Urgent need for reforms in law and policy for Mental Health in India

In this unprecedented time, the issues relating to mental health across world have been exposed. In India, even before the outbreak of the COVID-19 pandemic, there was already a mental health epidemic.

As per the World Health Organisation (WHO), about 15% of the total disease conditions around the world are related to mental illness. WHO has also noted that India has one of the largest populations suffering from mental illnesses ranging from depression and anxiety, to severe conditions like schizophrenia.

It is estimated that the economic loss due to mental health conditions during 2012-2030 is 1.03 trillion dollars.

The main cause for such an alarming situation is lack of understanding, awareness, sensitivity, and stigma attached towards people 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) include psychiatrists (0.3), nurses (0.12), psychologists (0.07) and social workers (0.07).

Current policies and laws on Mental Health in India

Starting with Article 21 of the Constitution of India, the right to life has been expanded to include the right to health. It is essential that mentally ill persons receive good quality mental healthcare and living conditions in their homes and society.

Way back in 1982, the Government of India launched the National Mental Health Programme (NMHP). After 38 years, it is still on paper. NMHP was introduced considering the heavy burden of mental illness on the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it.

The Mental Health Act, enacted in 1987, has been the target of criticism since its introduction. The National Health Policy, 2002 incorporates provisions on mental health. However, no separate policy on mental health exists. In 1996, the District Mental Health Program (DMHP) was added and re-strategized in 2003 to include two important schemes of Modernization of State Mental Hospitals and Up-gradation of Psychiatric Wings of Medical Colleges/General Hospitals. India signed and ratified the Convention on Rights of Persons with Disabilities and its Optional Protocol in 2007. In 2009, the Manpower Development Scheme (Scheme-A & B) was made part of the Program.

It is important to note that the DMHP envisages provision of basic mental health care services at the community level and has the following objectives:

a. To provide sustainable basic mental health services to the community and to integrate these services with other health services;

b. Early detection and treatment of patients within the community itself;

c. To reduce the stigma of mental illness through public awareness; and

d. To treat and rehabilitate mental patients within the community.

A Mental Health Policy Group (MHPG) was appointed by the Ministry of Health and Family Welfare (MoHFW) in 2012 to prepare a draft of DMHP for Twelfth Five Year Plan (2012–2017). The main objective was to reduce distress, disability, and premature mortality related to mental illness and to enhance recovery from mental illness by ensuring the availability of and accessibility to mental health care for all in the plan period, particularly the most vulnerable and underprivileged sections of the population.

Its other objectives were to reduce stigma, promote community participation, increase access to preventive services to at-risk population, ensure rights, broad-base mental health with other programs like rural and child health, motivate and empower workplace for staff, improve infrastructure for mental health service delivery, generate knowledge and evidence for service delivery, and establish governance, administrative, and accountability mechanisms.

A central mental health team has also been constituted to supervise and implement the programme. A Mental Health Monitoring System (MHIS) is being developed. Standardized training was proposed with the help of training manual.

After the National Mental Health Survey during 2014–2016, the Government of India started 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 new Act focused on the rights of a mentally ill person and repealed the Mental Health Act, 1987. Despite having many positive features, the Mental Health Act, 1987 has been the target of criticism since its introduction and was not effectively implemented due to the lack of resources.

Unfortunately, the new Act has been introduced without addressing the issues which troubled the Mental Health Act, 1987. The new Act ignores the presence of a mental health program in the country. The Act should have mandated all the states to implement NMHP, and the state mental authority should have been made responsible for the same. The only way the Act can correctly implement the right to mental healthcare is by enabling the implementation of NMHP across all states.

Issues to be addressed

India has highest number of suicides in the world. The high crime and drug addiction rate in India also has direct nexus with mental health. The pandemic has added unseen mental health issues which has unearthed drawbacks in the existing mental health infrastructure and laws/polices. This pandemic has emerged as an eye-opener to show that India’s mental healthcare system needs strengthening and more support from the Central or State governments. There is a complete lack of integrated mental healthcare and failure on implantation of the DMHP across India.

The consequences of the COVID-19 pandemic are visible on people’s mental well-being, and this is just the beginning. Unless we make serious commitments to scale up investment in mental health right now, the health, social, and economic consequences will be far-reaching.

The lost productivity resulting from depression and anxiety - two of the most common mental disorders - costs the global economy each year. In low and middle-income countries, more than 75% of people with mental disorders receive no treatment at all for their disorder. In India, mental health is on the back foot due to lack of resources and allocation of budget. It is high time to prioritise on mental health by investing and integrating mental healthcare into the private and public sectors.

Measures required

Experts note that effective implementation of the DMHP is the key to resolving many critical issues that mental healthcare delivery faces in India.

The new Act requires the government to provide “less restrictive community-based establishments including half-way homes, group homes and the like for persons who no longer require treatment” in restrictive mental health establishments. However, in reality, such rehabilitation facilities are either missing or inadequate in India’s landscape of mental healthcare services. The Central and State governments are yet to comply with the 2017 Supreme Court direction to set up or expand such half-way homes. As of 2020, the states have only provided a road-map towards implementation.

Treatment of mental health disorders needs to be taken seriously and given equal or rather more importance than even physical health as there is ‘no health without mental health’. The policymakers need to promote mental health and easy access to cost-effective treatment of common mental disorders at the primary healthcare level.

The present mental health situation in India requires dynamic policy and resource allocation by the government. There is urgent need to use media and social media and other community services to increase awareness and reduce the stigma around mental health illness by implementing nationwide programs. Reports from all across the world show that the pandemic has also led to serious psychological consequences like anxiety, stress, depression, fear and insomnia etc. Recently, India Today reported a 20% increase in the mental health cases in India post imposition of the lockdown in March 2020.

As seen above, some initial steps to improve on the mental healthcare system have been provided under the NMHP. Appropriate intervention, understanding about the issue, and easy accessibility of professionals are the way forward to improve the situation. This requires social, public and private teamwork to get the situation under control. There is an urgent need for providing psychological help with trained mental health professionals as first aid, to reduce distress and ensure easy access to mental-health facilities for citizens. Mental disorders also need to be covered under insurance, as a plea pending before the Supreme Court has prayed for.

Conclusion

While handling the consequences of the COVID-19 pandemic, the mental health of people needs to be handled hand in hand. There is an urgent need to depute specialized mental health professionals to work.

The pandemic and the rise in the number of suicides and the crime rate shows the need for an integrated mental healthcare policy covering mental health issues. There is an urgent need to develop infrastructure and prioritise mental health care resources, so that the mental health of most vulnerable groups is well-served. In the national interest, there is need for reforms in policies and appropriate implementation of the existing legal framework.

Manisha T Karia is an Advocate-on-Record at the Supreme Court of India. Dr. Kamini Deshmukh is the Director of International Association for Psychosocial Support.