This Article is written by
This Article is written by Saba Alam ( a student of BALLB from Aligarh Muslim University, Murshidabad Centre)
“In India, we need to break the stigma of talking about mental health and seeking support so that people can have better life outcomes. We must change the way we view mental health,”
said Dr Yasmin Haque, Indian Representative at UNICEF.
Introduction
One of the most neglected areas globally is issues related to mental health. Inthese unprecedented times of pandemic, the world is now facing a mental epidemic.
According to data from World Health Organisation (WHO) Report, mental illness makes about 15% of the total disease conditions around the world. This estimate also labelled India as the most depressing country in the world.
It is estimated that the economic loss due to mental health conditions during 2012-2030 is 1.03 trillion dollars. The numbers keep on staggering.
The main reason of this alarming situation is the lack of awareness, understanding and stigma attached towards the people who are facing mental health issues. There is a serious shortage of mental healthcare workers in India. As per WHO, mental health workforce in India (per 100,000 population) includes psychiatrists (0.3), nurses (0.12), psychologists (0.07) and social workers (0.07).
Mental Health Law and Policies: Early to Current Legislation
The first law in relation to mental illness in British India was the Lunacy Act 1858, which ceased in 1891.Under these acts, patients were detained for an indefinite period in poor living conditions, with little chance of recovery or discharge. This led to the introduction of the Indian Lunacy Act, 1912 which brought in fundamental change for the management of mental hospitals. However, this act neglected human rights and was concerned only with custodial deaths.
Consequently, after three whole decades the Mental Health Act, 1987 was enacted. It defined mental illness in a progressive way and emphasised the need to protect human rights, guardianship and the management of the property of people with a mental illness.
The criticisms of the MHA 1987 are mainly related to the legal procedures of licensing, admission and guardianship. Also,it involved the curtailment of personal liberty without the provision of a review by any judicial body. Consequently, the Mental Healthcare Act, 2017 was enacted and notified on May 29, 2018. The new Act focused on the rights of a mentally ill person and repealed the Mental Health Act, 1987.
Article 21 of the Indian Constitution, which states right to life has been expanded to right to health.
The government of India launched National Mental Health Programme in 1982. After 38 years, it is still on paper.The basic strategy of NMHP was to integrate the basic mental health care with general health services.
At the end of five years of initial implementation of NMHP it was observed that although there were some developments but the financial constraints limited its success. The concept of District Mental Health Programme (DMHP) was introduced in 1996 and various changes were made in the consecutive five-year plans.
In the XIth plan there was an effort to address the main barrier in the mental health service provisions i.e., the shortage of manpower. A central mental health team has also been constituted to supervise and implement the programme. A Mental Health Monitoring System (MHIS) is being developed.The NMHP in the XIIth plan has a focus on psychiatric problems specific to vulnerable sections of the population.
The program has had various modifications since the time of its inception and now that the time is approaching for the XIIth plan to conclude it would be an opportunity to have deliberations over the success and the failures of the program and to take the program to the next level.
Provisions of the Mental Health Care Act, 2017
After the National Mental Health Survey during 2014–2016, the Governmentstarted making efforts to improve the mental health services by formulating policies like the National Mental Health Policy (NMHP), 2014 and consequently, the Mental Healthcare Act, 2017 was enacted and notified on May 29, 2018.
The preamble of the Mental Healthcare Act, 2017 (MHCA) aims to provide mental healthcare and services for persons with mental illness and to promote, and fulfil the rights of such persons during delivery of mental healthcare and services. The act is progressive, patient-centric, and rights-based. Chapter 5 on the “Rights of the persons with mental illness” is the heart of this legislation.
Under this Act, various rights such as right to community living, right to confidentiality, right to access medical records, right to protection from cruelty and inhumane treatment, and right to equality and non-discrimination are all ensured.
It does not make distinctions amongst the PMI on the basis of poverty though all destitute and homeless Patient with Mental Illness (PMI) are entitled to free mental health treatment. It restricts electroconvulsive therapy (ECT) without anaesthesia and any type of ECT to children and also restricts psychosurgery.
One standing provision is that according to Section 309 of the Indian Penal Code, 1860, “Whoever attempts to commit suicide and does any act towards the commission of such offense, shall be punished with simple imprisonment for a term which may extend to 1 year or with fine, or with both”.
The government has a duty to provide care, treatment, and rehabilitation to a person having severe stress and who attempts to commit suicide, to reduce the risk of recurrence of such an attempt.
Issues to be addressed
According to the WHO Report, suicide is an emerging and serious public health issue in India.The National Mental Health Survey (NMHS) 2015–16 found that almost 80% of those suffering from mental illnesses did not receive treatment for more than a year. The pandemic had brought to light the pitfall of the current mental health law and policies. There is a failure on the part of the government in the infrastructure of mental healthcare programme at state level.
The Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2007. The Convention mandates the laws/rules governing the country to follow its recommendations. There was a grave need for the present law to suit the changing times and for it to be in line with the UNCRPD.
A major drawback is contained in Section 89 of the MHCA, 2017, which allows a person with mental illness to be admitted and treated without his consent, but with request from a nominated representative.
The Act ignores that the family assumes the role of primary caregivers first. Even the clinicians depend on the family. Thus, having adequate family support is the need of the patient, the clinician, and the healthcare administrators.
The Act also ignores the presence of a mental health program in the country.The Act should have mandated all the states to implement National Mental Health Programme and the state mental authority should have been made responsible for the same.
Over the 25 years of the existence of the DMHP, there have been only two Central Governmentsanctioned, systematic evaluations of the DMHP. The NMHS (2016) has found a majority of the states surveyed had less than 50% of their population covered by the DMHP.It continues to follow a top-down approach, with heavy administration challenges, and a lack of involvement of users and caregivers in the design, implementation and monitoring of the DMHP.
Measures required for redressing mental health
Effective legislation on mental health needs to address both the social and economic dimensions of deprivation that persons without access to mental healthcare face.Early screening of mental health and timely action can go a long way in improving the quality of people.
A strengthened system for quality data on suicides (attempted and deaths) from vital registration, hospital-based systems and other surveys for formulating policies and subsequent monitoring are effective suicide prevention initiatives. Strengthening life-skill trainings and counselling in educational institutions, workplace etc. further supplement prevention policies.
It is important for policy makers to retain an intersectoral and holistic approach to mental illness and mental health care which also pursues policy that addresses upstream determinants of mental health.
There is a call on governments, and public and private sector partners, to promote mental health for all children, adolescents and caregivers, protect those in need of help, and care for the most vulnerable, including:
- Urgent investment in adolescent mental health across sectors, not just in health, to support a whole-of-society approach to prevention, promotion and care.
- Urgent investment in strategies to promote good mental health including prevention of gender-based and other forms of violence
- Integrating interventions across health, education and social protection sectors – including parenting programmes and ensuring schools support mental health
- Breaking the silence surrounding mental illness, through addressing stigma and promoting better understanding of mental health.
It is high time that we all unitedly advocate for a vision of mental health care that allows various systems of care to work closely together to address mental health prevention, promotion and treatment. This includes integrating existing models of care which are more socially and culturally acceptable, such as community healers and supportive and informal counselling.
