The Indian Mental Healthcare Act, 2017 (IMHA) defines mental illness as a substantial disorder of perception, thinking, orientation and mood or memory that grossly impairs behaviour, judgement or the capacity to recognise reality or the ability to meet the ordinary demands of life, or of mental conditions linked to talcohol or drug abuse, but does not include the category of mental retardation which is recognised as arrested or incomplete development of a person’s mind, characterised by sub-normality of a person’s intelligence.
According to a 2017 World Health Organisation (WHO) Report, major or minor mental illnesses that require expert intervention are reported for 7.5 per cent of India’s population (Iyer, 2017). Also, out of roughly 60 million people in India suffering from mental illnesses, about 90 per cent are currently not receiving any treatment (Sharma, 2017). China Daily reports that 100 million people in China suffer from various mental illnesses. Computed against the population of China (1.378 billion people as per the 2016 World Bank data) this works out to be 7.25 per cent of the population. A 2016 Lancet study alarmingly points out that in the succeeding decade—the burden of mental illness is envisaged to increase more rapidly in India than in China with an estimated 1 in 10 prospective patients in India receiving evidence-based treatment (Mascarenhas, 2016). While the proportion of people suffering from mental illnesses is higher in India and China, other south Asian countries such as Indonesia has about 3.7 per cent of its population reportedly suffering from mental illnesses
Pressures on mental health
In India, as per the National Mental Health Survey (NMHS) 2015-16, the gender prevalence of lifetime psychotic disorders was about 1.5 per cent for males and 1.3 per cent for female. While, there was a male predominance in alcohol use disorders (9.1 per cent for males as against 0.5 per cent for females) and for bipolar affective disorder (BPAD) (0.6 per cent for males as against 0.4 per cent for females), a female predominance was observed for depressive disorders (for females 5.7 per cent; for males 4.8 per
cent) for neurotic and stress related disorders (NMHS, 2016).
Traditional biases towards women with various forms of violence targetting them including—unfair treatment within households, sexual harassment, stalking and rape are some of the triggers which may lead to mental health problems in women. Moreover, the recent surge in aspirations may turn out to be unrealistic and remain unmet which generate symptoms of mental illness. Information overload from sources such as the internet, television, smartphones and more can also add to the burden on mental health by presenting sensationalised, erroneous and sometimes personal accounts for mass consumption (Chaturvedi, Prasad, Angothu and Mathews, 2016).
A treatment gap in mental health in India
In a 12 state study by NMHS, 34,802 people were interviewed to find unweighted lifetime morbidity for any mental disorder. The morbidity rate
stood out at an astounding 13.9 per cent of the sampled population.
Mental illnesses remain largely untreated in India. Moreover, there is a dearth of data on occurrence/treatment gap for mental disorders. According to NMHS 2016, a treatment gap of 50-60 per cent was reported for schizophrenia whereas it was 88 per cent for depression and was as high as 97.2 per cent for alcohol use disorders. Studies on epilepsy from India have reported a state-wise treatment gap, ranging from 22 to 95 per cent. Overall, only about 1 in 10 people with mental health disorders are thought to receive evidence based treatment
An individual’s risk of suicide was observed to be 0.9 per cent (high risk) and 0.7 per cent (moderate risk); it was the highest in the 40-49 year age group, greater amongst females and those from urban areas, especially metros.
Across the states, the overall rates varied between 8.1 per cent in Assam to 19.9 per cent in Manipur for mental disorders including alcohol use disorders. For the risk of suicide, the rates varied from 2.2 per cent in Chhattisgarh to 12.5 per cent in Kerala. For tobacco use disorders the crude prevalence ranged from 5.5 per cent in Punjab to 38.3 per cent in Rajasthan. The reported percentage of subjects with other substance use disorders, primarily drugs was the highest in Punjab (2.5 per cent ) and the lowest in Kerala and Gujarat (0.1 per cent for both) (Fig. 1).
Dr B N Gangadhar, Director, National Institute of Mental Health and Neuro Science while speaking to G’nY informs, “people would accept treatment for mental disorders more readily if psychiatrists or mental health professional are available in all primary care services instead of only at a specialised centres. Primary care professionals can also offer treatment to the patients who are suffering
from mental disorders. School health education should also include a small component of mental health, so that it becomes a subject which is otherwise stigmatised.”
Mental illnesses remain, in most cases, under-reported. A significant contributor to the treatment gap in India is also social stigma surrounding mental illnesses. Moreover, there is a common assumption that mental illness patients would have the propensity to be violent, which further curtails their access to proper care (Trani, Bakshi, Kuhlberg, Narayana, Venkatraman, Mishra et al., 2015).
Dr Gangadhar specifies, “psychiatrist scarcity is one of the reasons due to which treatment gap is aggravating in India. The gap can be closed if all medical staff can pay attention to this matter. Some of the mental disorders are easily recognisable in the community and if promptly treated, can even be reversible. NIMHANS has been training primary care doctors in mental health across different parts of the country through distance education. The virtual knowledge network and telemedicine service of NIMHANS and its digital academy will help meet the challenges of shortage of trained mental
Dr K V Kishore Kumar, director of The Banyan, a mental health not-for-profit outfit while speaking with G’nY flags issues of stigmatisation of mental health stating that “stigma and discrimination are universal phenomena. We need to address this to help people with mental health problems to lead productive lives. This means early recognition and treatment, proactive support to families, ambulatory care for people who are vulnerable, linking the families to social welfare measures as part of their right and unhindered access to comprehensive mental health services—medical, psychiatric, rehabilitative and social welfare services.”
Mental health In India: policy and society
In 2005, the WHO published a resource book, based on a human rights approach that provided direction for enactment of legislations on mental health. The Indian Mental Healthcare Act (IMHA) 2017, fulfils 96 out of the 175 criteria laid down by the WHO, making India’s mental health law one of the most progressive in the world
As per Dr Kumar, “India’s mental health legislation is very progressive and perhaps comparable to the developed world. The Act focuses on rights of persons with mental health problems which includes comprehensive mental health services so that there is access to all those who need it, starting from the level of a village. It also includes the need for advance directives which is a written statement about how a person should be treated in the event he or she develops mental health problems. The Act also needs a person to appoint a nominated representative so that decisions can be taken at the time of crisis. It calls for the establishment of state and central mental health authority which will address all matters related to regulation as well as to the rights of people with mental health problems. Significantly, the Act also de-criminalises suicide and establishes procedures for administration of electroconvulsive therapy.”
The IMHA, 2017 looks to address institutional or policy-level aspects of mental healthcare in India. It establishes the rights of people with mental illnesses to access mental healthcare services where the central and state governments are directed to provide every district with adequate facilities. Dr Kumar while applauding the Legislation opines that “prevention of mental health in the country by focusing on the adolescents and young adults through life skills education should also become a part of the policy.”
Social support for people with mental problems, can begin with policy support. The IMHA, 2017 represents an attempt by the Indian government to bring the earlier Mental Health Act, 1987 in consonance with the obligations placed under the international UN Convention on Rights of Persons with Disabilities which India ratified in October 2007. The Act however, has certain discrepancies. For instance, other than treatment through bio-medicine, the Act should also look to promote mental well-being through the individuals’ social settings. Also, although the Bill had initially suggested a standardised process approved by a competent authority for ascertaining mental insolvency in the case of a person providing an advance directive in choosing the desired course of treatment, these clauses have been removed from the IMHA, 2017 (Pathare, 2017).
Reference and procedure for the committee to constitute periodic review and implementation of the IMHA, 2017 have not been specified (Satav, 2017). We must keep in mind that the IMHA, 2017 also needs to be supported by a robust mental healthcare infrastructure that looks to build mental health awareness among the population in India. With the number of people living in urban areas in India expected to increase exponentially, the pressures of modernisation are likely to be felt
The numbers of psychiatrists in India is projected to grow from about 6,900 in 2010 to 15,400 by 2020. Similarly, the numbers of clinical psychologists, psychiatric nurses and psychiatric social workers are also projected to increase from 1,350, 1,700 and 2,500 in 2010 to 2,150, 2,600 and 6,250 respectively by 2020 (Varma and Gupta, 2016). With many new technological developments also likely to be introduced in the treatment of people with mental illnesses in the future such as therapy through virtual reality, better medication, the use of mobile apps and so on, it becomes even more necessary for mental health policy and infrastructure to meet the needs of modern times (Smith, 2017).
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