Seasons of Trouble

The Maharashtra government’s efforts to provide mental-health care amid rising farmer suicides

19 April, 2020

NILESH DHANPAL’S CROPS failed with depressing regularity for three years. Across his eight acres of land in the village of Belimandali in Amravati district, cotton, tur—pigeon pea—and oranges, three popular crops that farmers in Maharashtra’s Vidarbha region depend on for their income, either rotted or yielded harvests of poor quality. One evening in December 2017, Dhanpal told his wife, Shubhangi, to save dinner for him, as he had to go out to check on some equipment. Shortly afterwards, an acquaintance of the family found him unconscious in a nearby toolshed, having swallowed a bottle of pesticide.

Despite efforts to make him vomit the poison and rush him to the closest hospital, Dhanpal, then 49 years old, passed away that night. His death was one among the 3,701 suicides of farmers and agricultural labourers in Maharashtra that year. He had a loan of Rs 7.5 lakh from two government banks, that his brothers had to subsequently pay off.

In the days leading up to his death, there were signs his family only knows how to read in hindsight. “He had started staying away from people, stopped talking much,” his elder brother, Narendra, told me. “He was extremely worried about his children’s future.” Narendra, a 58-year-old agricultural officer, lives with his wife, Meena, in the district headquarters of Amravati, 53 kilometers away from the village.

“He would tell me he didn’t know how he could go on like this,” Meena told me when I met her in Belmandali, in November last year. “He said he wanted to die. I kept telling him it would be okay, but being so far, I didn’t realise how serious things were.” 

Regret is corrosive, and Vidarbha is dotted with it. That is precisely what Maharashtra’s efforts to check mental illnesses and suicidal tendencies are trying to prevent. Yet, Dhanpal fell through the cracks in the system at a time when this district of Vidarbha was more equipped than ever to help farmers suffering with ailing mental health. Since 2015, Amravati has been one of 14 districts with a dedicated state scheme focussed on lowering farmer suicides. The Prerna Prakalp programme was started to catch farmers while they thought about suicide and help them before they took the final drastic step. The state also built its programme on the back of one of India’s pioneering experiments in community mental-health care, which took place in Vidarbha’s Amravati and Wardha districts. 

In 2014, Ghatladki village, one kilometre from Belimandali, was picked as a site for the Vidarbha Stress and Health Programme—known by the acronym VISHRAM. It was run by two NGOs, Sangath from Goa and Prakriti from Nagpur, and funded by the Tata Trust, which wanted to intervene in the matter of farmer suicides.

Similar to pilot projects in countries from the Global South, VISHRAM asked villagers to volunteer as local health workers, and trained them to not only recognise signs of ailing mental health—depression, anxiety, alcohol dependency, psychosis and suicidal tendencies—but crucially to counsel people suffering from any of these. Instead of setting up a system to refer villagers to psychiatrists and psychologists far away from villages, VISHRAM created a body of “lay counsellors,” who would check on fellow villagers daily. 

After a few years of training counsellors, VISHRAM ran from 2014 to 2015 in 30 villages in Amravati. Its results in the medical journal The Lancet, in 2017, showed the number of people with depression who sought care rose from 4.3 percent to 27.2 percent in the 18-month period. The prevalence of depression fell from 14.6 percent to 11.3 percent, and the prevalence of suicidal thoughts in the previous 12 months went down from 5.2 percent to 2.5 percent.

While the programme was running, medicines were readily available, doctors were close at hand, volunteers provided the kind of care people had never experienced before. VISHRAM’s work also spread awareness, going some way in weaning most people away from superstition and stigma. Villagers who spent thousands on godmen, believing mental illnesses to be a curse or black magic, now put their faith in modern medicine.

Syed Yunous was one of the counsellors trained by VISHRAM. He first got involved when seeking treatment for his brother, Syed Israr. For 12 years, Israr suffered from schizophrenia-like symptoms. He had outbursts of violence, wandered away from home and would not sleep well. Yunous spent nearly two lakh rupees, over three years, to treat him at a private hospital, and around forty thousand rupees on a local godman. Under VISHRAM, with one month’s constant care and regular medication, his brother started improving. Encouraged by how well he was treated, and captivated by the idea of mental-health care, Yunous joined up to be trained as a counsellor.  He and the other counsellors were trained to be good listeners, to keep judgements out of conversations with patients. They were told to not make their questions harsh and to not chastise patients for not being able to work. Counsellors were told to ask open-ended questions such as  “What do you think of your life?” or  “What do you want to be able to do today or tomorrow?” They were taught to build trust through almost-daily visits. 

The programme ended when the Tata Trust wrapped up funding and the state government decided to start its own scheme instead of carrying on with VISHRAM. Sadhna Tayade, Maharashtra’s director of health services, told me that they could not replicate VISHRAM because of the statewide lack of manpower. However, Prerna Prakalp did incorporate much from VISHRAM, with some modifications, she said. “It’s one thing to achieve results in just one area, but we have to take care of the entire state.” 

The team that ran the pilot has fallen out of touch with the patients and counsellors, and not followed up on the state of affairs since their departure. And yet, VISHRAM has acquired a curious afterlife. Yunous and the people who were treated have given the pilot the status of the “good old days.” Years after the programme ended, he carries on as an ad hoc counsellor. His case is unique as he is the only VISHRAM volunteer to have continued work in his area, working alongside, and sometimes clashing with, the state health workers implementing Prerna Prakalp.

VIDARBHA, MAHARASHTRA’S EASTERNMOST REGION, has suffered from cyclical droughts for almost a decade, making agriculture a sector fraught with risks and losses. The toll on farmers is severe and not understood in all its dimensions. Their plight is represented in the news cycle as gruesome statistics that do not adequately capture the psychological distress of their lives. In January 2020, the National Crime Records Bureau reported that the state had seen 3,594 farmer suicides in 2018, one of the highest in the country. According to a media report, in November last year, 300 farmers killed themselves in Maharashtra, with nearly half of the deaths in Vidarbha. The death toll rose dramatically from the previous month, and was the highest for a single month since 2015. 

Continually high suicide figures have made Vidarbha a hotbed for work in community mental-health care, a model of training people from a village to be counsellors for their own community, by the state and various NGOs. The state mental-health care programmes—the Prerna Prakalp Farmer Counselling Health Service Programme and the District Mental Healthcare Programme—are built to spread awareness about the gravity of distress that may lead to mental illnesses and possibly suicide, of depression and of anxiety of the kind Dhanpal displayed in his last few days.

Disconnected, asocial behavior, obsessive worries, inability to perform daily tasks or sleep or eat well have become recognised signs of failing mental health, as observed by health workers in hospitals and in villages. “Farmer suicide is very prevalant here,” admitted Swati Sunone, Amravati’s government-appointed psychiatrist under Prerna Prakalp. “Vidarbha’s ecological balance has been distorted, and climate change is rampant.” Unseasonal rains had damaged an estimated 1.9 million cotton bales in Maharashtra, as per media reports in December. Sunone expected the worst, and was soon proved right. Through counseling under Prerna Prakalp, she said, the state tries to at least help farmers carry on working in these circumstances. Since its inception in 2015, the programme has tried to bring mental-health care to people’s doorsteps, focussing on farmers at risk of suicide and their families. Operating in 14 suicide-prone districts of Vidarbha, it has trained the Accredited Social Health Activists—women volunteers who make up the frontline of India’s health workforce—to pick up on depression, anxiety and suicidal tendencies among farmers. 

The DMHP has a broader scope, and also addresses mental illnesses such as schizophrenia, alcohol dependency, psychosis and bipolar disorders. It has stationed a psychiatrist with a team of clinical psychologists, psychiatric social workers, and psychiatric nurses in each district. They hold a medical camp for medicines and counselling in each taluka primary health centre, or PHC, every month. Though it was started in 1997, it functioned only in the district of Raigad till 2018, when the Maharashtra government expanded it to 34 of the state’s 36 districts. 

ASHAs are now the backbone for both programmes. To carry out the Prerna Prakalp survey of which households are at risk in their area, they are armed with a 12-part questionnaire that determines moderate to severe symptoms of stress. Stress and tension have, for some years, been the catchall phrases for mental illnesses in Vidarbha. If the questionnaire shows a farmer’s mental health is suffering, the ASHA calls a helpline run by a team of counsellors in Pune. If a case is quite severe, the ASHA helps them reach the District General Hospital, colloquially called Irwin Hospital, in Amravati city.

On paper, this is a model scheme, bringing mental-health care as close to the people who need it as the state possibly can. However, in practice, it is hampered by an irregular supply of medicines, the sheer distance between villages and district headquarters where the psychiatrist and medicines are available, and overworked ASHAs worried they cannot fully care for their village’s mental health. The most recent data shows that farmer suicides have not abated in Maharashtra. It is difficult to assess what impact mental-health care can make in the face of agrarian distress and crippling debt cycles. While the teams of doctors, psychologists, psychiatric social workers and ASHAs are stretching themselves thin to make programmes work, the odds are overwhelmingly stacked against them. This has led counsellors, mental-health activists and program coordinators to work creatively, often in friction with each other.

“SOMETIMES, WE HAVE TO TELL ASHAs to break guidelines,” Sunone told me, when we met in Amravati. She encouraged many ASHAs to trust their instincts instead of just the mandated 12 questions. “I tell them to call the helpline even if they just feel something is wrong in a household. If they see something on a person’s face that makes them think they need help, even if the 12 answers don’t show that.” Sunone was on her way to a meeting with Sadhna Tayade, the state’s director of health services, in Mumbai. She planned to press the case for ASHAs to get their monetary compensation for Prerna Prakalp on time—Rs 100 for each patient they called the helpline for, and five rupees for each house surveyed.

Sunone too has had to work outside the box by relying on private enterprise rather than just the state structure. In Amravati’s Chandur Bazar taluka, she and her team reach most of their patients through the help of Yunous, the tailor and farmer who received training as a counsellor under VISHRAM. Yunous has established himself as a significant link between healthcare providers and villagers. The 40-year-old either brings patients to Sunone—for the monthly medical camp at the PHC and at her clinic at Irwin hospital—or updates her on regular patients for her to renew their prescriptions.  

There’s a significant difference, Yunous told me, in how he could counsel a patient when talking to them face to face, and what could be done over the phone. “Those counsellors are too far,” he said. “They won’t know how grave a farmer’s depression is.” Ghatladki and its surrounding villages, Belmandi included, are clearly Yunous’s territory. Though Ghatladki, a village of about seven thousand7 people, has seven ASHAs, Yunous considers himself and his training a cut above them. There appears to be an ongoing turf war between the ASHAs and Yunous to reach people in the area. A psychiatrist in Sunone’s team admitted that sometimes ASHAs resent what they see as Yunous’s interference. 

To reach more people, Yunous even put out advertisements in a local newsletter distributed at the annual fair, listing signs of mental illness such as “chidchidapan” (irritation), “udasinta” (sadness), “man na lagna” (inability to focus) and “nirasha” (depression). He claims to know how to navigate angry outbursts and deep depressive states. Most of his work is simply talking to people, giving them an outlet for their worries. “If a person is getting very angry, I tell them to count backwards from ten, or wear a rubber band around their wrist and snap that a few times,” he described. “If someone is very sad, I try to make them laugh, make them watch a comedy show.”

VISHRAM’s end was a blow to him. When Maharashtra started Prerna Prakalp, Yunous disgruntledly recalled, the state took patient records from the VISHRAM team and left volunteers like him out of the work. Rahul Shidaye, a clinical psychologist and the lead author of the VISHRAM study, said the team had hoped the state would scale up the VISHRAM project. They had presented their findings and offered technical help to the district health authorities in Amravati and in Nagpur, which are Vidarbha’s two administrative divisions. “We had seen it is feasible to work with people from villages to not only spread awareness but deliver health services,” said Shidaye, over a phone interview. “It was quite a breakthrough, as before VISHRAM, this had only been seen in randomised controlled trials. VISHRAM was more real life.”  

Still, Yunous has managed to establish himself as a middleman. Though he has helped spread awareness of, and access to, mental-health care in his area, he has also diagnosed people of his own volition, and gone to Sunone in their place to get their medicines prescribed, something that has alarmed other doctors.

Since 2014, Yunous has maintained meticulous records of patients in his area. He brings his own notings of a patient’s current symptoms to Sunone whenever he feels they cannot travel to the monthly camp or to Amravati. This could be because they are too ill—such as a schizophrenic villager Yunous “diagnosed” in early 2019, who is too paranoid to leave the house—or because a farmer cannot leave his fields or a labourer cannot afford to lose a day’s wages. “I’d show the book to Swati madam,” he said, “and she would prescribe medicines.” He has also bought medicines for people out of his own pocket, or paid for a car to take patients to hospitals.

Most villagers in Ghatladki and surrounding areas are grateful to him, and Sunone and her team trust him. However, this unorthodox way of treating has not gone down well with Sunone’s colleague, Amol Gulhane, the other government-appointed psychiatrist for the district. Gulhane was one of the psychiatrists who trained local counsellors for VISHRAM. While Sunone is tasked with the field visits in Amravati, Gulhane mans the Irwin hospital’s in-patient department. He has refused to prescribe medicines to Yunous without seeing the patient and chastised him for coming in their place, which the latter resents. Gulhane is right to be concerned. As confident as Yunous is in recognising mental illnesses, he is not a doctor. The Schedule-H drugs prescribed to patients need careful monitoring for dosage and side effects. 

The tension between Gulhane’s rule-abiding ways and Sunone and Yunous’s need to be creative highlights the gaps between the healthcare people want and the limits of what the state has offered.  Gulhane too understands these, and the difficulty people face in being able to travel out of villages. The aim of community mental-health care is to treat people in their own homes, instead of at clinics. Gulhane knows that a better system can exist, such as the NGO-led programme that first trained Yunous.


THE BIGGEST DIFFERENCE BETWEEN Prerna Prakalp and VISHRAM, according to Gulhane, was manpower. “We need a psychiatrist in at least every taluka, not just every district,” he told me. The government tried that at one point during Prerna Prakalp, but soon abandoned the idea due to a lack of trained personnel. 

The other hiccup, he pointed out, was that medical officers who man PHCs are not permanently posted in one spot. Mental-health treatment works on bonds of trust between the provider and the seeker. By the time one medical officer was trained and understood the patients and their problems in their taluka, they were transferred out.

The medical officers themselves admit that the irregular medication is a problem, something villagers across Vidarbha complain about. Ravinder Kowe, a medical officer in Amravati’s Chandur Ril taluka said that Prerna Prakalp was a good programme, but was frequently interrupted because of lack of medicines. Medication for mental health often takes a long time to have an impact. If patients do not get their supply, he said, they stop taking it altogether. 

Abhishek Mamarde, a psychiatrist with the Nagpur Regional Mental Hospital who was also involved with VISHRAM, said that regular medication makes people adhere to their prescriptions. That is why they felt better sooner, and thought that the pills they got through VISHRAM were of better quality. Patients fall off their regimen when they do not get medicines in time, and feel that the drugs do not work. According to Yunous, the pilot’s work was being undone, and people were falling ill again.

In this tussle between the ASHAs and Yunous, people such as Dhanpal still fall through the cracks. Their circumstances are morbidly dire. Farmers pointed out that if two or three crop cycles fail, then they get trapped under a mountain of debt. Even if they manage to pay one loan off, there is never enough profit to take home. They have to take on another loan the next year to buy seeds, fertilisers, any other equipment they need to tend to their fields. 

“Loans are in our fate,” said 24-year-old Manjesh Satpaise, from the district’s Tunglabad village, 34 kilometres away from Amravati city. There was simply no other way to be a farmer, he explained. Till 2014, the young man was hopeful he could escape agriculture. He graduated school and found work in Pune, in an iron factory. However, his father, Ashok Satpaise, a farmer and labourer, killed himself in February 2015, bringing Manjesh back to his village. Ashok had suffered a leg injury that had prevented him from working for a few years. He died before Prerna Prakalp was launched, and Manjesh later realised his father had sunk into deep depression. “He was home alone all day,” he told me. “He felt guilty he wasn’t earning for his family. We kept telling him it wasn’t his fault, but who knows what crossed his mind?” 

Satpaise’s death was one of four in Tonglabad in 2015. It attracted enough attention that the Congress leader Rahul Gandhi visited the village, met all affected families and ensured that they received their due compensation from the state. Yet, after having paid off the loans that his father had accrued, the Satpaise family still owes Rs 55 lakh to a local cooperative bank. 

In such constantly difficult circumstances, ASHAs cannot minutely observe everyone in their village. One ASHA is in charge of a thousand people. “It is tough to identify suicidal tendencies in time,” Priyanka Dhaskat, the ASHA block facilitator for Chandur Bazar, told me. The 27-year-old supervises ASHAs in the area and conducts regular training sessions. ASHAs are trained to watch out for abnormal and asocial behaviour, she explained, but suicidal tendencies can also be sudden and impulsive, which an ASHA may not catch. “Those who do get detected get a lot of help,” Dhaskat said. “Prerna Prakalp is good to treat long-term stress.” She, too, said that psychiatrists were needed in every taluka, not just in every district. 

Despite its limitations, Prerna Prakalp has made a visible dent. Amravati’s district collector, Shelesh Naval, who has to oversee all efforts to check farmer suicides, said that the programme ran well but could be better interlinked with socioeconomic and cultural factors. “It needs a more vibrant convergence,” he said, to take into account cultural traditions, the consumption of addictive substances, and marriage customs and the money that villagers had to spend on them. 

He shared data collected by the Prerna Prakalp teams under his jurisdiction, which showed that nearly eight hundred people in Amravati received help under the programme in 2018, with the number rising to over a thousand the following year. The data is collected by ASHAs surveying the households they are responsible for, and then given to the district’s Prerna Prakalp team. A clinical psychologist on the Amravati team, Bhavana Purohit, explained that the survey was carried out between April to March of each year. According to the survey data, available from April 2019 to February 2020, Amravati’s ASHAs had surveyed 2,44,468 houses out of the 4,05,051 in the district. They had found 439 farmers with mild depression, 258 with moderate and 140 with severe depression. Numbers “zig-zagged” from month to month, said Purohit, depending on many factors. Some months were good, some not so much. For example, their data showed, in November 2019, there were 19 suicides in Amravati and in December, there were 13.

In Tonglabad, Ujwala Thorat, an ASHA worker, told me that her training might be saving her husband’s life. Her 33-year-old husband, Deewakar Manik Thorat, a soybean farmer, has a loan of Rs 2 lakh from a government cooperative bank. In 2014, his father, Manik Suryabhan Thorat, died by suicide, having been burdened by a loan of Rs 60,000, failed crops and a family wedding. Ujwala’s mother-in-law Sindhu remembered the night before his death as uneventful. In the morning, Manik went to his fields and hanged himself. 

But for almost four years before his final act, he had been unable to sleep well. He obsessed over the loan, and would scare his family with his constant anger. “When the bank would send a notice, it would make things worse,” Sindhu said. The Thorats told me that they too were visited by Rahul Gandhi in 2015, which helped them clear their previous loans. However, in 2017, they had no choice but to take on another. “It takes seven to eight thousand rupees to produce just three kilograms of soybean,” Ujwala said.

Ujwala saw similar signs in her husband over the past year and intervened. His stress spiked, his head hurt constantly, he even got dizzy spells. “My husband's stress is at the medium level,” she said, putting him on the Prerna Prakalp diagnostic scale. But because she heard out his fears, and counselled him through them, he slowly got better. The results may be slow, and limited, but Manjesh Satpasie wished his father had received similar attention. Counselling would not have paid off their loans or improved their crop yields. “But it would have given my father someone to talk to, and ease his guilt,” he said. 

This reportage was supported by the Thakur Family Foundation. The Thakur Family Foundation has not exercised any editorial control over the contents of this reportage.

National Institute of Mental Health and Neurosciences helpline number: 0804611007