Why the new mental health bill is retrograde

B.S. Chavan

Mental health problems are more common than cancer and heart diseases combined. And, there are strong indicators that mental healthcare in the country is not sound. Despite high prevalence of mental disorders (58.2 to 73 per thousand population), more than 80 per cent of persons suffering from mental disorders are not getting proper treatment in the existing healthcare system. The major reasons for huge treatment gap ; the difference between the number of persons requiring treatment and number of persons who actually receive treatment, are, shortage of mental health professionals, stigma associated with seeking treatment from psychiatrists, limited mental- health facilities and the high cost of treatment.  These untreated cases are a huge burden on the family and society. 

Untreated mental disorders are known to lead to mental and physical disability, violence and high suicide rate. According to WHO, 1 in 4 persons suffers from mental disorders in both developed and developing countries. Out of the six leading causes of disability the major ones are mental disorders which include depression, alcoholism, schizophrenia, and bipolar disorder. In 2010 depression alone ranked second for global disease burden and it is predicted by the WHO that by 2020, depression will be the top most leading cause of years lived with disability worldwide. 

Untreated mental illness  

About 1 million people die by committing suicide every year worldwide and India has the highest number of suicides in the world.  According to the report released by WHO, in 2012, 2,58,075 people committed suicide in India. Majority of suicide victims are adolescents and young adults. It is the second leading cause of death in youth, aged 10 to 24 and it is estimated that in about 90 per cent of suicides, mental illness is the major attributing cause. If treated on time, many lives could be saved. 

Untreated mental disorders lead to many other complications. It has been estimated that 54 per cent of children with emotional and behavioural disturbances drop out of school. Alcohol and drug abuse among the school and college students is on the rise and has reached an alarming stage in the state of Punjab. Fun and experimentation are not the sole factors behind experimenting with drugs, as perceived, a large number of youth are undergoing stress, which prompts them to resort to drug and alcohol use. Stress is the precursor to a large number of mental health issues. The crime rate among the children, the drop out rate from the school, and indulging in antisocial activities to sustain the addiction of drug and alcohol are a few disturbing factors. Added to it, 60-80 per cent of people with mental illness remain unemployed leading to loss of productivity for the country. The delay in treatment triggers a vicious circle.   

Human rights violation

A large number of persons suffering from mental disorders lack proper treatment which results in facing discrimination and human rights violations. The consequences of untreated mental disorders include homelessness, incarceration and exploitation. Approximately one-third of total homeless people suffer from untreated psychiatric illnesses. These persons face physical and sexual abuse on the streets. During the initial stage of mental illness, it is possible to treat majority of them at a very low cost. The department of psychiatry, Govt. Medical College, Chandigarh, admits 3-4 homeless mentally ill persons a month. It is possible to treat their acute symptoms. However, the long standing illness causes permanent disability and these persons, mostly women, fail to recall their families. Most states in India do not have any residential facilities for homeless and the mentally ill. After the treatment of acute phase, they are left to fend for themselves, often feeding from garbage or, are sent to NGOs which provide only food and shelter, but no treatment. 

About 16 percent of untreated major mental disorder sufferers are lodged in jails and prisons, and are incarcerated with minor charges as they fail to defend themselves. Even the family members avoid them and do not apply for bail or fight the case in the court. People with untreated psychiatric illnesses spend twice as much time in jail as people with sound mental health and are more likely to commit suicide. Untreated cases also lead to prevalence of violence, although not as common as violence among the so-called normal individuals.

Laws to protect dignity 

In order to provide safety, security and medical care to persons with severe mental illness, the government needs to enact effective laws for protecting the human rights of the mentally ill. Mental health legislation is essential for protecting the rights and dignity of persons with mental disorders, and for developing accessible and effective mental health services. An effective legislation can provide a legal framework to integrate mental health services into the community and to overcome stigma, discrimination and exclusion of mentally-ill persons from the mainstream. 

Indian Lunacy Act, 1912 was governing  mental health in India till the Independence. It was repealed with the Mental Health Act (MHA) in 1987 so as to keep pace with advances in psychopathology and psychopharmacology. Various positive changes in the MHA, 1987 included a more humane approach to problems of the mentally ill by changing the terminology e.g. lunatics and criminal lunatics  were replaced by the term mentally ill person and mentally ill prisoner, new provisions on management of their property and protection of human rights were  included, Central and State Mental Health Authorities were created for safeguarding  the interests of the mentally ill person under one authority, procedure for admission and discharge of voluntary patients was simplified and liberalised. 

Although MHA,1987 act provided some respite both to the patients and the professionals, with the passage of time it has become inadequate. The mental health professionals in the psychiatry practice realised many shortcomings; MHA did not promote community-based mental healthcare and there was very limited attempt in incorporating mental healthcare into primary health care. The need was felt to amend MHA so that the new act could give priority to protecting the rights of persons with mental disorders, promotes development of community-based care and improves access to mental healthcare.

New legislation

In order to comply with United Nations Conventions on Rights of Persons with Disability (UNCRPD) and to satisfy the long- pending demands of mental health professional and the caregivers, the Government of India, in 2013, decided to make amendments in the MHA. During the process of amendments, the government realised that the existing act requires major revision and decided to make new legislation rather than amending the existing one. The new act is named as Mental Health Care Bill (MHCB), 2013. When the initial draft was brought in public domain, the mental health professionals representing two National Professional Bodies, Indian Psychiatry Society and Indian Association for Social Psychiatry, and the family members of persons with mental illness expressed serious concerns about the new legislation. Their anguish grew with time as not only they were kept out while preparing the First Draft, but also they were not given a hearing during subsequent discussions in the regional level consultation meetings.

The experts feel that the proposed legislation MHCB, 2013 has major drawbacks and in case the present government decides to go ahead with the existing draft, it will be retrogressive and will do more harm to the cause of mental health in the country than the existing MHA. 

The major problems in the MHCB are, the Bill marginalises the families, who, in India bear the major burden of care of the mentally ill. In fact, as compared to the west, where family support has broken down, joint and extended family system is still a vast Indian asset. The MHCB totally ignores the parents and families and, for the first time proposes that the patient can nominate any person as his nominated representative who will take all the major decisions regarding his care and property. Since many mentally ill patients lack insight during acute phase of illness, they can be easily cheated by the so-called nominated representatives, leaving the parents and other close relatives helpless. Further, shifting the burden of care on “other persons” who are not emotionally involved with the patients is unlikely to show compassion needed for such patients in the Indian setting. The Bill seeks to segregate the treatment of the mentally ill from the mainstream medical establishments and it is likely to increase stigma.  

Mental illness, except those which are severe or in need of long term treatment in a high dependency unit,  should be treated at par with medical/ surgical illnesses treatment for which facilities should be freely available in the general hospitals.  MHCB proposes that all the major decisions relating to treatment of mental illnesses will be taken by judiciary i.e. Mental Health Review Commission.  

Should courts intervene?

Should the courts direct the type and duration of treatment required for mental illness? If implemented, it will delay treatment, make it costly and complicated. The parents of minor children will not be able to seek indoor treatment without the permission of Mental Health Review Commission. The MHCB also proposes that patients suffering from major mental illness cannot be treated without their consent. This not only will increase disruption in the family, but will cause the severely mentally ill patients to cause disruption in society by aimless roaming, violence, or they may even end up in prisons due to untreated illness. The family members often seek the help from relatives and friends to bring such patients for treatment. 

The landmark development in India was starting of the psychiatry unit in general hospitals and medical colleges. This development brought mental illness close to medical illness. There was reduction in stigma as families were feeling comfortable in seeking treatment. However, these facilities are now proposed to be brought under the MHCB, which will make the treatment very cumbersome and stigmatising. This will also affect the postgraduate psychiatry training as the students will be denied the opportunity to see variety of cases as all the beds will soon get filled with chronic cases and there will be no bed for psychiatry emergencies.

Rehabilitation 

The biggest challenge in the treatment of mental illness is the rehabilitation, but MHCB  is totally silent about the care and rehabilitation of patients after discharge from long- stay facilities . These patients will require constant care and support while staying in the community and MHCB must address this issue like rest of the world has done. 

The author is of the opinion that in the present form, MHCB will be worse than existing Mental Health Act, 1987 and it will be rejected by the mental health professionals and the caregivers. Indian  family system is our heritage and the whole world is trying to learn from our rich family values. There are some aberrations, largely families are sympathetic and caring while looking after the mentally sick. 

 The writer is Professor and Head, Dept of Psychiatry, Govt Medical College, Chandigarh.