Taking out the stigmaDecember 10, 2018
The Mental Health Care Act 2017, which came into force in May this year, is set to make drastic changes in the treatment of psychological disorders. The Act, hailed as one of the most progressive pieces of legislation on mental health care in the world, entitles mentally ill patients to humane treatment and assures them the right to access mental health care. As per the Act, every person shall have the right to access mental health care and treatment from mental health services run or funded by the government. It entitles patients to access affordable and quality mental health services without any kind of discrimination. The Act has also decriminalised suicide attempts by mentally ill people.
“The Act is a phenomenal, rights-based approach, a game-changer in mental health care and one of the best health legislations in the world. It is an ideal and aspirational legislation,” observed Dr. Suresh Bada Math, Professor of Psychiatry at the National Institute of Mental Health and Neuro Sciences (NIMHANS)
Upholding the legislation, Dr. Mala Kapur Shankardass, Sociologist, Gerontologist, Health and Development Social Scientist and Associate Professor, Dept. of Sociology at Delhi’s Maitreyi College, said: “The Mental Healthcare Act is a good legislation which is very much required in the country for better outreach to affected people”.
The Act directs the government to make sufficient provision for providing a range of services required by persons with mental illness. It directs the government to ensure the availability of minimum mental health services run or funded by the government in each district. Patients should not be made to travel long distances to access mental health. If it is not available in the district where a person with mental illness resides, the person is entitled to access any other mental health service in the district and the cost of treatment will be borne by the government. It directs the government to make necessary budgetary provision for the effective implementation of the Act.
“It is a rights-based legislation. Hence it is the responsibility of the state to provide mental health care. But do all the states have the political will and the financial commitment to implement the Act? Considering various constraints like poor human resources, it may take time to set up and receive the funds that are warranted to ensure its effectiveness – which is why the impAct of the law may not be immediate and may not be seen in the near future,” said Dr. Math.
The Act also stipulates the criteria for the admission, treatment and discharge of mentally ill people. An adult patient can be admitted only if the patient has mental illness of a severity requiring admission, is likely to benefit from the admission and has the capacity to make decisions regarding admission and treatment. All admissions in the mental health establishment shall, as far as possible, be independent admissions except when such conditions exist as to make supported admission unavoidable. An independent patient shall not be given treatment without his informed consent. The independent patient can discharge themselves without the consent of the medical officer. However, the patient can be made to stay in the hospital for 24 hours if the mental health professional feels that the patient has impaired decision-making capacity, poses a risk to self or others and is incapable of self-care.
Disorder criteria: A drawback?
Though the Act focuses on the rights of patients, it is comes with lots of regulations and related control. “The rights of the mentally ill should be protected, but the numerous mechanisms involved may create more stigma to the patients. The main drawback of the Act is that the patients who do not meet the criteria of ‘substantial disorder with gross impairments’ for mental illness cannot be admitted even if they are keen to do so and their doctor is willing to provide treatment. It poses a violation of the right of individual to seek treatment in the most appropriate setting. Even though the criteria
for admission are described, the mental health review board does not have the power to review such admissions,” said Dr. John C. J., Senior Consultant, Psychiatrist, Medical Trust Hospital.
In case of the admission of minors, the nominated representative of a minor, usually the legal guardian, needs to apply for admission. Two professionals — two psychiatrists or one psychiatrist and one mental health professional — need to independently assess and conclude that the minor has a mental illness of the severity requiring admission, that it is in the best interest of the minor and that all community-based interventions are unsuitable or have failed. The admission of a minor should be reported to the mental health review board within seven days and if the minor remains in the hospital for more than 30 days, the mental health review board should be informed immediately. When the board is informed about the hospital stay of a minor exceeding 30 days, it must review the concerned minor within seven days.
For supported admission under the Act, two professionals — one psychiatrist and one mental health professional — should independently examine the patient in the preceding seven days and independently conclude that the mental illness is severe. Both professionals must certify that admission is the least restrictive option available and the patient’s capacity to make mental health care treatment decisions is impaired. If the patient requires hospital stay in excess of 30 days, the patient must be independently examined by two psychiatrists at any time during the preceding seven days. They should independently conclude that the patient meets severity criteria, and that admission is the least restrictive option and that the patient’s capacity to make decisions about mental health treatment is impaired.
Dearth of resources
Even as the Act gives utmost importance to the right of patients, the implementation of the Act poses a challenge for the authorities. “The challenges exist in trying to reach out to rural and illiterate populations and and those residing in areas where mental health care services are limited. The problem is about raising awareness regarding the Act and how it is an empowering tool. It has to be implemented properly and people must understand its uses,” said Dr. Mala Kapur Shankardass.
Dr. Suresh Bada Math observed that the main challenge is the abysmal number of trained mental health human resources when compared with the prevalence of mental disorders, which are mind-boggling in numbers. “Though approximately 10 crore people require mental health, only 7,000 (approximately) psychiatrists are available. The mental health human resources numbers in the public health sector are very meager, considering the rights-based mental health care [approach] and the number of people requiring attention. To fill this human resources gap, we may require 20 years or more,” he said
Dr Math said the current mental health budget is very minimal, while the required budget is at least Rs 3,000 crore per month just for treatment. “At present, there are only a few rehabilitation centers in the public sector. The non-availability of halfway homes, long-stay homes, supported accommodation, sheltered accommodation, vocational rehab centers and the lack of daycare centers are the uphill tasks faced by governments in implementing the Act,” he said . He added that the government has been proactive and has taken a number of initiatives, such as digital academies at NIMHANS, CIP Ranchi and at LGB institute, Tezpur. The aim of these academies is to exponentially increase human resources for mental health care. Dr. Math emphasized that, considering the large treatment gap, all stakeholders need to work for a long time before the dream of the Act can be fully realized.