How effective is the mental healthcare bill?

INTRODUCTION:

According to the WHO reports, suicide rate for males is 12.2 per 100, 000 population and for females is 9.1 per 100, 000 population in and from India, neuropsychiatric disorders are estimated to contribute to 11.6% of the global burden of disease.[1]Even though there are considerable amount of people battling health issues for decades now, less than 30 million people seek help.[2] Our lives have become more stressful, with almost every other person dealing with anxiety, yet we hardly see conclusive discussions relating to our mental health. With the recent focus on the unfortunate and untimely demise of Bollywood actor Sushant Singh Rajput, the focus has finally shifted on the ever growing issue of mental health and how it crosses all the boundaries and can happen to a man, woman, transgender or even the rich and not just the farmers. While every one has taken to social media and has urged people battling mental disorders to seek help, one needs to understand that seeking medical attention for such issues is, (a) a stigma, (b) expensive and (c) unrealistic in many cases as there are extremely less number of psychologists/psychiatrist in India.

According to NCRB report on Educational Status of Suicide Victims, out of 100%, 64% of the affected victims had been men. According to the table, the rate of male suicide had been considerably higher in each category.[3]

As it can be deduced from the above table, the suicide rate is higher in men, without a doubt. Further, according to same data, the rate of suicide among people of various age groups, also varies.[4]

As we can observe from the above table, the rate of suicide is lower amongst people belonging to younger age group, and the people belonging to the older age group. Those who are within the range of 15-45 are probably the most vulnerable. One of the reasons attributed for the same is the pressure to perform, compete and achieve. In today’s world, adolescents from a very young age are either pitted against one another in order to achieve the best in academic and cultural field, or they get involved in other issues, such as love life, friends and in some cases family issues such as domestic abuse/violence etc. We saw one such incident, when a young boy had allegedly committed suicide after he was allegedly falsely accused by a girl of sexual harassment. These issues eventually start taking toll on the mental health of the person.

When we look at the elder age group, it is clear that what they face is significantly different from the younger generation. The elder generation has a lot to worry about; job, family, health, wealth etc., and with so much to look after, people tend to forget to take care of their mind and soul. This is very clear from the untimely death of Sushant Singh Rajput. But while his death has come in light due to his celebrity status, there are several people such as the farmers, who end up committing suicide due to the unavailability of proper resources to them, which would help them in supporting their family. We see more men finding solace in such heinous actions as the society has conditioned them to hold their own selves accountable if they are unable to feed or shelter the family. Further, it is also reported and documented in several reports and research papers that men are more likely to take such drastic steps due to lack of communication. While it is too simplistic to say women are willing to share their problems and men tend to bottle them up. But it is true that, for generations, many societies have encouraged men to be "strong' and not admit they are struggling[5].

With so many issues, which have reached an aggravated state of affairs, is there any conclusive legislation to protect people? The Mental Healthcare Act, 2017 is the current legislation in place, which aims to provide a formulated plan to deal with the growing mental health crisis in the country.

THE MENTAL HEALTHCARE ACT, 2017

The Act aims to provide for mental healthcare and services for persons with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental healthcare and services and for matters connected.

The Act lays down following as the rights of persons with mental illness:

1. Right to make advance directives
2. Right to appoint a nominated representative
3. Right to access mental health care
4. Right to free service
5. Right to get quality service
6. Right to get free medicines
7. Right to community living
8. Right to protection from cruel, inhuman and degrading treatment
9. Right to live in an environment, safe and hygienic, having basic Amenities
10. Right to clothing
11. Right to refuse work and to get paid for work
12. Right to protection
13. Right to legal aid

The Act defines "mental illness" as a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behavior, capacity to recognize reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterized by sub normality of intelligence. This has been defined under section 2(s) of the Act. As it can be noted, the act provides a comprehensive  Section 2(p) defines the term "mental healthcare' as the health process which includes analysis and diagnosis of a person's mental condition and treatment as well as care and rehabilitation of such person for his mental illness or suspected mental illness. Further, the Act also states that mental illness shall be determined in accordance with such nationally or internationally accepted medical standards. The positive aspect of this act is that it tries to work along with the international norms on mental healthcare.

Section 3(3) of the Act works towards preventing discrimination which is rampant against people with mental illness. It states that the mental illness of a person shall not be determined on the basis of political, economic, social, cultural, racial, moral, work values, past treatments or hospitalizations etc.

Section 4 states that every person, even the one having mental illness shall be deemed to have capacity to make decisions regarding his mental healthcare or treatment, if such person has ability understand the information. Appreciate any reasonably foreseeable consequence and communicate the decision. Where a person makes a decision regarding his mental healthcare or treatment which is perceived by others as inappropriate or wrong, that by itself, shall not mean that the person does not have the capacity to make mental healthcare or treatment decision.

One of the most significant part of this Act is the concept of advanced directive, as under Section 5. An advance directive is a document in written which specifies the following;-

(a) the way the person wishes to be cared for and treated for a mental illness

(b) the way the person wishes not to be cared for and treated for a mental illness

(c) the individual or individuals, in order of precedence, he wants to appoint as his nominated representative (as provided under section 14 of the Act).

These advance directives come in picture when the person with mental illness ceases to have capacity to make mental healthcare or treatment decisions and shall remain effective until such person regains capacity to make mental healthcare or treatment decisions. This provision ensures that at the end of the day, the person with mental illness gets to choose the person who will make final decision in case the former ceases to make his/her own decisions. By virtue of Section 8(1), such directive can be revoked, cancelled or amended by the person who made it originally, at any time and further, such a direction has to be registered online to a Board which handles the same, as per Section 7.

The Act also talks about Central Mental Health Authority and State Mental Health Authority under Chapter VII and VIII, respectively. According to Section 33, the Central Government shall, within a period of nine months from the date on which this Act receives the assent of the President, by notification, establish, for the purposes of this Act, an Authority to be known as the Central Mental Health Authority. Same applies to State authorities, as stated under Section 45. Every mental health institute and mental health practitioners including clinical psychologists, mental health nurses and psychiatric social workers will have to be registered with this Authority.

These bodies will:

(a) register, supervise and maintain a register of all mental health establishments,
(b) develop quality and service provision norms for such establishments,
(c) maintain a register of mental health professionals,
(d) train law enforcement officials and mental health professionals on the provisions of the Act,
(e) receive complaints about deficiencies in provision of services, and
(f) advise the government on matters relating to mental health.

Chapter XI lays down the establishment of Mental Health Review Boards which has been constituted to protect the rights of persons with mental illness and manage advance directives.

The Act lays down that the following procedures/practices are prohibited or restricted:

(a) No tonsuring
(b) No compulsory wearing of uniforms
(c) No electroconvulsive therapy
(d) Restriction on ECT for minors
(e) No sterilization
(f) No mechanical retrains
(g) Restrictions on psychosurgery
(h) Restrictions on physical restraints
(i) No solitary confinement

It is worth noting that the Act directs the government to take appropriate steps to plan, design and implement public health programs in order to reduce suicides and attempted suicides un the country [as under Section 29(2)].

While there is a mental health act in place which is comprehensive, there is still a dire need of psychiatrist and health professionals to deal with this menace. As stated above in the article, there are very less number of health professionals in India.

In India, the undergraduate medical courses hardly focus on psychiatry. There are very few mandatory exams in the subject of psychiatry at the medical undergraduate level and the courses are not rigorous.There are not enough seats in medical colleges for post graduate education in Psychiatry. To add to it, super specialization courses are very few. India primarily has only two super specialization courses, one in Child & Adolescent Psychiatry, and the other in Geriatric Psychiatry. Further, due to lack of opportunities, many psychiatrists leave the country for better prospects abroad. Lack of opportunities coupled with lack of awareness and social stigma forces these medical professionals to settle outside. According to reports from the Indian Union Ministry of Health and Family Welfare, the country needs around 13,000 psychiatrists. To achieve an ideal ratio of psychiatrists to population is about 1: 8000 to 10,000 but currently has just about 3,500 - which is about one psychiatrist for over 2 lakh people. With regard to other mental health professionals the ratio is even worse - the need of Clinical Psychologists is 20,000 and there are only 1000 available; for Psychiatric Social Workers, the requirement is 35,000, but only 900 are available, for Psychiatric Nurses, we need 30,000 and only 1500 are available.[6]

According to a report by the World Health Organization, mental health expenditures by the government health department/ministry are 0.06% of the total health budget and mental hospital expenditures were not available.[7] Also, there haven’t been any schemes or provisions which deals with a persons mental health by the government, or any private authority. Even health insurance schemes rarely or never cover mental health issues, even though seeking help for the same is expensive.

CONCLUSION:

It is the need of the hour that mental health is given the same importance as any other illness which happens to human body. People need to address the importance of therapy and need to indulge with psychologists and psychiatrists without any fear of discrimination and shunning by the society. But any such goal can only be achieved if people address the stigma and swear to remove it from its root. While everyone is busy celebrating the life of Sushant Singh Rajput, it must be understood that there are many like him who are in need of medical help and attention. His death has come as shock to the whole country, but at the same time it also makes us reflect on our own conduct and how we deal with the issue of mental health. As it has been made clear in the article that while women do suffer from mental illness, the suicide rate is higher for men and this stems from the patriarchal idea that men don’t feel pain and that "boys don’t cry'. These actions of ours need to be changed if want to bring about mental peace and happiness in our society. Further, form a legal and administrative perspective, it is an urgency that the government rolls out provisions, schemes and most importantly better educational programs for psychologists and psychiatrists so that they are able to pursue their practice in India itself. The number of medical professionals in India is generally low, with mental health professional’s number even lower, hence, more awareness needs to be created. Young generation needs to be taught the importance of mental health and should be urged to take up career in these fields. It is high time that we, as a society, unite, and fights the evil of mental health!

[2] https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/we-need-more-mental-health-care-professionals-in-india/articleshow/66146320.cms
[3]https://ncrb.gov.in/sites/default/files/adsi_reports_previous_year/table-2.8_2008.pdf
[4]https://ncrb.gov.in/sites/default/files/adsi_reports_previous_year/table-2.5_2008.pdf
[5]https://www.bbc.com/future/article/20190313-why-more-men-kill-themselves-than-women
[6]https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/we-need-more-mental-health-care-professionals-in-india/articleshow/66146320.cms
[7]https://www.who.int/mental_health/evidence/atlas/profiles/ind_mh_profile.pdf?ua=1