Mental health is an integral part of health; it is more than the absence of mental illnesses. It is the foundation for the well-being and effective functioning of individuals. It includes mental well-being, prevention of mental disorders, treatment and rehabilitation.
WHO estimates that the burden of mental health problems in India is 2443 disability-adjusted life years (DALYs) per 10000 populations; the age-adjusted suicide rate per 100000 population is 21.1. The economic loss due to mental health conditions, between 2012-2030, is estimated at USD 1.03 trillion. WHO has labelled India as the world’s ‘most depressing country’.
Issues Related to Mental Healthcare
- Lack of sensitivity: People with any kind of mental health issues are often tagged as ‘lunatics’ by society.
- Lack of access, affordability, and awareness:
- The National Mental Health Survey (NMHS), 2015-16 found that nearly 80% of those suffering from mental disorders did not receive treatment for over a year.
- This survey also identified large treatment gaps in mental healthcare, ranging from 28% to 83% across different mental disorders (National Institute of Mental Health and Neurosciences (NIMHANS), 2016).
- The stigma around mental health issues: This leads to a vicious cycle of shame, suffering and isolation of the patients.
- Shortage of mental healthcare workforce: In 2011, there were 0·301 psychiatrists and 0·047 psychologists for every 100,000 patients suffering from a mental health disorder in India. (WHO)
- Lack of State services and insurance coverage: Results in most expenses on treatment – when sought – being out-of-pocket expenses, thus worsening the economic strain on the poor and vulnerable.
- Minimal State Intervention:
- As of 2021, only a few states included a separate line item in their budgets towards mental health infrastructure. Rs. 5 million in 2018-19 was reduced to Rs. 4 million in 2019-20 and has remained at the same level in subsequent years – even 2021-22 where several reports have indicated the worsening of mental health issues during the Covid-19 pandemic.
- Developed countries allocate 5-18% of their annual healthcare budget to mental health, while India allocates roughly 0.05% (OECD, 2014)
- Economic Burden:
- NMHS (2015-16) revealed that the median out-of-pocket expenditure by families on treatment and travel to access care was Rs. 1,000-1,500 per month.
- WHO estimates the economic loss to India on account of mental health disorders to be US$ 1.03 trillion.
The mental health situation in India demands
- Active policy interventions and resource allocation by the government.
- Measures to train and sensitize the community/society to reduce the stigma around mental health.
- Awareness through persistent nationwide efforts to educate society about mental diseases as done by Accredited Social Health Activist (ASHA) by the Ministry of Health and family welfare.
- Steps to connect the patients with each other by forming a peer network, so that they could listen and support each other.
- People experiencing mental health problems should get the same access to safe and effective care as those with physical health problems.
- Mental illness must mandatorily be put under the ambit of life insurance. This will help people to see mental illness with the same lens they use for physical diseases.
- The Mental Health Policy, of 2014 upholds a participatory and rights-based approach to quality service provisions.
- The Mental Healthcare Act, of 2017 provides the legal framework for providing services to protect, promote and fulfil the rights of people with mental illnesses. These are in line with the United Nations Convention on the Rights of People with Disabilities (UNCRPD).
- To address the burden of mental disorders, the Government of India is implementing the National Mental Health Program (NMHP) since 1982.
- With the objective to address the shortage of qualified mental health professionals in the country, the Government, under NMHP is implementing Manpower Development Schemes for the establishment of Centres of Excellence and strengthening/ establishment of Postgraduate (PG) Departments in mental health specialties.
- To generate awareness among the masses about mental illnesses Information, Education and Communication (IEC) activities are an integral part of the NMHP.
- The National Mental Health Program and Health and Wellness Centres are efforts to provide quality care at the primary healthcare level. Deaddiction centres and rehabilitation services are also available.
- Mental Healthcare Act, 2017(MHA)
Significant Provisions of MHA, 2017
- As part of Section 19, the government was responsible for creating opportunities to access less restrictive options for community living such as halfway homes, sheltered accommodations, rehab homes, and supported accommodations.
- Under Section 5 of the Act, people are empowered to make “advance directives”. They can nominate a representative for themselves, thereby potentially helping to eliminate absolute forms of guardianship in favour of supported decision-making.
- Mandates: All States are required to establish a State Mental Health Authority and Mental Health Review Boards (MHRB) bodies that can further draft standards for mental healthcare institutes, oversee their functioning and ensure they comply with the Act.
Stigma: In 2017, the MHA in essence dismantled the clinical heritage attached to asylums.
Discourage Long-term institutionalization: The MHA emphasizes patients’ right to live independently and in their communities, calling it a “watershed moment for the right to health movement in India.”
Discourages using physical restraints: The Act discourages using physical restraints (such as chaining), and objects to unmodified electro-convulsive therapy (ECT), instead it encourages the rights to hygiene, sanitation, food, recreation, privacy, and infrastructure.
Psychosocial approach: Experts noted that this was the first time a psychosocial approach to mental healthcare was adopted.
Consider Environmental factors: The Act acknowledged that environmental factors such as income, social status, and education impact mental well-being, and therefore, recovery needs psychiatric as well as social input.
Consider patients’ rights and will: The Act has shifted from providing only treatment to centring the rights and the will of the person.
Challenges to implementation
Non-compliance with MHA regulations
- Further, many States have not notified minimum standards which are meant to ensure the quality of MHEs.
Absence of community-based services
- The Act shifted the obligation of care onto different stakeholders including caregivers, government institutions, police officials, and mental health practitioners.
- Poor budgetary allocation and utilization of funds further create a scenario where shelter homes remain underequipped, establishments are understaffed, and professionals and service providers are not adequately trained to deliver mental healthcare.
- 55.4% of people who lived in mental healthcare facilities were referred to by the police or magistrates as most people have histories of homelessness, poverty, and a lack of education and they thus have no place to go after recovery.
- The dearth of alternative community-based services in the form of homes for assisted or independent living, community-based mental healthcare services, and socio-economic opportunities further complicates access to rehabilitation.
- It looks at a person with mental illness as a “criminal” deserving of incarceration.
- In many cases, families refuse to take them because of the stigma attached to incarceration or the idea that the person is no longer functional in society.
Absence of MHRBs
In many states establishment of State Mental Health Authority and Mental Health Review Boards (MHRBs), bodies are yet to be done or remain defunct.
Gender discrimination plays a role here
- Women are more likely to be abandoned due to “family disruption, marital discords and violence in intimate relationships,” according to a study.
- Many long-term patients at mental healthcare institutions, especially women have no place to go.