About 85 per cent of India’s mentally ill don’t have access to care. As the emphasis shifts to enhancing treatment on the occasion of the World Mental Health Day, a look at the ills that afflict our healthcare system…

Neel was diagnosed with a mental disorder called Schizophrenia in 1991 and the treatment started immediately in a premier national institute. However, like most psychiatric patients, he goes off medication very often and needs to be hospitalised with police help. He lives with his widowed mother and two sisters and the family dynamics is not conducive to his progress. In 2007- 08, he once again had a relapse because of stopping medicines; and was very disturbed and angry. But the police refused to shift him this time. The psychiatrist wrote a letter to the magistrate to issue a Reception order for the police to shift him to the hospital as per law. However, the magistrate wanted to see Neel in the court before issuing the order. The police were unable to pick him up because of his threats to commit suicide or attack someone at home. Eventually he attacked his sister; The police asked the family to file an FIR for criminal assault which they did. The family moved out of the house; Neel was picked up by the police, produced before the magistrate, who refused to believe that he was mentally ill. Hence Neel was sent to the jail for criminal activity. The jailer finds him suffering from acute psychosis and so gets him into the psychiatric hospital. He was back to “normal” after a month’s treatment. If only there was some crisis and emergency help available in 2008, Neel could have been shifted to the hospital without being declared a criminal with jail records! The hospital could have also admitted him under temporary treatment order under the law instead of asking for Reception Order. Though the law permits 90 days hospitalisation under this order, many psychiatrists prefer to make the family get a Reception Order

The above case illustrates how isolation from mainstream health services can adversely impact mentally-ill patients in India. This year’s World Mental Health Day calls for “Mental Health in Primary Care: Enhancing Treatment and Promoting Mental Health”. The theme is of particular interest to India where the majority of the prevailing 65 million persons with mental disorders are dependent on public health services. Of the 65 million, 15 million are afflicted with severe psychosis; 30 to 50 million suffer from mild to moderate psychiatric disorders. Prompted by the Lancet launch of the movement for GMH (Global Mental Health), the theme also advocates scaling up operations through evidence-based research at PHCs that provide the first level of contact between the rural client and the district health centre. Isolation from the mainstream health systems and services is a quintessential feature of the National Mental Health Program (NMHP) and the District Mental Health Program (DMHP) in India, resulting in a treatment gap of nearly 85 per cent. Let us examine some of the issues that are responsible for this poor performance as compared to TB, Cancer and even HIV/AIDS.

Need for training

Integration of mental health with general health needs training for the medical practitioners to diagnose co morbidity of mental disorders with physical ailments at the PHC level. Inclusion of Psychiatry as a credit course in MBBS would have reduced the burden of OJT for the PHC doctors. Strangely enough, this is not happening, despite court orders, due to consistent lack of coordination between the Department of Medical Education and the Health Ministry. As on March, 2008, 1, 46,036 Sub Centres, 23,458 PHCs and 4,276 CHCs are functioning in the country with only 13 per cent of the PHCs without a doctor. The alarming deficiency in mental health is a shortage of 7,000 psychiatrists but even the existing 2,800 are inequitably distributed with a majority in urban areas; whereas 80 per cent of the potential and existing patients are rural-based. Recently, the MoH, under the Delhi High Court orders, facilitated an addition of 125 seats per year in PG Psychiatry but the need is for 7,000 Psychiatrists. Deficiency among the support staff is even more startling. Yet, there is neither a policy, nor a programme to galvanise mental healthcare through public health system in PHCs.

Not a priority

Mental health has never been a priority for the Health Ministry though India pioneered PHC-level psychiatric treatment in the early 1970s, followed by the Bellary project that pilot-tested the District Mental Health Program (DMHP) in 1980. But, DMHP had failed to achieve total coverage of 600 districts even by 2000. Allocation of Rs. 1000 crore under the 11th Plan is commendable; but the Planning Commission’s “EMI” style of funding is a frightening exercise. Hundred districts per plan period is the average intake of the programme, leaving the rest for subsequent phases.

Even in the10th Plan, most districts have received only the first instalment of the DMHP grants. The lack of managerial approach accounts for inefficient utilisation of even the little that is made available. The revised objectives of DMHP in 1996 went beyond the medical model to a social model such as easy accessibility of treatment. In a recent incident in a town about 60 km from Bangalore, the district administration was unable to help the two mentally ill daughters of a very poor family; firstly because there is no psychiatrist in the district hospital and secondly because of the non availability of ambulance facility that could reach them to NIMHANS until the local MLA intervened! There is no provision to reach the treatment to the doorstep of involuntary patients; ignorance and stigma cause further delay so that even if the treatment is available in the local PHC, it may never be accessed. Unless there is an outreach policy embedded in DMHP, mere availability of psychiatric help need not necessarily imply its accessibility. This is not possible until the State Mental Health Authorities (SMHA) are made accountable for monitoring DMHP programmes under Sec 4 of the Mental Health Act 1987.

The 2008 mid-term evaluation of the DMHP highlights the disastrous results of delinking of mental health from the District health systems. Underutilisation of DMHP funds by the State governments continues to be the pattern on account of inability to plan with a global perspective at the national level. It is also amazing to note the uneven performance profile of State Governments. Tamil Nadu has almost 16 DMHP districts, UP has 12 compared to four each in Karnataka and Assam. There is no structural linkage with the grassroots either through the ANMs of the district health programme or the AASHA workers under NRHM, accounting for its top-heavy medical- instead of community- and family-centric model. Nearly 80 per cent of mental patients live with their families and yet the DMHP does not talk of a single Family Caregiver or Patient training programme.

NMHP is a medical monolith unlike the TB, Cancer and HIV/AIDS programmes where the social component ranks foremost in the community projects. The Rs. 1000 crore budget under the 11th Plan is also woefully inadequate in view of the target population of 60 to 65 million MI persons. As a striking contrast, we find a budget of Rs. 1,447 crores for TB (1.9 million cases in 2007), Rs. 2,400 crores for Cancer (2.5 million patients) and Rs. 1,100 for three million HIV/AIDS cases (in addition to Global funding).

The success stories of these programmes call for a complete organisational, administrative and financial revamping of NMHP under a dedicated national level nodal agency like the NACO with wider participation from civil society .

Discriminatory law

Sneha was in her B.Com. first year when she fell a victim to MI. However, she was able to continue her studies with treatment and finally got the symptoms under control. She completed her B.Com and decided to look for a job. She picked up typing skills and is currently supporting family income by teaching school children. Though keen on a government teacher’s job, she is unable to access the Disability Quota because Persons with Disabilities Act 1995 and the amendments therein do not provide any job quota for persons with mental disabilities on par with the quota for physical disabilities. Like Sneha, there are many Indians with mental disabilities, especially from BPL families, who are functional but are unfortunately facing a law which is itself discriminatory.

Nirmala Srinivasan is the Founder of AMEND (1992), the first autonomous self-help group for families of persons under treatment for mental illness. She is presently a member of the Central Coordinating Committee under the aegis of the MoSJE(GOI), besides being a member of the KA Mental Health Sub-Committee.