Mental Healthcare in India

Humans are said to be physically holding on to stress in the least obvious ways. So release your shoulders, unclench your jaw, move your tongue from the roof of your mouth and sit back as you read this.

Mental health issues have been disregarded in the Indian society for the longest time. Till date, the masses do sympathise when a famous personality speaks out with regards to their mental health, but it still is a stigma which is yet to be normalised through awareness and education. Or even when it is normalised, all they receive is unsolicited advice from their acquaintances on their issues rather than being referred to a professional. Thus it is very evident that mental ailments, unlike physical illnesses, are complex and are not very easily diagnosable. So, how does the law provide recourse for the affected? How does it play a vital role and guides for treatment in an appropriate direction?

Background

Mental illnesses and treatments have been speculated throughout history, and there were instances where some of them were treated with compassion but generally just with stigma, marginalisation and injustice. In India, different legislations regarding mental health was shaped by the British. Pre-independence, many parts of legislations were combined to form the Indian Lunacy Act, 1912, that borrowed a lot of its components from the English Lunatics Act, 1845. Post-independence, there was an aim to draft an updated mental health care act, but there was a delay and the statute took many years to be embraced. Conclusively, the Mental Health Act (MHA), 1987 came into force. Due to the lapse in the passage of the Act had a lot of loopholes in its provisions.[1]

For instance, the Act witnessed a beginning for human approach and recognition of human rights, but it also did not include critical areas like consent. There was significant involvement of the police and the courts in procedures such as admittance and discharge of the patients, thus failing to remove the criminal aspect of admitting such patients with mental illness.[2]

Back in the days, the management of patients suffering from mental ailments was being done behind closed wards. This put them at a disadvantaged position because it increased their chances for vulnerability causing human rights violation which could further their mental ailment.

The Convention on the rights of persons with disabilities (CRPD) was passed by the United Nations (UN) General Assembly in 2006 which India signed and ratified in 2007. The CPRD demanded the existing legislation be revised and replaced. This was eventually responsible for the passing of the Rights of Persons with Disabilities Act, 2016 and Mental Health Care (MHC) Act, 2017, respectively.[3]

The National Mental Health Survey of India, 2015-16

Another key reason that the MHC Act, 2017 came into force is the National Mental Health Survey of India. This was implemented by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru. The National Mental Health Survey of India-2016 was conducted on persons who were representative of 12 states of India. It included 34802 individuals and the response rate at households was 91.9%. The age distribution was akin to that India’s  2011 Census. The objectives were to assess the prevalence and pattern of mental disorders, recognise the treatment gap and assess the effectiveness of the current mental health services. The major takeaways were:

  • Mental health issues were associated with a residence with the case in urban metros was higher than in rural and urban non-metro areas.
  • 1 in 20 people in India suffers from depression.
  • 1% of the population reported high suicidal risk.
  • The ones common among men were bipolar disorders and alcohol use disorders; meanwhile, depressive, stress-related and neurotic disorders were common among women. 
  • Despite the works in providing mental health care, the study revealed that a massive treatment gap exists for all kinds of mental problems. It ranges from 28% to 83% for mental disorders and 86% for alcohol use disorders. The utmost treatment gap was for alcohol use disorders.
  • Despite the illness being present for more than 12 months, individuals suffering from such mental illnesses had not obtained any treatment. This was reported at 80%.[4]

The stigma towards the mentally affected persons affects their access to work, education and marriage and also affects their family members. Thus the survey posed as a wakeup call and which needed immediate attention from the socio, political and legal spheres.

The Mental Health Care (MHC) Act, 2017

The MHC Act received President’s assent on 7 April 2017 and initiated on 29 May 2018. It aims to provide for healthcare services for individuals with mental illness and also to ensure they have the right to live their life without being discriminated.

Definition

Section 2(s) of the Act 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, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, especially characterised by subnormality of intelligence”.[5]

Human Rights of persons with mental illness

Chapter V of the MHC Act, 2017,  consists of the rights of those with mental affliction. Firstly, it ensures every individual shall have the right that enables them to access mental health care and treatment. The Act secures free treatment for persons who are homeless/belong to Below Poverty Line. Every person with mental illness is guaranteed the right to live with dignity, the right to equality and non-discrimination. They shall also have the right to legal aid, right to information, right to confidentiality in terms of their mental health, mental healthcare, treatment and physical healthcare.

Advance Directive

Section 5, talks about Advance Directive where an individual with mental ailment has the right to make a directive in advance, in writing that expresses how the person wants to be/not to be treated for the disease. It also states whom do they appoint as their nominated representative. The advance directive demands to be certified by a medical practitioner or a professional registered with the Mental Health Board.[6]

Mental Health Authority

The Act encourages the government to structure and organise the Central Mental Health Authority at national-level and State Mental Health Authority at the state level. Under this Authority, all institutes that are associated with mental health, specialists and practitioners that include clinical psychologists, nurses and social workers are required to be registered.

Apart from registering, these bodies will also develop service delivery models and rules for mental health care institutions, preserve a register of mental health professionals, tutor law enforcement officials and health professionals on the facilities of the MHC Act, gather complaints about drawbacks and notify the government on such matters.

Mental Health Review Board

The Act mandates a review board which will be constituted to ensure that the rights of persons with mental illness are protected and supervise advance directives.

Mental Health treatment

The Act also specifies the procedure to be adhered to for admission, treatment and discharge of mentally affected patients. For example, an individual with mental illness cannot be endangered to electro-convulsive therapy without the use of muscle relaxants and anaesthesia. This therapy can also not be performed on minors.

Anybody with mental illness cannot be chained in any manner or form whatsoever under any instances, nor can they be put to solitary confinement.

Insurance

The Act directs every health insurer to cater to policyholders with mental illnesses the same way they do to physical illnesses or injuries. What this would mean is that the mental health benefits cannot have more restrictions than those normal ones which apply to physical health benefits.[7]

Decriminalising Suicide

Another significant aspect of the Act is that Section 115 of the Act, decriminalises suicide and anybody who attempts suicide should be assumed to be suffering from a mental ailment at that point of time. They will not be penalised or punished under the Indian Penal Code, 1860. To reduce stress and prevent the risk of recurrence, the government has a duty to offer care, therapy and rehabilitation to that person.[8] 

Conclusion

Mental health issues, as said before, are really sensitive and especially during unprecedented times like now, they cannot be side-lined. Living through a global pandemic can be very demanding. The coronavirus disease 2019 (COVID-19) epidemic may cause fear and anxiety due to the uncertainty about a novel disease.

The thought about what can happen can be overwhelming for everyone. Public health measures, like social distancing, can make folks feel detached and lonely and can intensify stress. Ultimately these acts are obligatory to reduce the spread of COVID-19. But for one to reach out, they should be in a self-diagnosable situation where they realise they’re not all right. This is not the case with every mentally affected person, and the 2016 survey proves the same. India’s increasing mental health crisis can no longer be denied.

The ignorance towards mental health care is very evident as it is rarely mentioned in any election manifestos of political parties in India. On the other hand, ensuring the good health of citizens is a fundamental right guaranteed by the constitution.

The government should lead rigorous efforts to improve the mental asylum setting. It should engage more number of psychiatrists, psychologists, social and NGO workers to bridge the treatment gap. Law reforms should go beyond papers and should provide actionable ideas that make the mental health care system all-inclusive within the public health care system umbrella.

There also is a need for follow-up research, maybe another National level mental health survey to find the outcome, and analyse the changes in suicide rates, willingness to seek help. Until then, it can only be relied upon a time to tell the long-standing outcome of this Act and its functioning.

The current need of the hour is to aggravate the common people to understand mental health. To do so, there is a need for a constant stream of funds. These will be used for enlightening, educating and establishing awareness on matters concerning mental health and its long-lasting issues. The accessibility of professional help and timely intervention is the only way to advance the current situation. It is also necessary to propagate that beings with mental illness, like everyone, are worthy to live their lives with dignity. This demands a collaborative effort from all branches of the functioning society to change things over time.


[1] Richard M. Duffy & Brendan D. Kelly, India’s Mental  Healthcare Act, 2017- Building Laws, Protecting Rights, xvi- xxii, (1st ed. 2020)

[2] Neredumilli Prasanna Kumar, Padma V, Radharani S, Mental Healthcare Act 2017: Review and upcoming issues, Archives of Mental Health 19, 9-14 (2018)

[3] Neredumilli Prasanna Kumar, Padma V, Radharani S, Mental Healthcare Act 2017: Review and upcoming issues, Archives of Mental Health 19, 9-14 (2018)

[4] NIMHANS (2016), National Mental Health Survey of India, 2015-16: Summary, Bengaluru: MINHANS Publication No. 128

[5] The Mental Health Care Act,  §2 (2017)

[6] The Mental Health Care Act,  §5 (2017)

[7] The Mental Health Care Act, (2017)

[8] The Mental Health Care Act,  §115 (2017)

Krishnasree S from NMIMS, Mumbai

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