Introduction | Mental Health
India is the most depressed country in the world and at least 6.5 per cent of the Indian population suffers from some form of serious mental disorder.
Following the death of the Bollywood actor Sushant Singh Rajput, people encountered a fervent debate over the condition of mental health in India. The average suicide rate in India is 10.9 for every lakh people and the majority of people who commit suicide are below 44 years of age. Given the disturbing statistics related to mental health in India, the enactment of the Mental Healthcare Act, 2017 (hereafter referred as “the Act”) following the ratification by India of the Convention on Rights of Persons with Disabilities, was a positive step in the mental health reform in India. Though it remains to be seen whether the Act has been drafted keeping in mind the predicament of our country and the idiosyncrasy of the population and whether, after more than two years of its enactment, apposite adherence to the provisions of this legislation is holding or not.
Mental illness is a taboo in our country and the stereotypes related to mental illness do not let people acknowledge the fact that there are other forms of mental illness apart from the one extreme case of lunacy. A noteworthy issue that requires attention is PMIs in Prisons. The current legislation has brought the PMIs in prisons under its supervision but evidence shows that the benefits have not reached the distressed population.
Community Mental Health Care Services is a promising solution to resolve most of the issues related to mental illness in our country. They keep a flexible approach and deal with several issues at the same time that will be discussed in later parts.
Key Takeaways from the Act
The Act is a step forward towards the reformation of mental healthcare system in India. Though the Act attempted to deal with all the issues at hand, it isn’t free from lacunas. Chapter III of the Act allows every person, including a person with past mental illness and treatment for the same, shall have the right to make an advance directive where he can specify the way he wishes and not wishes to be cared and treated for mental illness and appoint individual(s), in order of precedence, as his nominated representative(s). Though it is a desirable move towards mental healthcare in India, the efficacy of this provision in India seems a little illusionary. The literacy rate in India, as per the 2011 census, is 72.99% and as per Census, a person aged seven and above who can both read and write with understanding in any language, is treated as literate and a person need not receive any formal education or acquire any minimum qualification to be treated as literate. In simpler terms, when a large percentage of the population doesn’t have a basic understanding of mental illness let alone the Act and Advance Directive, efficacious implementation of such a provision would be superfluous.
Another shortcoming of the Act is ignorance of the psychological aspect of the mental illness. Studies show that psychotherapy, or “talk therapy,” is sometimes used alone for treatment of mild depression. The current legislation has entirely overlooked the psychological aspect of mental health.
Chapter V of the Act provides numerous rights such as the right to access mental-health care; right to community living; right to protection from cruel, inhuman and degrading treatment; right to equality and non-discrimination; right to information; right to confidentiality; restriction on the release of information in respect of mental illness; right to access medical records; right to personal contacts and communication; right to legal aid and right to make complaints about deficiencies in the provision of services.
Section 95 of the Act prohibits Electro-compulsive Therapy without the use of anaesthesia and muscle relaxants and completely restricts this procedure in case of minors except when, in the opinion of the psychiatrist in charge of such minor’s treatment, such therapy is necessary then with the informed consent of the guardian of the minor and the concerned board. This section also prohibits sterilization and chaining as a form of treatment of the PMI.
An applaudable development of this Act is decriminalization of attempt to suicide. The Section 115 of the Act says that any attempt to suicide would be assumed to be under severe stress until proven otherwise and such person will be given the due treatment he or she needs to prevent further attempts to commit suicide.
What are Community-Based Mental Health Services?
As the name suggests community-based mental health services provide care and treatment to the persons with mental illness outside the hospital setting. They bridge the gap between the PMI and access to the meagre number of proper mental healthcare establishments. They promote mental health awareness; counter the discrimination against people with mental illness; support and promote PMI’s social inclusion and work towards anti-stigmatization of mental illness and preventing mental health-related problems.
The World Psychiatric Association’s (WPA) guidance on community mental health care identifies community-oriented care as a population and public health focus, community-based case finding, services available within half a day’s travel, participatory decision making, self-help and peer support for service users, treatment initiation in primary care facilities and communities, stepped care, specialist supervision, collaboration with non-governmental organizations, and networks across services, communities, and traditional and religious healers. The third edition of the World Bank’s Disease Control Priorities recommends community recommends training gatekeepers for early identification and delivery of low-intensity psychosocial support, establishing peer and family support groups, raising awareness about harmful substance use, implementing workplace stress reduction programs, supporting community-based rehabilitation, and establishing community programs for child and adolescent mental disorders such as parenting programs with special attention to early childhood enrichment and life skills for adolescents for the efficacious functioning of mental health services.
There is a disparity concerning the services provided under community-based support systems for mental health. In Canada, the services include housing facilities that offer to counsel the people in crisis; case management, where the case managers help and work with one individual at a time; treatment in the community is catered by social workers, nurses and case managers. Peer support and self-help programmes and crisis services that operate 24 hours a day to provide immediate care to the people in need. In Turkey, these services focus exclusively on providing help to the PMI in the society itself and reducing stigma attached to mental illness in society. Psychiatrists, nurses, social workers, psychologists and ergo-therapist form the core team and they coordinate with local and non-governmental institutions to provide support to PMI and their family. The primary aim of these services is to prevent hospitalization as much as possible.
Researchers have suggested three models for the systematic implementation of community mental health services.
- National policy which has an overall statement of strategic intent that gives direction to the whole system of mental health care.
- Implementation plan with an operational document setting out the definite steps needed to implement the national policy and that specifies what tasks are to be completed, by whom, by when, with which resources, and identifying the reporting lines, and the incentives and sanctions if tasks are completed or not completed.
- Mental health programs that layout detailed plans either for a local area or for a particular sector like primary care that specify how one component of the overall care system should be developed.
The stigma attached to mental illness is one of the serious issues in India. Researchers suggest a two-fold mechanism to combat this problem, educating the people about mental health which works towards breaking myths and stereotypes related to the issue and encouraging social contact, where the community mental health workers interact with the general public about different issues related to mental health. The Time to Change campaign launched in 2007 in England is the biggest campaign which works towards anti-stigmatizing of mental illness through national advertising, PR, social media, community engagement and information resources. The main focus of the campaign is changing the attitude of people towards people dealing with mental health issues along with rising awareness about the same.
India has to learn from the strategies used by different countries for community based mental health care services. The inadequate number of community-based mental healthcare services needs an overhaul and the government should implement policies that suit our population instead of a hesitant formulation of an Act to keep up with the international standards.
Prisons and Mental Illness
Researchers claim that mentally ill are more frequently involved in criminal behaviour and prisoner’s living conditions in prison make them more susceptible to psychiatric disorders. The research and study with respect to prisoners with mental illness in India are very less. Indian prisons often lack proper basic health services let alone proper mental health service. Suicide and self-harm behaviour is a major concern in prisons. In a 10-year retrospective study, out of 179 autopsies, nearly 14 were suicide cases by prisoners. 71.42% of them were in lock-ups while 28.57% were in prison.
Section 103 of the Act mandates the admission of mentally ill prisoners in the psychiatric ward in the medical wing of the prison and if such services are unavailable then they are to be admitted into a suitable mental health establishment for care and treatment. The presence of this provision in the Act has been proved to be redundant. According to the PIL filed in the Karnataka High Court, 4,916 prisoners suffer from mental illness in Karnataka. These instances indicate that there is a lack of conformity with respect to the Act inside the prisons. The concept of Mental Health Courts in California can be just the solution to this crisis. California implemented its first mental health court in 1999 to support the mentally ill offenders, help them go back to society and bring down the recidivism rates. These courts accept people with substantial mental illness and the participation in mental health court is voluntary and screening and referral to mental health courts occur soon after arrest. These courts use a structure of case management based intensive supervision (which consist of a team of members of the justice system, mental health providers etc) and individual accountability. Studies have found that adult mental health courts have a positive effect on participants’ rehabilitation and criminal behaviour during and after their participation. Since its inception, the orange county mental health court programs have saved nearly $7,380,000 in jail and prison bed costs.
The Act is a reluctant approach towards a potential progressive law in mental health; adorned with all the precise provisions and rights guaranteed to the PMI, it falls short of combating the real issues head-on. Given the rampant lack of awareness about mental health, all the novel provisions for the PMI become tautological. Though the Act talks about sensitizing the people about mental health, it doesn’t provide with promising methods for the same. The community-based service modals which are being adopted by countries should be the prime focus of this legislation as it not only provides support to the needy on a community level it also raises awareness about mental health and focuses on changing people’s attitude towards PMIs but the current legislation by merely paying a lip-service to the same has absolved itself from formulating the necessary guidelines, rules and regulations for efficient implementation.
Considering the numerous myths and stereotypes related to mental health educating and sensitizing the population of our country with respect to the issue is going to be a herculean task that needs a roadmap of procedures, guidance and specifications on what tasks are to be completed, by whom, by when and with which resources.
In a country where people shy away from accepting any form of mental illness, legislation providing provisions like Advance Directive and Right of PMI would be the textbook example of walking before running. The primary focus of the government should be providing services like the community-based support services that keep a flexible approach to tackle the issue It’s time to quit trifling and adopt methods that promise results and start sensitizing the people so that they accept mental illness as a serious issue that needs unanimous support to overcome it.
About the Author: Oshi [2018-23] is pursuing her UG Law course from National University of Study and Research in Law, Ranchi
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