India needs to look at the experience of countries that have moved away from asylum-based treatments and embraced community integrated psychiatry as the treatment model

Mental illness, of course, is not literally a “thing” — or physical object — and hence it can “exist” only in the same sort of way in which other theoretical concepts exist.

Thomas Szasz

During depression the world disappears. Language itself. One has nothing to say. Nothing.

Kate Millet

These quotes show how much the world is divided when it comes to mental illness. We see people with mental illness everyday — in our own family, neighbourhood, on the streets — but the field of psychiatry, involved in the care of this neglected group of patients, faces a lot of criticism. The early history of psychiatry and non-evidence-based modes of treatment that existed before medications made their debut could have been a reason. It could also be due to the political misuse of psychiatry to silence opposing voices, especially by the Nazis and other dictatorial regimes. The most important factor seems to be the combination of years of negative propaganda and the influence of the media, especially the visual and print media, which have contributed to generating fear and apathy towards psychiatry. It is worth asking if this has helped the most vulnerable, mentally unwell person on the street, neglected by family and walking naked, lost in strange beliefs and perceptual disturbances.

Appropriate treatment helps patients with mental illness get better. Most developed countries have moved away from asylum-based treatments, and have embraced community integrated psychiatry as the treatment model. It also entails treating patients in the acute wards and moving them as soon as possible back to the community, where they would continue follow-up. In providing care, especially in acute settings, and for patients with major mental illnesses like schizophrenia and severe depression, psychiatrists often face patients with poor insight into their condition and impaired judgment. It is difficult to provide care to the patient who does not have the capacity to decide on getting treated or cannot make an informed choice about the best treatment option. Treatment is then provided involuntarily, keeping their best interest in mind. This doesn’t mean a collaborative effort is not attempted.

In Australia and India

As per the Mental Health Act (MHA) in Australia, acutely ill patients are admitted using an Inpatient Treatment Order (ITO), if any doctor feels that the patient requires specialist psychiatric care, but is unable to seek care on his own. The involuntary order is reviewed by a psychiatrist within 24 hours of its issuance and it is decided if the patient needs to remain on it. Once made involuntary, the responsibility of patient safety and treatment is under the treating team. Another important aspect in Australia is the presence of the Guardianship Board — a body with judicial powers — that needs to be notified of every involuntary treatment order soon after it is made. Patients, who feel the ITO was uncalled for, can appeal to the board against it. The board conducts a hearing in the next few days. After hearing the evidence from the treating team and the patient, it decides if the ITO is to continue. This prevents the misuse of power by the treating team. Most developed countries have provisions in their MHA to protect patient interests and to make a mental health-care plan after discussing the merits and demerits of the treatment with patients, their family or friends.

In a country like India, where the burden of illness is huge and facilities for psychiatric care are minimal, it is essential that adequate acute care is provided in every district. It is impossible to ensure care for the patient without a suitable MHA, which would simplify access to treatment, and at the same time prevent misuse. The Indian government’s plan to integrate mental health care with primary health care is ambitious. However, the role of the private sector and non-governmental organisations cannot be ignored. It is important that all the available treatment facilities (in government and private medical colleges, private hospitals, charity institutions) are covered within the ambit of the act and stringent checks put in place to ensure the safety and recovery of patients.

In this context, it is disheartening to know that the formulation of the new MHA is shrouded in mystery and that various activists are raising their doubts about its possible impact. Any draft MHA, without adequate debate and discussion, and feedback from all concerned, may not be able to capture the actual needs of patients. The experience of countries, where this has already been achieved, should be sufficient to warrant its necessity. Hence, it is time that authorities share information regarding important proposals and changes and convene discussions with the public to dispel misconceptions. Worst-case scenarios do not make the rule, but can be accommodated within the MHA as a means of audit and for checks and balances to prevent its misuse.

(Dr. Jayakumar Menon is a neuropsychiatrist at the Royal Adelaide Hospital, Australia. Email: drjkmenon@rediff.com)

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Dr. Jayakumar Menon respondsNovember 2, 2012

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