as well.
However, it is also suggested that women may become
more independent and self-confident.[24]
The need for family therapy or individual therapy services
in which required point in the direction of Indianizing
therapy in the context of the changing society, negotiation
of roles, rapid advancements of society, and its relation
230
to intergenerational differences and strained yet cherished
ties with the joint family that are integral to the family
set up.
Economic changes: poverty, employment, and
displacement
Technological advances although have reduced certain
barriers for growth and economic development of India in
the twenty first century leading up to India being one of the
top 15 countries to have most number of Billionaires, but
still on average per capita income of the Indian population
in the year 2014 is 6 times lower than world average as per
the International Monetary Fund data.[25]
Per capita income of Indian population is $ 1471 in the
year 2015 compared with $ 460 in the year 2000.[26] Over
the last few years, there is a slow but consistent increase in
the number employees in the private sector. As 1.78 Crore
Indians are in some form of Government employment
during 2010 compared with 1.76 Crore during 2012. At the
same time 1.08 Crore Indian were in some form of Private
sector employment during 2010 compared with 1.19
Crore during 2012. Private sector is less likely to provide
a secure job than a government job and often the private
jobs being performance and target based there is higher
chances of such private employees to work under continued
stress. Probably, these private sector employees are more
vulnerable to develop stress-related disorders (http://mospi.
nic.in/Mospi_New/upload/India_in_figures-2015.pdf last
accessed on May 9th, 2016).
Urbanization and globalization
Following economic liberalization and globalization policy
of 1991 in India, urbanization has gained momentum with
nearly 160 million added in 20 years, by 2011 nearly
31.16% living in urban areas. New employment, better
education, and movement of the earning member of the
family are the reasons for the migration of about 85% of
male population from rural to urban in India, as per the
report released in 2008. There are significant differences
between the reasons for migration between women
and men. In women, it was the marriage or movement
of earning member, which were the major reasons for
migration either rural to rural or rural to urban compared
to men.[27]
Geographic mobility: migration outside India,
migration within India
Migration is the process of social change whereby an
individual moves from one cultural setting to another for
the purposes of settling down either permanently or for a
prolonged period.[28] Migration may be internal migration,
which may be from rural to urban or from urban to rural,
intrastate or interstate, or may be to another country. This
gained momentum due to better financial options, better
livelihood, and education or for reason such as marriage.
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It is pertinent to consider the timing of migration with
reference to biographic and historical transitions such as
childhood versus adulthood, first or second-generation
migrants with special emphasis in determination of the
socialization process.[1]
Problems such as loneliness, helplessness, frustration,
increased household, and social burdening are common
among the migrants.[29] The various stressors faced by a
migrant are determined by several factors. These include
age, sex, forced, or voluntary migration, vast differences of
the host state/country in climate, language, food, culture,
interdependent versus individualistic societies, whether one
has migrated alone or with others.[1] Distance from native
place was found to be a factor impeding adjustment, as it
determined frequency with which one could return to their
hometown.[1] However, technological advancements allow
faster contact with family via various modalities, which
may help alleviate difficulties in reaching families prior to
these advancements. Bhugra[29] also suggests that migration
and its effects on mental health must be evaluated based on
the phase of migration as individual is in.
The two points in migration associated with
psychopathology are immediately after arrival when
adjustment is difficult and several years after settling down
when one is disheartened by the lack of achievement they
had anticipated. This disappointment may result in lower
self esteem increasing susceptibility to depression or other
psychiatric disorders.[30]
Rural to rural migration has been decreasing and rural to
urban and urban to urban migrations have been increasing [31],
the goal or main reason behind changing the residence
would be improving their living conditions or to escape
from debts and poverty. There are some special groups
such as women, children, elderly, lesbian, gay, bisexual,
and transgender individuals, who are more prone to certain
mental health issues during the migration process.[32]
Studies suggest that unhealthy lifestyles may be resorted to
after immigration due to difficulty in maintaining healthy
lifestyle as an outcome of complications of the migration
process. Migrants from developing countries who moved
to developed countries are considered to be a high-
risk group for human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS). This may be
an outcome of social exclusion and cultural and language
barriers in offering and accessing the health and other
services at the place of destination.[33]
Banal et al.[34] in a study on Kashmiri migrants in Jammu
describe that psychiatric morbidity was found to be more
in migrant population than in controls. The most prevalent
disorders were found to be posttraumatic stress disorder,
depression, and other mental health problems. Similarly,
in a sample of slum residents in New Delhi, migrated
from other states were found to be more at risk for mental
illness as an outcome of poor social support, relationship
Indian Journal of Social Psychiatry | July-September 2016 | Volume 32 | Issue 3
problems with other members of the family, increased
worry about health, easily getting angry and irritated, lack
of satisfaction about the living condition.[3,5]
Evaluation of psychiatric illnesses and treatment for
migratory populations would do well to keep in mind the
complex processes involved in the surfacing of mental
health issues in this population.
Social mobility and caste system
A significant factor for huge discrepancies for lack of
the uniform economic and social growth in India is the
existing caste system. Culturally for hundreds of years
certain segment of population was oppressed and refused
equal opportunities for education and employment. After
independence, affirmative action and a system of fixed
reservation for Scheduled Castes and Scheduled Tribes at
educational institutions, jobs and at legislature houses has
lead to significant changes in their social mobility within
the Indian society. Household surveys during 1983–2005
are suggestive of significant intergenerational changes of
education and employment among the Scheduled Castes
and Scheduled Tribes in comparison with nonscheduled
castes and scheduled tribes’ population of India and almost
convergent rates between these two groups.[36] Some have
observed more social mobility among the scheduled castes,
which were considered as untouchable in comparison
to Scheduled Tribes. Relative geographical isolation
was postulated as one of the reasons for this observed
difference.[37]
However, some strongly disagree that the quota system or
positive discrimination has been effective in bringing the
much anticipated social mobility within society. According
to Gregory Clarke, despite extensive social engineering,
India is unusually immobile society, which he hypothesized
that it could be due to strong marital endogamy.[38]
Endogamous marriages within the same caste or subcaste
leads to greater chances of inheriting recessive disorders, as
well as schizophrenia.
Effect of Technology, internet, telephones, media,
and cinema
The twenty first century has seen a rapid influx of
technological innovations with newer, more efficient,
sophisticated, and more recently pocket friendly varieties
of technology emerging every day. Use of smart phones
and easy access to the internet may have earlier been seen
as luxuries reserved for a more economically well off
strata of society. What once may have been a luxury is
now gradually emerging a “necessity”, as a large part of
the Indian society now has access to these technological
advancements. On the contrary, media and cinema,
mediums that already had a comfortable dedicated social
audience recently have reinvented themselves to be a
bolder, unapologetic, often sensational means of being a
reflection of Indian society. The joining of hands between
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the internet, telephones, media, and cinema has resulted in
the best depiction of the concept of a “global village”.
Changes in technology have resulted in more transient,
private and atomized local communities, and broader social
networks consisting of complex, diverse, and international
networks of individuals. The networks can be seen first at a
local level, wherein the contact may be more physical and
solid and face to face, and then at a cyber level wherein the
contact may be fluid and anonymous. Various easy methods
of communicating and sharing information including chat
rooms, user groups, web forums, virtual reality worlds,
and sites specifically dedicated to ‘social networking’ are
available. Some of the advantages of internet-based social
networks mentioned in this article include ease of being in
touch, bringing disparate groups together, act as a support
group online, provide anonymity and hence safety from
being judged, thereby elimination of prejudice is possible.
One of the biggest advantages online social communities
provide to those handicapped by class, sexuality, disability
is that it allows one to overcome the many barriers they are
likely to face when they meet someone in person.[39]
There are, however, several challenges to online social
networks as well. Psychological effects of reduced face-to-
face time are being debated now.[39] Anonymity may also
come at a cost as evidenced from the growing number
of cyber crimes. Cyberbullying is another growing trend
seen among children in schools and colleges wherein the
perpetrator bullies another on online social networking
sites. Compulsive gaming online is a manifestation of
excessive use of video game on users' in the form of
truancy from school to play, losing academic grades at
school, decreased social activities, irritability if unable to
play longer period of time, or advised to stop, an increase
in expression of aggression, wrist pain and neck pain.[40]
Internet addiction as a diagnosis is still at the crossroads
with questions such as on whether one would consider it
an addiction or behavior on a continuum of usage versus
being classified as a case of poor impulse control.[41]
Studies conducted in viewing the same as an addiction
have found that those found dependent on the internet
were found to delay other work to spend time online,
lose sleep due to late-night logons, and feel life would be
boring without the Internet. The hours spent on the Internet
by those who are addicted to it was greater than those
nonaddicted to the Internet They also experienced higher
loneliness in comparison with those who were categorized
as nonaddicted. [4,2]
Another study suggested that sex (male), daily time spent
on Internet use, reward seeking, and connecting and social
influence gratifications dichotomize the Internet addict and
nonaddict cohorts. [4,2]
Technology has also had its implication on work life
balance of individuals. In a study Rao and Indla [4,3] discuss
why having access to all three aspects of life has become
232
but a distant dream. Technology has made it possible to do
tasks from everywhere blurring lines between work and
home. It has also increased expectations of speedy work
and replies increasing longer hours spent at work and
greater stress experienced.
On a positive note, several social networking sites,
newspapers, and news channels have tried to increase
awareness of mental illness such a depression, bipolar
affective disorder, and anorexia nervosa to name a few via
public disclosures of famous celebrities in an attempt to
normalize, garner support and reduce stigma faced by many
others who may be suffering from the similar psychiatric
illness. A study assessing two major Indian dailies over
the course of 3 months reported that media plays a
significant role in educating the public about psychiatric
illness and often joins hands with professionals in taking
expert opinions on issues related to news.[44] Further, the
Indian Psychiatric Society has also suggested guidelines
for reporting news of suicide, a growing problem in a
nonsensational, discrete, sensitive, and neutral manner[45] so
that media may be used as a tool for change to reduce the
stigma surrounding mental illnesses.[46] In the past, cinema
has been guilty of a portrayal of mental illness that is
often inaccurate and exaggerated, however, as political and
economic stabilization are slowly being achieved, attitudes
are changing once again with recent movies display more
understanding toward characters with mental illness.[47]
Cinema has also taken a positive turn toward the trend of
female–centered movies with various themes evoking the
current social changes.
War, terrorism, and disasters
A wide variety of psychiatric morbidity is reported as
a result of conflict situations that includes adjustment
disorders, posttraumatic stress disorder, depression, panic
disorder, and substance use disorders nevertheless nearly
half of the population are also resilient.[48] In the twenty
first century, India is witnessing low-intensity conflicts
in several regions across the country including those
related to terrorism, religious extremism, regionalism,
and Naxalism. The mental health consequences of these
conflicts can include those directly related to violence and
also because of stressful social and material conditions
such as unemployment, poverty, malnutrition, and so on.
Low-intensity conflict zones like Kashmir have seen an
increase in psychiatric morbidity and a recent study among
noncombatant civilians documented the prevalence of
depression to be 55.72% with the prevalence in the youth
(15–25 yrs) being even higher at 66.67%.[49] There is a
need to be prepared for a surge of newer forms of conflicts
such as cyber warfare, bioterrorism, and their mental health
consequences.
There is an increase in the number of disasters both natural
and manmade globally; the consequences on mental health
of survivors could be immense. The naturalness of several
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Chaturvedi, et al.: How are social changes in the twenty first century relevant to mental health?
so called natural disasters is questionable – pressure
on environment, growing population, intensification of
economic activity in vulnerable areas could contribute
to their more frequent occurrence.[50] In a study among
children and adolescents in the Andaman and Nicobar
islands following a Tsunami triggered by an earthquake
in 2004, children from the tribal communities who had
joint families were more resilient and had less psychiatric
morbidity.[51] It has been argued, on the contrary, that
the loss of a family member in a primarily family-
oriented culture and belief in fatalism could predict poor
psychological outcomes in primary survivors, as was
reported following the Uttarakand floods and landslides of
2013.[52] Mass accidents during religious congregations and
festivals have been reported in the last decade; the mental
health consequences are not yet reported.
With growing urbanization and industrialization, there is
a need to learn from previous experiences of industrial
disasters such as the Bhopal gas (methyl isocyanate) tragedy
in 1984. General population “longitudinal epidemiological
study of mental health effects” was initiated by the Indian
Council of Medical Research (ICMR), New Delhi, but
unfortunately the findings of the study were not reflected in
the mental health care of the population.[53]
Social changes and psychosis
Urbanization is associated with a two-fold increased risk of
psychosis.[54] There are speculations that this may be due
to loss of social capital and social fragmentation. Rates of
schizophrenia and other psychoses are elevated in migrant
and minority ethnic populations particularly in second-
generation migrants from developing countries. The initial
findings from the large scale epidemiological studies about
prognosis being better in developing countries including
India may have changed.[55] Even the earlier studies by
ICMR indicated that urban centers had better prognosis.[56]
Improved maternal and child care may herald the birth
of cohorts with poor prognosis due to survival into
adolescence, which would have otherwise been eliminated.
The large scale migration of refugees due to wars may lead
to an increase in experience of adversity, which is a risk
factor for development of psychosis.[57] ‘Nuclearization’ of
families and change in family structure may reduce social
support for patients with psychosis.
Social changes and depression/mood disorders
The estimate of the global burden of disease predicts that
depression, estimated to be the fourth leading cause of
disability worldwide, will be the second leading cause
of disability worldwide by 2020 as per the World Health
Organization.[58] As a part of the World Mental Health
Survey Initiative by the WHO, a cross-national study on
the epidemiology of depression in 2011 revealed that the
percentage of the screen-positive respondents who had
lifetime major depressive episode (MDE) was highest in
India with a percentage of 39.5%. The study also indicates
Indian Journal of Social Psychiatry | July-September 2016 | Volume 32 | Issue 3
that other factors associated with depression include being
of female sex and lesser number of years of education.
However, young age was associated with less risk in India
in comparison with other countries.[59]
Associated Chamber of Commerce and Industry of India[60],
in a recent study conducted across 150 companies across
18 broad sectors like media, telecom, and knowledge
processing outsourcing and so on found that 42.5% of
employees in private sectors are seen to have depression
or anxiety disorder, compared with government employees
with lesser levels of psychological demand at work.
Increasingly demanding schedules and high stress were
seen to be determining factors causing depression and
anxiety and further also causing daytime fatigue, physical
discomfort, performance deterioration, low pain threshold,
and increased absenteeism.
Depression over the past decade has also focused on
depression at age extremities including adolescent and elderly
populations. Assessment for mood disorders among south
Indian adolescents observed that 37.1% were mildly, 19.4%
were moderately, and 4.3% were severely depressed.[61]
In addition, depression and stress were found to be
significantly associated with a number of adverse events
over the course of time, poor academic functioning,[62] and
suicidal behavior.[63] Among the elderly, the suicide rate in
the population above 55 years of age is 189/100,000 and
about one in five of all successful suicides are committed
by individuals above the age of 65 with implicated factors
including social isolation, financial difficulties, physical
comorbidities, and psychiatric illness.[64]
The WHO World Mental Health survey initiative for
bipolar disorder[65] indicated that the aggregate lifetime
prevalence of BP-I disorder was 0.6%, BP-II was 0.4%,
subthreshold BP was 1.4%, and Bipolar Spectrum (BPS)
was 2.4%, whereas less than half of those with lifetime
BPS received mental health treatment, particularly in
low-income countries wherein only 25% reported contact
with the mental health system. India was seen to have the
lowest lifetime prevalence of BPS.
Suicide, including farmers’ suicide
Majority of suicides in India have socioeconomic reasons
as precipitating or triggering factors particularly in
farmers. Certain states have very higher rates of suicide,
that is, 40 per one lakh population in Puducherry and
26 per one lakh population in Telangana compared with
Indian average of suicide of 10.6 per one lakh population.
[66]
Indebtedness, inadequate crop production leading to
economic difficulties, family problems, and substance-
related problems were described as the main reasons
from suicides of farmers in India.[67] Climatic changes
with reduced rain fall for many years in association
with reduced availability of ground water and water
mismanagement might have contributed significantly to
the crop-related indebtedness in farmers.
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Chaturvedi, et al.: How are social changes in the twenty first century relevant to mental health?
Social changes and diet, lifestyle, eating disorders
The urbanization of India in the current century might see
a further reduction in physical activity, which is associated
with agrarian rural societies. The changes in dietary habits
from the traditional lacto-vegetarianism in many societies to
consumption of a more western diet coupled with sedentary
lifestyle will invariably reflect in the growing obesity
and metabolic disorders epidemic in India.[68] Traditional
sociocultural views in India regarding commensality have
associated being “full bodied” with being healthy and also
with psychological wellbeing.[69] There is a growing rise
in eating disorders as has been an increasing emphasis on
thinness and fat phobia particularly among women. Two
thirds of psychiatrists in Bangalore reported seeing at least
one case of eating disorder indicating that these are not
uncommon in urban India.[70] The changing concepts of
body image among men might also be reflected in reporting
of bigorexia cases in India.
Social changes and common mental disorders
Despite the high economic growth rates, there is a problem
with the redistribution of incomes in India with consequent
income disparity and inequality (https://www.imf.org/
external/pubs/ft/sdn/2015/sdn1513.pdf). This coupled
with other factors due to rapid social changes such as
the experience of insecurity and hopelessness, the risks
of violence and physical ill-health may make the poor
vulnerable to common mental disorders.[71] The direct and
indirect costs of mental ill-health worsen the economic
condition, setting up a vicious cycle of poverty and mental
disorder. The policy makers will need to focus on including
common mental disorders among other diseases associated
with poverty and low education. The ongoing national
mental health survey may provide an accurate picture of
the magnitude of the problem and the underlying social
underpinnings.
Social changes and extremes of age
The changing styles of parenting and school environment,
family discord, single parenting, risk of abuse, and early
exposure to technology may shape the presentation and
prognosis of several childhood mental disorders. The
demographic dividend provided by the current generation
in India may become a problem as this generation ages.
Poor availability of social support may affect mental health
in both the extremes of age.
Social changes and substance use
Age at having first alcoholic drink has lowered over the past
few decades. In 2012, a survey conducted by Community
against Drunk Driving in association with National
Crime Records Bureau and Delhi Police revealed that,
approximately, 90 % of men, 65% of women who consume
alcohol, admitted consuming alcohol before their age was
18.[72] These Social changes can pose significant problems
234
for the general health of community in terms increased
Road Traffic Accidents and related morbidity. Also mental
disorders like alcohol dependence and related disorders can
have more morbidity when the age of first use is lower.
Significant drop in age at first consumption of alcohol has
also been found by other researchers.[73] Such early age of
onset of substance usage can pose significant burden on
society both directly affecting the health conditions of the
individuals using substances and indirectly by affecting the
productivity of those consuming.
Social changes and interventions in psychiatry
The various social changes discussed calls a clear
understanding on the part of the therapist regarding,
whether the current manifestations of symptoms or
psychological distress may be influenced by social changes.
Understanding of technological advancements, work-related
policies, government policies, and some knowledge or
curiosity of the cultural background of the client may help
in addressing the challenges faced. Formulating therapy
strategies that understand the contemporary fabric of Indian
society and their needs is crucial at this point as tradition
models of psychotherapy maybe be rooted in concepts
from a western societal perspective.[74] History taking must
include a cultural formulation.[75]
The modality of therapy itself has in the event of
technological advancements begun to include mode
of therapy including telepsychology, synchronous
communication via online chat or asynchronous via
emails, and so on, text based or non-text based. Various
applications on smart phones also assist therapy, as well
as e-therapy to keep track of therapy homework progress,
track mood changes keeping in mind the feasibility and
suitability of the client for the same[76], as well as ensuring
appropriate protocols for ethical practice of the same.
With the rapid strides in pharmacology and genetics there is
likelihood to see more personalized medical management.
Mental health care will become more accessible (the costs
have to be borne by governments), as also the scope for
rehabilitation than ever before. All of this, however, augurs
well overall for mental health.
Awareness, help seeking, Stigma, and
discrimination
Stigma affects persons with psychiatric disorder in that they
are ostracized leading to self-stigma, social exclusion and
poor social supports, denied equal opportunities, reducing
help seeking behavior further reducing access to mental
health care, and delaying the process of recovery.
Stigma can often be a rather strongly held belief rendering it
difficult to dismiss. Working against stigma has to be done
both from the grass root level up to governmental structures
and vice versa. Community mental health programmes
and School mental health programmes are the need of
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Chaturvedi, et al.: How are social changes in the twenty first century relevant to mental health?
the hour. India is rooted in values of interdependence and
communal ties and bonds. Using our strength, which is
the family system, community level projects to dilute, and
eradicate existing misconceptions, care of mentally ill must
be taken to the community level. We must also consider
easily accessible low‑cost mental health services need to
be organized in the community that should also address the
issue of cost of accessing the services.[77] Introduction of
syllabus on mental health in schools and colleges should
also be considered to tackle stigma at its roots.
Sarkar and Punnoose[78] suggest that training among
medical, nursing, and other health profession is important
to ensure adequate referral for patients, who might need
psychiatric services.
In recent years, several celebrities have publically disclosed
their experience of having suffered psychiatric illness and
treatment outcomes. It is yet to be seen how far these
messages might have reached out to the public and the
outcome of the same. Mental health professionals should
also liaison with media and engage in disseminating
information to the public through interviews or articles
so as to promote talk about mental health and increase
awareness among the general public.[79]
Social changes and mental health Policy
As the concept of what is mental disorder can change over
time social changes all over the world can have a significant
impact in the mental health policy. Technological advances
can also lead to variety of new mental health diagnosis
such as internet, smart phone, and online gambling
addictions. A recent Indian metaanalysis found that smart
phone addiction in Indian adolescents ranges from 39 to
44%.[80] Rapidly changing socioeconomic and demographic
circumstances and increasingly accepted rights-based
approach for persons with mental illness has lead to
several changes in the mental health legislations. India has
initiated the process of changing its existing mental health
legislation, that is, Mental Health Act 1987 and has created
a new legislation Mental Health Care Bill 2013, which
unfortunately has not got the executive approval.[81]
Changes in conceptual understanding about the importance
of mental health, the burden mental disorders can pose on
society, many countries have considered changes in their
mental health policies. In the United Kingdom “No health
without Mental Health” slogan was considered in the year
2011 and several steps are being taken to achieve an overall
better mental health.[82]
Recognizing the importance of lack of national level
mental health policy, government of India has released
one in 2014. This is the first ever mental health policy
for India, which itself is an indication that government of
India is committed toward assessing and emerging new
mental health needs of Indian population. The strategic
areas identified in this policy and action are promotion of
Indian Journal of Social Psychiatry | July-September 2016 | Volume 32 | Issue 3
mental health, prevention of mental disorders and suicide,
universal access to mental health care, enhanced availability
of human resources for mental health, community
participation, research, monitoring, and evaluation.[83]
Conclusions
The future of psychiatric practice in relation to newer
social factors like, virtual reality, technology, and
gadgets is likely to change with advances in technology
and their usage. One would have to examine ‘loss of
touch with virtual reality’ and probe stress related to
technology to understand the distress of the individuals.[84]
Workplace is being replaced by computer laptops and
notebooks. People accustomed to these run their office
from anywhere and everywhere. There will be a need to
redefine ‘work place’ as ‘where ever the laptop is’ and
identify newer and variable mobile work place related
stress disorders.[84] Other demographic changes in India
such as an increase in the aging population will call for
health services and policy to be geared to handle public
health problems such as dementia. There will be a greater
need to evolve services and treatment strategies that take
into account sex issues and rights of the underprivileged.
The newer technologies will help improve systems of
mental health care delivery but at the same time there
will be a need to tackle issues emerging from technology
addiction. Urban migration, ‘nuclearization’ of families,
greater caste mobility will complexly influence mental
health problems. Broader lifestyle changes will not only
impact mental health as also physical health. Awareness,
help-seeking and access to care will certainly improve
as a result of the various social changes. Many of these
positive developments along with an increasing focus
on a rights based approach should hopefully create more
services that are recovery oriented.
Financial support and sponsorship
Nil.
Conflict of interest
There are no conflicts of interest.
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