Mental illness is a leading cause of disability, with 450 million people affected globally1,2. In low- and middle-income countries, mental illness accounts for more than 70 per cent of the population3,4, with about 90 per cent having limited access to specialist care5,6. India faces a considerable burden with over 197 million diagnosed with one or more mental illnesses5-9. The magnitude of the problem might be different among tribal populations considering their unique and diverse living conditions – with variations in cultural beliefs and traditional healing practices10,11. Comprehensive data and an understanding of the mental health issues in tribal communities are thus critical for developing culturally acceptable mental healthcare interventions.
India has the world’s second largest tribal population. Indian tribes account for approximately 8.3 per cent of the country’s total population. There are 635 tribes in India, divided into five major tribal belts, and they inhabit hilly and plain forest regions. Mental disorders are on the rise as urbanization continues. It is therefore, critical to address healthcare needs of the tribal communities to meet the 2030 Sustainable Development Goals (SDGs). Without prioritizing and focusing on the healthcare needs of the country’s indigenous populations, achieving SDGs will be challenging12. However, the extent of mental health problems amongst tribal populations is unknown. Against this background we systematically reviewed community-based studies on mental health issues among tribal populations in India.
Material & Methods
Data sources: An online search was conducted for studies examining mental health morbidities among Indian tribal populations. Articles were searched on PubMed, Embase, ProQuest databases and Google Scholar. In addition, the reference lists of all included papers were checked to identify any omitted relevant articles. Two of the authors (PV and KCS) assessed the identified publications independently to determine their eligibility for inclusion, discrepancies were sorted by another author (PM).
Inclusion and exclusion criteria: Mental health issues were defined in this review as conditions related to psychosis, mood disorders, anxiety disorders, alcohol and other substance use disorders, personality disorders or developmental disorders or other related mental health issues. Studies indicating habitual use of a substance and excessive use of alcohol were included. We did not include smoking/tobacco use as their presence does not per se indicate a mental health problem. Community-based quantitative observational studies focussing on tribal communities and generating primary data were included and studies dealing with only a subset of tribal population were excluded. Studies examining secondary data were excluded as well.
Search strategies and quality assessment: The following search strategies were used to identify studies published between January 1, 1990 and May 31, 2021 and in English: ‘Mental disorders’(Mesh) OR ‘Psychological phenomena’ (Mesh) OR ‘Mental disorders’ OR ‘Psychiatric*’ OR ‘Post trauma’ OR ‘Suicide’ OR ‘Psychiatric disorder*’ OR ‘Psychiatric diagnosis’ OR ‘Behavior disorders’ OR ‘Severe mental disorder*’ OR ‘Psychological phenomenas’ OR ‘Psychologic processes and principles’ OR ‘Psychologic processes’ OR ‘Psychological processes*’ AND ‘Indigenous peoples’ (Mesh) OR ‘Indigenous peoples’ OR ‘First nation people*’ OR ‘Native people*’ OR ‘Tribal people*’ OR ‘Tribal population’ OR ‘Tribal community’ OR ‘Tribal culture’ OR ‘Schedule Tribe*’ OR ‘Under privileged societ*’ OR ‘Tribe*’ OR ‘Adivasi*’ AND ‘India’ (Mesh) OR ‘India’ with all State names and all types of tribes in India. All relevant studies were evaluated for a quality check using the JBI critical appraisal checklist for studies reporting prevalence data (Table I)13-23. We assessed the study design, sampling procedure, comparison, assessment tool and analysis methods. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered on PROSPERO (CRD42020178099).
Data extraction and synthesis: Two authors (KCS and PV) extracted data independently using the refined standard excel sheet; all authors refined the file through insertion of comments. Each study was examined to obtain the following information: study location (State), major tribes, sample size, participant age, scale or instrument used to measure problems and mental health issues. We presented the data using descriptive statistics, on frequency (n) and percentage (%) to capture the magnitude of mental health issues among tribal population and used meta-analysis using random-effects models with MetaXL software version 5.3 in MS Excel 2016 to determine the pooled prevalence of alcohol use disorder with construction of a forest plot. Following sensitivity analysis, we excluded the alcohol use disorder results of Ray et al19 in 2018 study (72%, AUDIT score); however, I2 value was still high at 99 per cent. Sensitivity analysis after excluding two more studies, Negi et al18, 2016 (24.9%, used WHO Step Survey instrument) and Sadath et al20 in 2022 (17%, used self-reported cases), I2 value was about 85 per cent. We finally included results of four studies that assessed alcohol dependency using pre-decided tools.
A total of 935 articles were identified of which 63 were selected for full-text review after the title and abstract screening. A total of 11 studies were finally included after full-text review. The PRISMA flow chart is shown in Figure 1.
Study characteristics: The following was the geographical distribution of the 11 studies selected for full-text review; Arunachal Pradesh (n=4), West Bengal (n=2), Kerala (n=2), Jharkhand (n=1), Himachal Pradesh (n=1), Rajasthan and Madhya Pradesh (n=1). The number of study participants ranged from 172 to 3582, with four studies having participants, number in greater than 2000, two studies including more than 700-750 individuals, three studies recruiting a population more than 200 and two studies including less than 200 participants. The Adivasi, Adiyar, Bhutia, Idu Mishimi, Kanaladi, Kanduvadiyar, Kattunaikkar, Khamti, Kurama, Kurichyar, Mullukkurumar, Munda, Oraon, Paniya, Santhal, Singhpho, Tangsa, Thachanadar and Tutsa were the major tribes studied in these investigation. However, two studies did not provide information on the individual tribes18,19. The mean age of the participants varied between 18 to 60 yr, with a range from 13 to 85 yr, and two studies did not record participants’ age. A brief description of the 11 studies included in final review is presented in Table II13-23.
Study outcomes: Substance use was presented as the major mental health issue by most of the investigators; seven presented on alcohol use disorder14-16,18-20,22 and one opium use15. The pooled prevalence of alcohol use disorder was 40 per cent (37-44%) (Fig. 2); opium use was 7.8 per cent.
Suicidal attempts were recorded in two studies21,22; prevalence being 14.2 per cent (n=31) and 22.03 per cent (n=39), respectively. Both these studies were conducted in Arunachal Pradesh. Using a self-reported questionnaire Hackett et al17 in 2007 found that 27 per cent (n=195) of the Paniya and Kurama tribes had common mental disorders. A study conducted in Jharkhand revealed behavioural and emotional issues among 13-17 yr old Munda, Santhal and Oraon teenagers13. Conduct issues (9.61%), emotional symptoms (5.12%), hyperactivity (4.23%) and peer problems (1.41%) were identified. In Arunachal Pradesh, a study using a patient health questionnaire found stress-related and somatoform disorders (anxiety 6.4%) and mood disorders (depression 8.3%) among the Idu Mishimi tribes22. Using the Positive and Negative Emotion Health Scale (PANAS), a recent study in the States of Rajasthan and Madhya Pradesh assessed the reaction to severe stress and adjustment disorders (distress 0.9%) amongst 23-53 yr old Adivasi communities23. Table II provides a detailed description of mental illness identified.
Methods of diagnosis: The tools used for mental illness assessment and diagnosis by various studies were ‘Strengths and Difficulties Questionnaire’, ‘WHO STEPS survey instrument’, ‘AUDIT scores’, ‘Columbia Suicide Severity Rating Scale’ and ‘Positive and Negative Emotion Health Scale’. However, the majority of the studies used predesigned and pretested questionnaires.
Understanding tribal populations’ mental health morbidities are necessary to address their wellbeing, and to develop culturally appropriate interventions and align healthcare systems accordingly. This systematic evaluation of community-based studies to ascertain the prevalence of mental health problems among Indian tribals was a step toward this direction. We identified eleven studies addressing mental health issues in tribal populations. However, fewer studies targeted primitive tribes, particularly vulnerable tribal groups (PVTG). These investigations used various techniques, and included substance use including problem alcohol use, anxiety, depression, suicide and other mental health morbidities. Our findings highlight the necessity of using uniform study methodologies that will make use of standardized tools help compare the prevalence of mental health problems in tribal populations.
This review attempted to explore mental health issues, and most of the studies addressed problem alcohol use14-16,18-20,22. This might be because alcohol use is culturally accepted among tribal populations with limited awareness about its harmfulness24. Few studies addressed other mental health conditions such as depression and anxiety. To estimate the actual prevalence of mental disorders in tribal populations, developing culturally appropriate tools will be necessary. This was attempted by a group of researchers23; prevalence of mental health morbidities recorded by them differed from other investigation. Many studies explored substance and alcohol use, but fewer studies examined other mental health issues.
The majority of research has been on tribal groups that live in rural areas and cohabit with non-tribal residents. Only a few studies are conducted exclusively on indigenous populations. Isolated indigenous populations may experience unique mental health challenges. Likewise, communities cohabiting with non-tribal groups may have altered traditional beliefs and living arrangements, resulting in a variety of other mental health concerns. The study designs and procedures also varied significantly. For example, two studies assessed the prevalence of binge drinking while focusing on the detection of non-communicable diseases (NCDs). Prior national studies detected high prevalence of substance use and earlier qualitative research revealed that peer influence, traditional beliefs and cultural acceptance, all contributed to the early exposure of local tribal community to practices related to alcohol use24.
Identifying mental illness in the tribal community is complicated and ambiguous. Using self-administered questionnaires, in tribal populations may not record the prevailing mental diseases among study groups13,17, as cultural contexts influence perceptions about diseases. Nonetheless, Snodgrass et al23 attempted to create a scale for identifying mental disorders that is more relevant in the regional tribal cultural context. Psychological factors contributing to the high rate of suicide in some tribal society has been explored21,22. However, absence of psychiatric clinics preclude further in-depth assessment. Some of the investigations used in this review determined the prevalence of cigarette, alcohol and opium usage14-20. Given that most of these studies on substance use were conducted to ascertain the prevalence of risk factors for NCDs in the tribal population, the emphasis was placed on current cigarette and alcohol use. In addition, given the diversity of tribal cultures, authors’ interactions with tribal people are crucial for understanding their cultural context.
In 1982, the Indian government launched its first National Mental Health Programme (1982) to ensure universal access to primary mental healthcare25,26. As part of this programme, the District Mental Health Programme was established to improve mental health care. However, this programme did not have indigenous population’s mental health care needs in consideration. Indigenous people are primarily rural and marginalized members of the society. Their remote habitats lack basic minimum healthcare infrastructural support, and the indigenous mental health agenda has remained ignored and neglected for long, which is a prominent policy implementation gap. As a result, they deserve special considerations when it comes to healthcare27-30.
Strengths and limitations: Although prevalence of psychological morbidities in a tribal community cannot be determined by conducting small scale studies, this review has systematically captured available investigation and illustrated the research gap and emphasized the need for future in-depth research. However, our review has certain limitations. The tribes and tribal regions addressed by the studies we synthesized are few as compared to those present in India. Moreover, most of the studies were cross-sectional, and there was heterogeneity in the methods followed and tools used. The results obtained from these studies cannot therefore be generalized.
In conclusion, this systematic review established that only a few community-based studies have been conducted on mental health issues among tribal populations over the last three decades. Of them, even fewer studies focused exclusively on tribal communities. A limited range of mental health issues, primarily alcoholism, anxiety, depression and suicide were explored by these investigations.
Acknowledgment: The authors acknowledge Dr Banamber Sahoo, Library and Information Officer, for his support and Dr Girish C. Das for helping in the meta-analysis.
Financial support & sponsorship: None.
Conflicts of Interest: None.
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