Mental Healthcare in India

“There is no health without mental health” – David Satcher (Former US surgeon General)

Context:

As per the Lancet study recently released, 37% of global suicide deaths among women and 24% among men occurred in India.  This highlights the growing mental health challenge India is currently battling with.

Mental health and mental Illness

• WHO defines mental health as “a state of well-being in which every individual realizes his/her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her/his community.”
• The Mental Healthcare Act, 2017 defines “mental illness” as a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.
  • However, it does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterised by sub-normality of intelligence.

Status of Mental Health and Healthcare in India:

Mental Health:

• According to WHO Report “Depression and Other Common Mental Disorders – Global Health Estimates” (2017), the estimated prevalence of depressive disorders in India is 4.5% of the total population. Further, 38 million people suffer from anxiety disorders.
• According to National Mental Health Survey (2015-16) nearly 13% suffer from minor to major mental disorders and the prevalence of depressive disorders in India is estimated to be 2.7% of the total population
• According to 2011 Census, there were 15 lakh mentally retarded and 7.2 lakh mentally ill people in India.

Budgetary Allocation: Mental health expenditure is only 0.06% (compared to 0.44% of Bangladesh) of the total health budget.  

Infrastructure and Human Resource:

• There are only 43 government-run mental hospitals across all of India to provide services to more than 70 million people living with mental disorders.
• There are 0.30 psychiatrists (compared to China’s 1.7), 0.17 nurses, and 0.05 psychologists per 1, 00,000 mentally ill patients in the country.

Policy Approach:

1. National Mental Health Programme (NMHP), 1982: The programme was launched for detection, management and treatment of mental illness. In 1996, District Mental Health Program (DMHP) was launched under NMHP. The major components of DMHP are counselling in schools and colleges, workplace stress management, life skills training, suicide prevention services and IEC activities for generation of awareness and removal of stigma associated with Mental Illness.

2.Mental Health Act, 1987- The Act was enforced in 1993, replacing the Lunacy Act of 1912. The Act largely aimed at the regulation and administration of mental health care in institutional settings. It also included provisions for treatment of persons with mental illness in general hospitals and provisions for discharge from institutions.

3.  National Mental Health Policy, 2014: The policy aims to promote mental health, prevent mental illness, enable recovery from mental illness, promote destigmatization and desegregation, and ensure socio-economic inclusion of mentally ill people.
4. Rights of Persons with Disabilities Act, 2017: The Act acknowledges mental illness as a disability and seeks to enhance the Rights and Entitlements of the Disabled and provide effective mechanism for ensuring their empowerment and inclusion in the society
5. Mental Healthcare Act, 2017: The Act seeks to ensure rights of the person with mental illness to receive care and to live a life with dignity. The key features of the Act are:

a) Rights of Persons with Mental Illness:

• Right to Access to Healthcare– Every person shall have a right to access mental health care and treatment from mental health services run or funded by the appropriate government. It also assures free treatment to those who are homeless or below the poverty line. The Act also requires insurance policies to place mental health treatment at par with physical health.
• Right to live with dignity: Every person with mental illness shall have a right to live with dignity
• Right to Confidentiality: A person with mental illness shall have the right to confidentiality in respect of his mental health, mental healthcare, treatment and physical healthcare

b) Advance Directive:

The Act empowers person with mental illness to make an advance directive that states how he/she wants to be treated for the illness and who his/her nominated representative shall be.

c) Authorities:

• The Act mandates the government to set up Central Mental Health Authority at national-level and State Mental Health Authority in every State.
• Further, every mental health institute and mental health practitioners including clinical psychologists, mental health nurses and psychiatric social workers will have to be registered with the Authority.

d) Mental Health Treatment:

• A mentally ill person shall not be subjected to electro-convulsive therapy without the use of muscle relaxants and anaesthesia. Further, electroconvulsive therapy cannot be used on minors
• Sterilisation will not be performed on such persons.
• They shall not be chained in any manner or under any circumstances
• They shall not be subjected to seclusion or solitary confinement.

e) Decriminalization of Suicide: Until recently suicide was a punishable offence under IPC Section 309. The Act decriminalizes suicide stating whoever attempts suicide will be presumed to be under severe stress, and shall not be punished for it.

Issues and Challenges:

1. Issues with Mental Healthcare Act, 2017:

a) The Act neglects the prevention and promotion of mental well-being and recognizes mental illness as a clinical issue which can only be treated by medicines and clinical procedures.

b) The Act does not provide a clear procedure for preparing the Advance Directive. Further, doctors are of the opinion that they are in the best position to take decisions on aspects of treatment since patients or their nominated representatives may have limited knowledge on mental health and mental illness.

c) The Act provides a narrow and restricted definition of mental health professionals and does not include psychotherapists, counsellors and psychoanalysts.

d) Further, given the infrastructural and human resource constraints, the implementation of the Act poses a huge challenge.

2. Treatment Gap: According to estimates nearly 92% of the people who need mental health care and treatment do not have access to any form of mental health care.

Note: Treatment gap is the difference between those suffering from mental illnesses and those availing medical/psychiatric care

3. Mental Healthcare Resources:

• Mental healthcare resources in India are inadequate with poor infrastructure and abysmally low number of healthcare professionals.
• Further, there is huge rural-urban disparity with most of the mental healthcare facilities being concentrated in urban areas.

4. Social stigma: A potent mix of superstition, social stigma and discrimination and reliance on ‘faith healers’ is a major concern. Lack of awareness and illiteracy contributing to social stigma further aggravates the issues related to mental health and hinders treatment and social inclusion of patients.
5.  Economic Burden: The economic burden of mental illness contributes significantly to the treatment gap in India. There are both direct (cost of long-term treatment) and indirect costs (,the inability of the patient and caregiver to work, social isolation, psychological stress) contribute significantly to the economic burden.
6. Human Rights Violation: Violations of human rights have been reported in mental asylums and also at homes and places of traditional healing. In India, mental hospitals still practice certain obscure practices that violate human rights. Further poor infrastructure such as closed structures, a lack of maintenance, unclean toilets and sleeping areas etc clearly violate the basic human right to a life with dignity.

Example: Erwadi Tragedy

In 2001, 28 patients who were chained at a home for mentally-ill people died after a fire that engulfed the home in Erwadi village in the Ramanathapuram district (Tamil Nadu)

Civil society initiatives:

1. Atmiyata Project:

It is a community led project which aims to improve community awareness and facilitate access to both mental health and social care. Community volunteers are trained to provide psychological counselling, social care and referral services to those with mental health problems

2. The Live, Love, Laugh Foundation (TLLLF), started by actor Deepika Padukone:

The foundation has partnered with Association of People with Disability (APD) to enhance rural mental healthcare in Davangere district, Karnataka. It has also taken up different other projects such as ‘You are not Alone’ (a school awareness programme), ‘Together against Depression’ (a doctor’s awareness programme) and ‘Dobara Pucho’ (a public awareness programme on mental health)

3. SAATHI: It is a South-Asian Mental Health Outreach Program of ASHA International which aims to promote awareness about mental health and emotional wellbeing, improve access to care and connect people to community supports and wellness resources

India’s International Commitments:

1. Sustainable Development Goals:

SDG 3: Good Health and wellbeing

• Target 3.4 “By 2030, reduce by one third premature mortality from Non communicable diseases through prevention and treatment and promote mental health and well-being.”
• Target 3.5 requests that countries: “Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.”

2. UN Convention on Rights of Persons with Disabilities

The Convention identifies mental illness as a disability and seeks commitment from ratifying countries to promote human rights and fundamental freedoms by all persons with disabilities and promote and respect their inherent dignity. India’s Mental Healthcare Act, 2017 has been formulated on the lines of the convention.

Best Practice

WHO recognizes mental healthcare system in Thiruvantathapuram, Kerala as a best practice. Since 1999, Thiruvananthapuram District has integrated mental health services into primary care. Trained medical officers diagnose and treat mental disorders as part of their general primary care functions. Further, a multidisciplinary district mental health team provides direct management of complex cases and in-service training and support of primary care workers. Free and timely and adequate availability of psychotropic medications in the clinics has reduced the economic burden of patients.

Way Forward:

1. The government should make appropriate budgetary provisions to address the existing infrastructure gaps.
2. Proper survey should be conducted to identify shortages in mental health professionals and operational barriers to effective implementation of mental health programs
3. There is an urgent need of easily available diagnostic test and low cost treatment to provide better primary mental health care. Further, the government should ensure insurance covers for mental illness to reduce the economic burden
4. Early Interventions:

• There is a need to create living conditions and environment that support healthy mental health. It is important to develop a society that respects and protects basic, civil, political, and cultural rights
• It is important to aim at child development by early childhood interventions like preschool psychosocial activities, nutritional and psycho-social help
• To reduce the burden of mental disorders in women, there is need to ensure socio-economic empowerment and safety of women.  

5. It is important to generate public awareness about the commonness of mental disorders, understanding of mental disorders as illnesses, treatment and the importance of acceptance by the family and the community.

6. Coordinated efforts from all stakeholders (government, medical fraternity, civil society, educational institutions, family, peer group and community) are needed to address the growing concern of mental health in India.