A Closer Look at NIMHANS' Perinatal Psychiatry Approaches
As a visiting researcher at NIMHANS, I had the privilege of working in one of India's premier mental health institutions in Bangalore, Karnataka.
My focus for this visit has a dual interest: I was there to develop a prenatal yoga module for women of ethnic minority backgrounds with the Integrative Medicine Department. I was also interested in learning more about transcultural and perinatal psychiatry from a clinical standpoint. Perinatal psychiatry deals with mothers’ mental health during pregnancy and after childbirth and, recently, the well-being of their newborns and partners.
I am a postdoctoral researcher at the SPI Lab, and I have spent the last three and a half years studying and researching perinatal mental health. I am particularly interested in interventions to improve mothers' mental well-being and social support (see my recent blog on the SHAPER-PND study). I am also fascinated by how society and culture influence perspectives on mental health.
My first impression of NIMHANS was that it was a quiet haven, with manicured botanical gardens, ancient trees, monkeys, dogs, patients, visitors, and healthcare staff, with buildings that camouflaged beautifully in the greenery. Yes, it is a bustling and busy hospital, with many departments and clinics dedicated to mental health and neurology areas.
I was particularly interested in the Mother and Baby Unit (MBU), where mothers and their babies (up to 2 years) can stay together, frequently with the maternal grandmother or the father. This is the first and, as far as I am aware, only mother and baby unit in India led by Professor Prabha Chandra, whom I deeply admire. This unique inpatient ward caters to the mental health needs of pregnant and postpartum women and the needs of newborn babies and infants. The MBU provides various services, including psychiatric assessment, counselling, and pharmacological interventions, to ensure the mother’s and child’s well-being.
In India in particular, where social services are in their infancy (excuse the pun!), mental health care also means social care, with provisions in terms of financial, housing and disability support, as well as the management of interpersonal household issues (domestic violence, abuse, and addiction in the household). The care they provide holistically impacts the well-being, recovery, and support of patients in the short and long term.
With NIMHANS being a tertiary care centre, many patients had symptoms for a while, first seeking care from Ayurvedic doctors, religious leaders, informal care in ashrams, and psychiatrists from local hospitals and eventually finding their way to NIMHANS, as perhaps a more severe stage of symptomatology.
Indeed, I was struck by the level of stigma surrounding mental health in India, particularly in the context of pregnancy and childbirth. Many patients expressed concerns about being labelled as "crazy" or "unfit" as mothers, held beliefs around mystical and religious phenomena (being “possessed” by a deceased person or a deity is still very common in India), and many patients describing what I thought was severe and obvious symptoms of mental illness as “tension”. One of the cultural differences that really surprised me (though, in hindsight, it appears to be a reflection of the culture) was the reluctance of many women and young girls to disclose their mental health history to their prospective husbands.
For example, take Latha’s story (not her real name), who I met one Friday morning in the Perinatal Outpatients clinic. Latha is from a low socio-economic background, left school at 15, and has worked as a maid since. She has experienced periods of prevalent low mood and social withdrawal, punctuated by a few episodes of elated mood and dangerous behaviour. She was assessed at NIMHANS at the age of 14 and was diagnosed with bipolar disorder; she has been offered medication since.
Shortly after her second episode of mania (extremely elevated and excitable mood usually associated with bipolar disorder), marriage was arranged without her consent. At 19, she was married to a stranger. Her family, fearing that she would not be seen as a “good prospect”, hid her diagnosis and told the groom’s family that she had minor sleep issues in the past. Latha stopped taking the medication that helped her with the psychiatric issues just before her wedding, so her new family didn’t know she had a psychiatric diagnosis.
After her wedding, she moved to her husband’s house (that included her in-laws and other family members in a “joint family” setting, prevalent in India). She was expected to cook for the entire household (7 people in total), clean the house and look after the children in the family while having no social ties in a new and unfamiliar city. Her mother-in-law criticised her appearance, ability to look after the household and temperament, and pressured her to have a child as soon as possible. Within a year of marriage, Latha gave birth to a girl to the disapproval of her husband and their family (who wanted a boy, still very prevalent in India and a common finding in mothers at the MBU). Less than a month after delivery, she experienced another episode of mania. Her husband’s family have decided that Latha is not worthy of their family and has insisted that she move back to her family of origin and their son to re-marry a “more suitable” girl. Latha is at risk of poverty, social exclusion, and stigma, not just due to her diagnosis but also due to her being abandoned by her husband.
When I heard stories like this, and trust me, there were dozens of similar cases daily; it really made me feel that there is so much more to mental illness than just a diagnosis; mental illness is a result of context, social circumstances, and mostly, privilege just as much as it can be a biochemical dysregulation.
I must admit that there were some biases in my observations — India’s middle classes (and the less privileged too, but perhaps to the cost of indebting themselves) will rely on private healthcare. A government psychiatric hospital — and I am paraphrasing from what I heard many psychiatrists say, in the vast majority, is for the less privileged (many files were marked “BPL”, below the poverty line) or for the ones that have exhausted all their options in the private sector. This means that severe mental illness and complex cases are disproportionately represented at NIMHANS, but that gave me a birds-eye view of how psychiatrists manage heavy workloads (the waiting areas in clinics were always completely full), complex cases (where entire families and communities were being taken in consideration in treatment plans), and very limited resources (from minimal funding or grants used to support the largest number of BPL patients possible).
This was an incredible experience for me, possible only thanks to the support of Prof Carmine Pariante (ITM’s Editor and my supervisor) and generous contributions by the British Association of Psychopharmacology’s Hannah Steinberg Award. Keep an eye out for my next article, on NIMHANS Centre for Integrative Medicine with Yoga and Ayurveda.
I will leave you with a cup of steaming spiced chai in the sun.