After long neglect, mental health care set for salutory changes

It’s difficult to make out what’s wrong with 28-year-old Prabhat wearing a striped shirt, sitting next to a grilled window at Chamatkari Hanuman Mandir at Jan Sauli near Chhindwara, till one looks up and close.

He is chained to the grills as his father decided against taking a chance to avoid public nuisance. Thousands of kilometres away, Makhan Lal is lying under a tree outside All India Institute of Medical Sciences in Delhi, with dirt and filth all over his body. He too is chained to the tree precisely for the same reason.

Prabhat and Makhan are not isolated cases. They are among innumerable Indian mental health patients who received nothing but inhuman-treatment, caning, chaining, terrible asylums and gross apathy from the society. It was the shocking incident of 28 chained inmates of a faith-based mental asylum in Erwadi in Tamil Nadu torched alive in an accidental fire in 2001 that prompted the policymakers to have a rethink on mental health.

Twelve years later, a new legislation now seeks to change the landscape of mental health care, which remained in a neglected state for years. As India has close to 50 million people who may be having one form of mental disorder or other, the law when implemented, would give the same right to lakhs of mental patients what people suffering from physical illnesses have.

Experienced psychiatrists say, there are thousands of families ub India with some sort of mental illness. The disorders range from autism, intellectual disability and attention deficit hyperactivity disorder in childhood, to depression, anxiety, schizophrenia, bipolar disorder and substance use in adulthood and dementia in old age.

The legislative bill that seeks to replace the Mental Health Act of 1987 will protect the rights of persons with mental illness and promote their access to quality mental health care. Every mental health patient will be protected from cruel, inhuman treatment in mental health institutions, which will have to register themselves with Central Mental health Authority, to be set up under the new law. There will also be a state level mental health authority and a review commission.

Every right of mental patients will be protected. They would live in safe and hygienic conditions, have adequate sanitary conditions, privacy, personal clothing and wholesome food and protected from physical, verbal, emotional and sexual abuse by hospital or asylum staff. The law would make it mandatory for women patients to get sanitary napkins during menstruation and prohibit compulsory tonsuring – a common practice in mental asylums.

Ambulance can be used in the same manner as provided to persons with physical illness. The emergency facilities and emergency services for mental illness will be of the same quality. The living conditions in hospitals too would have to improve. If the police come across any mentally unstable person, it has to be reported to a magistrate so that the person’s treatment can be arranged in a medical set up.

Original form

If the bill is passed in its original form, the Insurance Regulatory Development Authority “shall endeavour” to ensure medical insurance covers mental illness in the same manner as it is available for treatment of physical illness. “The intention is to bring mental illness under medical insurance.

But the earlier draft (of the bill) was more emphatic,” said Alok Sarin, consultant psychiatrist at Sitaram Bhartia Institute of Science and Research in Delhi. The insurance clause, if accepted, may lead to coverage of hospital stay just like physical illness. “Mental patients need hospital stay if they are behaviourally disturbed, non-responsive to medicine and if they show suicidal tendency. Few hours of hospital stay is needed when elctro-convulsive therapy is applied to a patient,” Sarin said.

“Persons with mental illness should be treated like persons with health problems and the environment around them should be made conducive to facilitate recovery, rehabilitation and full participation in society,” says the bill.

Advanced directive is another key feature of the legislation. “An advanced directive is a mandate that specifies a person’s preference for treatment, should the person lose the capacity to make treatment decisions in the future. The use of advance directives in terminal illness has been in place for some time, but its use in psychiatry is a rather recent phenomenon,” says an editorial in the Indian Journal of Psychiatry.

“Advanced directive is a written document like a will that can be written when symptoms are developing for the first time. The care-giver including the state would have to act accordingly. This can reduce instances of involuntary treatment. But like every law it will depend on how the actual law is implemented,” said Rahul Shidhaye, a clinical psychologist at Public Health Foundation of India.

As the legislation makes it a legal right for mentally-ill patients to access quality treatment, the government will have to increase the number of mental hospitals as well doctors and paramedical staff. At the moment, India has only about 30,000 beds and 6,000 to 7,000 psychiatrists. This needs to be increased.

The ongoing district mental health programme needs to be overhauled as it is being implemented poorly by a handful of psychiatrists who do not have any background in community medicine. The DMHP has weak research and evaluation component.  Massive bureaucratic delays in releasing fund, is crippling DMHP too.

“As 90 per cent of mentally ill patients do not receive treatment, the government can integrate the mental health care programme with primary health care. We know what to do with a patient suffering from depression, but don’t know how to offer treatment in a government programme at the district level,” Shidhaye said.