Invisible Wounds: Confronting Mental Health Challenges in the Indian Navy

INTRODUCTION Suicides and suicide attempts have a ripple effect that not only adversely affects the individual but also has an impact on families, colleagues, friends, communities, and societies, at large. Asia accounts for approximately 60% of global suicides.[1,2] Countries, namely China, India, and Japan account for almost 40% of the world’s suicides. Suicidal behavior is a significant public health problem in nations with large standing Navies. A few aspects that are peculiar to the Navy, namely depression due to prolonged periods of separation from family, alcohol/substance abuse, posttraumatic stress disorders (when exposed to active conflict), etc., are known risk factors for the increase in suicidal tendencies. Moreover, naval personnel have differential access to firearms, a common means of suicide in some countries. Data brings out that there has been a rising trend in mental health issues such as intentional self-harm/suicide cases in Indian Navy over the last decade. The causes of suicide range from personal issues like marital discord, relationship complications, and financial problems to some service-related issues like leave, etc. This editorial intends to review the existing strategies of suicide prevention in the Navy and suggest new measures, as even one life lost to a suicide is one too many. EXISTING SUICIDE PREVENTION STRATEGIES The suicide prevention strategies presently in-vogue in Indian Navy can be broadly classified as primary and secondary prevention strategies. Primary prevention strategies Primary prevention strategies include a concerted effort to have a robust divisional system for the early resolution of service-related factors like leave, non-adjustment with service life, etc. Group activities such as picnics, games, and recreational activities are organized at the unit level to foster comradery. An attempt to foster positive Mental Health through various means like regular Yoga/pranayama, physical training during the day, etc. Lectures/case-based interactive sessions, movies, posters, and fact sheets to take care of mental health issues such as marital discord, relationship, and financial issues are being organized regularly at unit and station levels. Secondary prevention strategies Early identification of sailors showing signs of stress or social reclusivity is an important step. Station Mental Health Centres (SMHCs) in each command for serving personnel and their dependents under the Station Commander have been created with the availability of Clinical/Counselling Psychologist, Social Worker, Yoga Teacher, and Medical Assistant (MA) qualified in Psychiatric Nursing. Effective implementation of the battle buddy approach is emphasized, in which each buddy is expected to assist his partner. He is best placed to observe the changes in behaviors of his/her partner and in case of any warning signs, early evaluation through health channels is being facilitated. In strategy for mental health assistance, resilience, and training To combat this menace and to positively impact Mental Health in Indian Navy, there was a felt need for an out-of-box initiative. A thorough research was undertaken by this Directorate General on the directives of the Chief of the Naval Staff. Best practices being employed by countries having large standing Armed Forces were studied. Post-deliberation by all stakeholders, a Indian Navy Strategy for Mental Health Assistance, Resilience, and Training (IN-SMART) was promulgated. Further, based on the feedback from the environment, an amplifying instruction was also. The essential components of this new suicide prevention ecosystem are appended: Mental health assistance The activities for Mental Health Assistance include interactive and counselling sessions conducted by the Unit Mental Health Resilience Coordinators (UMHRCs), Ships/Unit Medical Officer, counsellors at SMHCs, Psychiatry departments of the Naval hospitals, and experts handling tele-helplines. Mental health resilience The concept of trained UMHRCs would augment the Mental Health Resilience of the personnel at the unit-level (especially, those borne in operational units) who can be a single point of contact for Mental Health Issues. Personnel can seek help from UMHRCs without stigma and with no fear of their identity being disclosed. Mental health training and awareness It includes the training of the trainers, training of all nodal officers, awareness programs at the station, and unit level conducted by experts. A half-day training capsule has been incorporated in the curriculum at all training courses of more than 4 weeks’ duration. Objective follow-up The implementation of the strategy will be followed-up objectively with certain specific indicators that include details of Mental Health Training programs in various stations under the Administrative Area (including a number of medical officers, nonmedical and paramedical personnel trained) and Mental Health Awareness programs, lectures, topics, and number of attendees/beneficiaries. Six hundred and sixty-one Interactive sessions on Secrets of Communication, Happy Married Life, Digital Detox, etc., have been conducted by the Psychiatrists/Community Medicine Specialists/Medical Officers/Domain Experts for Naval personnel across Indian Navy, since the promulgation of the Strategy. Workshops by Art of Living, Isha Foundation, and Bharamkumaris/Sister Shivani have been undertaken. Almost, entire naval forces have benefitted from the interventions under this Strategy, since its promulgation. Sixty-day resilience program The Chief of the Naval Staff had directed all stakeholders to commence a 60-day resilience program focused on enhancing Mental Health Strength and inner harmony. A total of 485 activities were conducted under this initiative. It was well received by the naval personnel and their dependents and was successful in fostering a positive mental health ecosystem in Indian Navy. The activities of creating awareness, resilience-building, and facilitating professional help provided a stimulus to IN SMART. DISCUSSION The suicide rate in Indian Navy is less than the suicide rate in the general population of India, which is 12.4 per lakh.[3] It is also lower in comparison to the rates in large militaries such as the USA, France, Canada, Australia, Sweden, and Ukraine.[4] After examining the International best practices in suicide prevention and existing strategies in Indian Navy, it has been brought out that strategies being employed in the service cover almost all the best practices Internationally validated. Inputs on the implementation of the current strategy have brought out that SMHCs have been set up at Station Health Organizations, “Keep Your Mate Safe” training sessions for courses more than 28 days have been promulgated along with the curriculum, Mental Health capsule course for MAs is being conducted at MA training school, lectures and case-based interactive sessions are being conducted by commands at regular intervals. There exists a toll-free pan Navy 24 × 7 Suicide Helpline “Manobal”, exclusively for Indian Navy personnel. Furthermore, MoHFW has established a dedicated Tele-Manas node for Armed Forces personnel and their dependents at a Medical College in Western India for the benefit of all three Services. Tier-I (psychological counsellors) and Tier-Il (psychiatrists) counselling services are available for the personnel in distress at this node. Furthermore, a Wellness Centre “Niramaya” has been established at the Command Hospital of the Service to provide a wide range of Mental Health counselling services for the naval community. Telephone, video-chat, and physical consultation by trained psychological counsellors are available daily at the centre. Suicide is a multifactorial, complex behavior being influenced and modified by genetic, environmental, and cultural influences.[5-7] Suicide in the military also has special significance with certain aspects of military service that can lead to serious mental disorders that increase the risk of suicidal behavior despite military organizations having control over a broad range of factors (notably the direct delivery of mental health care) that could mitigate suicide risk.[8] In view of the above, it can be summarized that Naval personnel have a basket of choices to fall back on if they feel mentally distressed and feel the requirement of professional help in case of a psychological crisis. However, the measures to increase Mental Health resilience among naval personnel should be evolving and constantly align with feedback from Inquiries conducted after each case of a suicide. Recommendations Every effort should be taken to destigmatize and early identification of mental illnesses. Generally, there is a tendency to ignore mental health issues; however, it is pertinent to mention here that there is no difference between a physical and a mental illness. Following are some of the recommendations to further augment organizational capability and add resilience to the Mental Health Ecosystem in Indian Navy: (a) Mental Health awareness should commence when a candidate undergoes abinitio training and subsequently periodic training on coping skills must continue throughout the service at regular intervals. For this, training establishments and units may employ or outsource trained civilian psychological counsellors (b) Reinforcement of positive Mental Health during all structured courses subsequently undertaken by sailors and young officers may be done, so that mental health awareness is internalized by all. It is important to note that these reinforcement sessions should be part of mainstream training and not as an add-on activity (c) Modern-day menaces such as online gambling, Ponzi schemes, and vulnerability to honey trapping due to being part of the Armed Forces, require focus and constant sensitization by the Divisional hierarchy and embedded provost personnel of the Unit. The feasibility of using artificial intelligence to identify unusual patterns of financial transactions may be explored by the Naval Pay Office (d) Alcohol and substance abuse literacy programs may be undertaken to reduce substance abuse-related mental and physical morbidity (e) To comprehensively analyze the reasons for suicide in each case and develop scientific measures to counter the same, there is a requirement for designated training school/unit as Incident Study and Analysis Cell. A bank of anonymized case studies can be developed, based on Bol findings of suicide analysis and can be used as training material during various courses including Commanding Officer/Executive Officer Pre-Commissioning Training (PCT) courses (f) Wide Publicity of existing Mental Health initiatives like Helplines-Manobal/Tele-Manas and Services like Niramaya should be continued. In addition, Posters/Standees/Banners should be displayed at prominent places emphasizing all the above (g) There are more than 70 Mental Health and Physiological Counsellors Course trained senior sailors, who can be judiciously posted to training establishments and Ships. This will augment the availability of Psychology-trained (Non-Medical) personnel (h) Divisional Officers and Divisional Chiefs have potential for the early identification of vulnerable individuals. Therefore, the Divisional System as first-line responders has a pivotal role in addressing the challenges associated with stigma and facilitate referral to the Medical experts. CONCLUSION IN SMART ecosystem has added much-needed dynamism that is required in tracking a problem as complex as suicide. The strategy is intended to make continuous definitive and concerted efforts to achieve the ultimate goal of mental wellness among the personnel of Indian Navy and the reduction of suicides in the service. Any mental health program would succeed only if it is leadership-driven and the implementation is closely monitored by the Commanding Officer at the Unit level and Commanders at the Station level.

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