Employment in people with severe mental illnesses receiving public sector psychiatric services in India
Introduction
Severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have a profound impact on occupational functioning, with rates of employment generally below 25% for people living in developed countries (Jonsdottir and Waghorn, 2015; Marwaha et al., 2009). In contrast, research suggests higher rates of employment for people with SMI who are living in developing countries. For example, studies report work rates between 40% and 76% for persons with SMI living in India (e.g., Srinivasan and Tirupati, 2005; Srivastava et al., 2009; Thara, 2004), and between 52% and 77% for people with SMI in China (Ran et al., 2011; Xiao et al., 2015; Yang et al., 2013).
Despite the evidence suggesting higher rates of work for people with SMI in developing countries, many studies have significant methodological limitations. For example, almost all studies lack important information about work, including types of jobs, employers, hours worked, and income earned, and none have examined the perceived benefits of work or problems related to work. Some studies had small samples and excluded women (Prasad and Acharya, 2014; Srinivasan and Thara, 1997). Additionally, few studies from developing countries have evaluated interest in work among unemployed persons (Nagaswami et al., 1985). As vocational rehabilitation is generally not available in developing countries, such information is critical to the development of vocational services for people with SMI in these countries.
In order to better understand work functioning in people with SMI in developing countries we conducted a two-site study of employment in 550 people who were receiving private psychiatric outpatient treatment and were living in urban or rural areas in India. The findings indicated that 60.9% of participants were working, with higher employment rates in rural than urban areas, largely due to working in family owned farms (Khare et al., 2020). A high proportion of unemployed people were interested in work (77.4%), similar to studies in developed countries (Frounfelker et al., 2011; McQuilken et al., 2003; Mueser et al., 2001; Westcott et al., 2015). Further, most participants wanted assistance with work, such as help finding a job or coping with mental illness. The findings suggest that many unemployed individuals are interested in work and could benefit from vocational services tailored to their unique cultural context.
The participants in Khare et al. (2020) were receiving outpatient services at private hospitals, which are common treatment providers in India and other developing countries (Indian Ministry of Statistics and Programme Implementation, 2019; Mackintosh et al., 2016). While both public and private treatment providers charge for services in India and some other developing countries (Dixon et al., 2006; Rajkumar, 2015), public sector services are provided at no cost to families who cannot afford them (Aljunid, 1995). The likely differences in economic standing between people receiving public vs. private sector psychiatric services suggests that employment rates might be higher in the former group due to their greater incentive to work. Indeed, Khare et al. (2020) reported that employment rates among participants receiving private psychiatric services were higher in those who had lower family income. On the other hand, family economic resources other than income could also be important, such as whether the family owns a business that could employ the relative with SMI. The current study addressed these questions by examining employment in people with SMI who are receiving outpatient services at a public hospital in India.
Other under-studied topics include interest in working among unemployed people receiving public sector psychiatric services in India, and motivation for work among those who are employed. Studies from developed countries suggest that although money is an important motivator for work, other benefits of work are frequently reported, such as help coping with psychiatric symptoms, improved self-esteem, and making social connections (Arns and Linney, 1993; Dunn et al., 2010, 2008; Marwaha and Johnson, 2005; Netto et al., 2016). From a broader perspective on motivation, these reasons for working align with Maslow's (1954) hierarchy of needs theory, which posits that lower level needs (physiological, safety, belongingness) must be fulfilled before attending to higher level needs such as self-esteem and self-actualization. Developing countries are characterized by poorer economies than developed countries, and usually do not provide disability payments for SMI, which may contribute to the need to work to earn a living. Unemployed people receiving public sector services may have a particularly strong motivation to work to improve the economic conditions of their family.
Lastly, there is limited information about what hinders work among unemployed people with SMI in developing countries. Qualitative studies from China, India, and South Africa indicate that the stigma of mental illness is a barrier to work (Loganathan and Murthy, 2011; van Niekerk, 2009; Zou et al., 2014), although it was not identified as a major obstacle in Khare et al. (2020). Studies from India and Nigeria suggest that a range of other factors may interfere with employment in people with SMI, including symptoms, medication side-effects, physical health problems, inadequate skills or education, and lack of family or social support (Eaton, 2008; Thomas et al., 2019), consistent with studies from developed countries (Henry and Lucca, 2004; Honey, 2004; Marwaha and Johnson, 2005). A study with integrated quantitative and qualitative methods evaluating barriers to work could improve the understanding of factors impeding employment, similar to studies conducted in developed countries (e.g., Kukla et al., 2015).
To address these questions, this study examined work functioning in people with SMI receiving psychiatric outpatient treatment from a public hospital in India using the same methods as Khare et al's (2020) study of people receiving private treatment. In addition to the evaluation of specific types of work and other characteristics of employment (e.g., employer, hours worked), the perceived benefits and problems related to work were examined. Furthermore, interest in work, barriers to employment, and desired job supports were ascertained among the unemployed participants.
Section snippets
Method
The study was conducted at the psychiatry outpatient department of the Regional Mental Hospital, a public hospital located in the city of Pune which serves several districts in the western part of the state of Maharashtra, India. The Regional Mental Hospital is the largest psychiatric hospital in India, with an inpatient capacity of over 1500 beds. The outpatient department serves approximately 200 patients per day. The study was approved by the Directorate of Health Services, Government of
Characteristics of study participants
The characteristics of the study participants are presented in Table 1. The mean age was 39.3 years old and the mean duration of psychiatric illness was 13.4 years. The majority of participants were urban dwellers (82.7%), male (65.3%), and ever married (64.0%). Thirty-one percent had a 12th grade or higher education level. Most of the participants had schizophrenia or schizoaffective disorder (90%), and a history of psychiatric hospitalization (89.3%). None of the participants reported being a
Discussion
The rate of employment among the 150 participants with SMI who were receiving psychiatric outpatient treatment at a public hospital in an urban district in western India was 40%. This rate is lower than the employment rate in the general population in India (World Bank, 2011), but similar to other studies of work in people with SMI in urban areas in developing countries (Midin et al., 2011; Prasad and Acharya, 2014; Rahman and Indran, 1997; Srivastava et al., 2009), underscoring the global
Funding
This research was not supported by any public, commercial, or not-for-profit organization.
CRediT authorship contribution statement
Chitra Khare: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing - original draft, Visualization, Project administration. Kim T. Mueser: Conceptualization, Methodology, Writing - review & editing, Supervision. Madhumita Bahaley: Resources, Writing - review & editing. Sigal Vax: Formal analysis, Visualization, Writing - review & editing. Susan R. McGurk: Conceptualization, Methodology, Writing - review & editing, Supervision.
Declaration of Competing Interest
The authors declare that they have no conflict of interest.
Acknowledgments
We are grateful to the Directorate of Health Services, Government of Maharashtra, India for giving us permission to conduct the study at the Regional Mental Hospital, Pune. We would like to thank the psychiatrists, medical officers and staff of the Regional Mental Hospital, Pune, and staff at the Center for Psychiatric Rehabilitation, Boston University, and the study participants. We are thankful to Renee Spencer Ph.D., for providing feedback on the earlier version of the qualitative analysis
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