The challenge is to ensure that mental health services reach communities quickly
The article in The Hindu “Don’t shrink the scope of the Mental Health Act,” (Op-Ed, October 23, 2012) on the Mental Health Act, by Dr. Jayakumar Menon, is timely. There are many issues which generate a lot of heat and dust among the stakeholders of mental health and illness. They include psychiatrists, psychologists, psychiatric nurses, social workers, the media, non-governmental organisations, government and, most importantly, patients, their family members and caregivers.
Why is legislation required for mental illness? On the one hand the proponents of holistic health argue for clubbing mental health with physical health so that the stigma is avoided. On the other, social activists do battle for a separate and unique law exclusively for psychiatric disorders; lest they are marginalised and made outcastes.
The fact is that legislation does help in implementing health services provided by the state. The political promises and executive actions function better. Guidelines can be established by the law which would be binding on policy-makers. It would enable funding, accountability and availability of the services to the needy.
Mental health services: The history of mental health services in India is linked to the history of mental hospitals in the country. Initially, lunatic asylums were meant for European soldiers who were insane. All these asylums were run on the jail model with similar rules being in force. Due to overwhelming criticism about these hospitals, a more humanistic approach evolved, with mental hospitals replacing asylums. The number of mental hospitals has gone up to 45 from 31 in 1947.
The recent shift of providing mental health services from a specialised hospital to a general hospital setting has its advantages. The very model of sickness has turned towards a biological model from one with psychological and social roots. However, the more important and urgent challenge is in ensuring how soon mental health services reach the community. The ambitious National Mental Health Programme (NMHP) has been a failure if not a non-starter.
The Mental Health Act, 1987: The MHA 1987 is in itself a great effort forward, replacing the century-old Indian Lunacy Act 1912 which was in force for 80 years. The Mental Health Act, drafted by the Indian Psychiatric Society in 1950 received the assent of the President in 1987 but was implemented from April 1993 only. Though the Act is conceptually far ahead of its predecessor, the drawbacks are so many that it needed a revision in less than 20 years. On the positive side, the act presents a more humane approach; clear guidelines were enumerated for admitting various categories of the mentally ill, a proper method of establishing State and Central mental health authorities was made and discharges simplified. However the Act lacked the direction in providing simpler mental health services at the community level. The role of the family, which is so essential in management, is completely ignored. The boundaries between rehabilitation centres and mental health centres are very blurred, leading to a lot of confusion.
What needs to be changed: The State and Central mental health authorities need to be given both administrative and financial powers. The Act exempts government hospitals in stipulating norms which is absolutely unfair. Does it mean that the government can run the organisation with no staff and infrastructure? It may not surprise many that a few government hospitals have well-trained doctors, nurses and psychologists. Why should a general nursing home be asked to get a separate licence if it were to admit patients with any mental illness? If an individual with a head injury develops abnormal behaviour, should the hospital transfer such a patient to a nursing home where there are no facilities to deal with head injuries at all but has the licence to admit patients? No word is written about rehab programmes nor is any direction envisaged.
New Mental Health Care Bill: The Mental Health Care Bill 2011 is likely to get parliamentary approval sooner than later. The significant step in the Bill is the exemption of attempted suicide from prosecution, which is welcome. But the Bill takes a retrograde step in legislation of a particular method of treatment. The electro convulsive treatment (ECT) for children and without anaesthesia is barred, much against scientific and logical thinking. Such things are best left to the experts. Surprisingly the Bill also restricts the period of treatment which should again be a professional case-by-case decision.
The Mental Health Bill, as Dr. Menon hopes, should not shrink the scope of the mental health services. Any mental health legislation should be more therapeutic than legal and more humane than regulatory. Because you are dealing with the sick, not with litigation.
(Dr. N.N. Raju is general secretary, Indian Psychiatric Society, and vice-principal and professor of psychiatry, Andhra Medical College, Visakhapatnam. E-mail: email@example.com)