State of Mental Healthcare in India

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Mental Healthcare as an issue holds a muted visibility in the realms of Indian policy-making. The Mental Healthcare Act, 2017 was passed by Parliament only this April after a long wait of 3 years. With another World Mental Health Day passing by in October, it is only appropriate to take stock of the situation in India.

The World Health Organisation (WHO) in its latest report estimates that over 300 million people globally live under depression; the figure resulting from c.18% annual growth between 2005-2015. When it comes to the state of its mental health care, India stood a lowly 11th on a comparison of 15 countries from Asia-Pacific according to The Economist Intelligence Unit.

Indian youth of ages 15-29 years have the highest suicide rate in the world at 35 deaths for every 100,000 people. 14% of Indians suffer from one form of mental disorder or the other with 11% requiring immediate attention as per the National Mental Health Survey. Moreover, the fear of social stigma ensures that nearly 80% of patients do not receive any treatment, even a year after exhibiting the initial symptoms.

The problem only gains intensity in urban areas thanks to long work hours, strained relationships, tiring commute, a consumerist culture, support system breakdown and rising economic instability. Substance abuse and social anxiety do not help.

Infrastructural bottlenecks

Access and affordability of treatment is the big challenge. There are only 43 government funded mental hospitals in the country serving an estimated 50 million plus patients. This translates into around 3 psychiatrists, even fewer psychologists, less than 2 specialist nurses, and 1 mental healthcare social worker for a million Indians. Government’s spend on mental health is just 0.06% of its total health budget vs. a standard 5-7% contribution in developed nations.

India’s health budget as a proportion of GDP is already one of the lowest in the world. It is no wonder insurance companies cherry-pick and refuse to protect mentally-ill patients, thereby making admission to a good hospital out of reach for most.

Mental Healthcare Act (2017)

The Mental Healthcare (MHC) Act (2017) repeals the previous legislation passed in 1987 to be in line with present needs and international norms. The Act seeks to ensure compliance with the UN Convention on the Rights of Persons with Disabilities (UNCRPD) to which India became a signatory in 2007 by formulating guidelines around the treatment of mental illness.

The law now defines mental illness as a disorder of thinking which greatly impairs judgement, behaviour or the cognitive capacity of the person. It includes conditions associated with alcohol and drug abuse. This is in sharp contrast to the previous definition which simply sought to define a mentally ill person as someone needing treatment for a recognised mental disorder.

Hence the subject is not looked at in a linear fashion as an ailment requiring treatment, but instead as a condition manifesting itself when the affected person interacts with family and society. For the first time, an Indian legislative framework upholds the right to confidentiality, right to free treatment for those below the poverty line, right to legal aid, right to live with dignity and the right to seek redressal in case of deficiency in treatment.

The government has directed to set up Mental Health Authorities in all States and the Centre, with every mental healthcare institution and practitioner including clinical psychologists, specialist nurses, and psychiatric social workers requiring registration to plug-in any gaps in accountability.

Every insurer is obligated to provide appropriate cover for mental illness on the same basis as other “physical” illnesses. This will smoothen the road to accessibility and affordability for many. The Act stipulates provisions for “advance directives” by which the patient can choose/refuse the specific treatment they want to undergo. This comes as a significant departure from the earlier law of 1987 which did not recognize the decision-making capacity of a person suffering from mental illness.

A Mental Health Review Board i.e. a quasi-judicial body will be constituted to protect the rights of persons with mental illness and manage the procedure of advance directives. However, the Board has been given discretionary power to dismiss a patient’s decision if these are made in a moment of incapacity which could be misused.

Suicide which was earlier a punishable offence under the Indian Penal Code has finally been decriminalised under the Act. This is a very positive development as it recognises the said action as symptomatic of an illness instead of choosing to incarcerate the patient. The Act seeks to impose a duty on the government to rehabilitate such people.

The Act prohibits Electroconvulsive Therapy (ECT) without the use of muscle relaxants and anaesthesia. ECT will not be performed on minors except with the informed consent of the guardian or a competent institutional approval. Chaining of persons with psychological disabilities, subjecting him/her to seclusion or solitary confinement is forbidden. Physical restraints may only be used if necessary.

The provisions of the MHC Act (2017) makes for a progressive piece of legislation but as expected its success depends on implementation and empirical monitoring of ground realities. The biggest crippling factor of the MHC Act (2017) is that it creates obligations on the state for meeting various rights of patients without earmarking the resources required for meeting them. Lack of funding and unclear mapping of the allocation process is a critical deterrent to the successful implementation of this law.

Furthermore, in 2005, the WHO published a Resource Book on mental health, human rights and legislation, including a checklist of 175 specific items that must be addressed in mental health legislation or policy. MHC Act (2017) is said to take heed of 96/175 (55.4%) of these standards. Including other domestic healthcare-related legislation, 118/175 (68.0%) of the standards are addressed in Indian law.

Areas of low concordance include rights of families and caregivers, principles of competence and guardianship, rights of non-protesting patients and application of involuntary community treatment. The poor state of basic infrastructure, of course, demands a substantial and more importantly a recurring financial support from the government.

National Health Policy 2017 envisages community-based mobilization to provide psychological support for strengthening mental health services in the country. Keeping a vigil watch on the ground, running awareness and sensitization campaigns and most importantly ensuring healthy and consistent financial flows to the system would be a right step in improving the state of mental health in India.

The article got originally published at Transfin.

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