Guest Column: Promise, pitfalls of addressing mental health illness in India

The Mental Health Care Act (MHCA), 2017, is progressive only in its mandate and preamble, but is restrictive in procedures. While focusing on the protection of the rights of persons with mental illness during treatment, the Act has ended up compromising the very right to treatment. The MHCA needs to be amended.

October 10 is observed as World Mental Health Day and the theme for this year is: Mental health is a universal human right.

October 10 is observed as World Mental Health Day. (HT File)

In India, the Mental Health Care Act (MHCA), 2017, provides for mental health care and services for persons with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental health care. The legislation, notified in 2018, is laudable and progressive, providing for high-quality affordable mental health care in government-run institutions to all as a statutory right. However, there are a multitude of problems in the Act, to the extent that it compromises the very right to treatment of the persons with mental illness it basically seeks to protect.

In India, the most recent mental health survey done in 2016 by the government and the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, reported the rates of mental illness to be 10.6% of which about 3.2% constitute severe mental illness; and 15 crore Indians need active intervention. About 15% of them end up in suicide.

There is severe shortage of mental health-care professionals and treatment facilities in India. There are only about 9,000 psychiatrists practising in India, which is 0.3/lakh population, whereas the recommendation is of 1 per 10,000 population. The most recent survey of psychiatrists in India shows that only 40% mental health care is provided in the government sector, and 60% is in the private sector. The mental health gap i.e. the gap between the number of patients who need treatment and those who actually get it, is 80%, which means that only 20% of patients who need psychiatric treatment get it and 80% are left untreated. With no treatment available, the brunt is borne by the families of such individuals.

The irony is that most mental illnesses are treatable and the pain and suffering is preventable in large measures. Some of the problems that patients and families face in accessing care are highlighted below:

*Inadequacy of mental healthcare facilities, manpower and infrastructure: To meet the MHCA mandate of making mental health care accessible to all, according to one estimate, would require about ₹94,000 crore a year. The total health budget of the Government of India for this year is 2% ( ₹86,000 crore) of the total fiscal outlay, of which a miniscule 0.7% ( ₹1,035 crore) has been allocated to mental health. No wonder that the Act has not been implemented in most states of India.

The Act states that mental health care should be integrated with general health care at all levels, but actually the Act segregates the two. It will be impossible for the government to provide for universal mental health care in the country, until and unless, it comes up with more innovative solutions such as digital mental health care, or public private partnership, etc.

*Severe mental illness is wrongly equated with dangerousness: Section 89 of the Act states that a person with mental illness can be admitted (without consent) if the person: i) has caused or threatened to cause bodily harm to self; ii) or to others, iii) or is unable to care for self to a degree that places the individual at risk of harm to self. Most patients with severe mental illness do not indulge in harm and are not dangerous, except that due to non-treatment, there will be risk of deterioration that may end up in a state of causing harm to self or others. Patients who have not yet caused the harm but are too disturbed needing immediate treatment, are excluded from treatment as per the Act.

According to the Act, the patient has a right to decide whether he wants treatment or not. If a severely mentally ill person with lost insight and judgement, who needs immediate treatment but refuses it, cannot be admitted for treatment against his will until and unless he has caused harm to self or others. This is a major flaw and is opposed to the spirit of the Act.

*Family’s role compromised: The Act provides for a new concept of a nominated representative (NR), where a person with mental illness can appoint in writing anyone as her/his NR who can take all decisions about the care and treatment of the patient. This clause is taken from the UK law and is totally alien to Indian society. In India, parents and families take care of persons with mental illness. However, if such a person acting under the influence of delusions or hallucinations or inducement by vested interest, nominates someone else as the NR, the parents and families will lose all rights and expose patients to exploitation. Control over a patient’s property and assets can become the prime motivation of the NR to not get treatment of the patient. Families have been relegated to a secondary position after the NR, reflecting insensitivity and disregard for the robust family system that prevails in India. Also, the Act is silent on the rights of the family and society.

*Law is alien to Indian socio-cultural system: Under Section 5 of the Act, every person has a right to make an advance directive (AD) in writing, specifying the way the person wishes to be treated/or not treated for a mental illness. Every medical officer has to give treatment in accordance with the valid AD, overruling the judgment of the treating psychiatrist. This clause makes an improbable pre supposition that the patients with mental illness will have a rational mind and a good knowledge of their illness, of various treatment modalities available, their relative merits and demerits. Our population has very little knowledge about mental illness and its treatment. They often believe in supernatural powers. A patient during a disturbed mental state due to some disorder such as mania or schizophrenia, often refuse treatment due to lack of insight. Such a person may give an AD of no treatment. The family will have a tough time to manage this patient or in getting the AD overruled before treatment can be started. It causes both delay and harassment. The Act has been taken from UK and Canada laws where families do not take responsibility for care of members with mental illness.

*Judicial overreach: Judicial officers have been given the task of adjudicating on medical decisions, which is wrong. Only psychiatrists can opine on medical decisions taken by psychiatrists.

*Act is stigmatizing: A separate Act for mental health care segregates it from general health care and is stigmatising. Separate mental health laws are a legacy of the past when there was no treatment for the illness. Mental health care should be considered on a par with physical health care and easily accessible in all general health care establishments. Regulatory control of this degree on mental health care does not help or guarantee quality of care. Rather, it is a retrogressive step where mental illness is again pushed into the shackles of judiciary, whereas, the psychiatry profession has struggled for decades to bring mental health care out of asylums into general hospitals, then into the community and now into homes.

The MHCA is progressive only in its mandate and preamble, but is restrictive in procedures. The Act while focusing on protection of the rights of persons with mental illness during treatment has ended up compromising the very right to treatment. MHCA needs to be amended. savita.pgi@gmail.com

The writer, a former head of the department of psychiatry at Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, is a consulting psychiatrist at Fortis Hospital in Mohali. Views expressed are personal.