Saturday, 27 October 2012

Suicide nation: Can the mental health bill change anything in India?

Suicide nation: Can the mental health bill change anything in India?

by Oct 26, 2012

India has one of the highest suicide death rates in the world—both in terms of people who attempt suicide and those who die. Unfortunately, a large number of them are young adults and women, mostly from rural India.

India is also home to one of the largest number of people suffering from various mental health problems ranging from simple anxiety disorders to schizophrenia. Although about 10 percent of our disease-burden is caused by poor mental health, it hasn’t received a fraction of the attention it deserves. Poor mental healthcare facilities, particularly in rural areas; lack of social awareness and efforts to mitigate the impact of chronic conditions; and poor commitment and capacity have made the lives of millions of Indians with some mental health issue utterly miserable.

However, the situation may get better if the government is able to pass a new mental healthcare bill in the next parliament session. Earlier this month, a Group of Ministers (GoM) gave its nod to the new bill. Concurrently, the allocation for mental health has also been raised in the Twelfth Plan.

The new mental health policy, along with increased allocation by the planning commission, can considerably transform the otherwise bleak situation in India despite the infrastructural, socio-cultural and capacity bottlenecks that need to be overcome.

Firstpost spoke to Vikram Patel, member of the policy group that drafted the national mental health policy, about what stirred the government to finally act and how the new bill will ensure better care for the mentally ill.
Patel is joint director of the London-based Centre for Global Mental Health and will head the Centre for Mental Health launched by the Public Health Foundation of India in New Delhi in September.

Excerpts from the interview:

The greatest change in the Mental Health Bill in the Twelfth Plan is the inclusion of the word ‘care.’ Reuters

Q: What do you think has led to the government finally waking up to its responsibilities on mental healthcare?

A: I think there are several factors. Firstly, it is evidence-based. The research from India shows how common mental health problems are, what its impacts on people’s lives are and increasingly how these can now be treated even in places where there are very few mental health professionals.

Secondly, in the last 10-15 years India has seen a transition in its epidemiological profile —from primarily infant, maternal health and infectious diseases to non-communicable diseases. As part of the latter, mental illnesses have become proportionately more important.

The third important factor is that there is a demand for better healthcare coming from civil society, people who are affected by mental illness and their families. Fourthly, the scandals of human rights abuses of people with mental illness, which are now prominently being reported in the media.

And finally, suicides. It is often in the news these days, especially in the context of farmers, and increasingly among others as well. Also, there is also a larger global concern about mental disorders in developing countries, which obviously will have an impact on Indian policy making.

Q: Is economics also a concern since mental health problems reduce productivity?

A: Yes, it is. Actually it is a very big concern. There are many different economic arguments. Firstly, having a mental illness profoundly influences the ability of a person to be economically productive. Secondly, certain mental illnesses exclude people from economic opportunities. Thirdly, there is enormous cost associated with caring for people with mental illness in terms of caregivers, who have to stop working, and cost of treatment.

Q: What do you make of the new mental healthcare bill? What significant advances does it make in terms of attitudes towards mental illness and management of mental healthcare?

A: First of all, it is a fantastic bill. It represents in my mind a radical improvement in the existing mental healthcare act. A key element of that difference is the word ‘care’. For the first time, in our country, we have a draft bill that actually entitles people – this is not true for any other health problem – to receiving care.

I think the draft mental healthcare bill if it goes through its legislative process will completely transform the idea of a government-led healthcare system, which is an entitlement for people with mental illness. Hopefully, it will form a model for other health problems as well.

And it is also consistent with the best mental healthcare legislations in developed countries around issues of capacity and consent, for example. It has many safeguards to ensure that the rights of people with mental illness are protected, including in rare situations when their capacity is so impaired that they may require involuntary care.

Q: Do you have any reservations about the bill?

A: Obviously, the biggest reservation is implementation. A key element here is safeguards for people with mental illness when they receive involuntary admission. The procedures are far superior to anything we have had before. The concern is how well will it actually be implemented in the real world. That is something which we need a keep a close watch on.

The clause about involuntary care has raised some concerns. It is in the nature of the area of work that there is no clear-cut rule if someone is able to give consent or not. There is a level of subjectivity here. You have to accept that. Under certain circumstances, people with mental illness will lose the ability or have a reduced ability to give an informed decision about treatment. The question is how do you judge that. And how do you ensure that when someone says they don’t want treatment that they have thought through the pros and cons. This Bill goes a long way in trying to ensure that people’s right to choose care is protected. But we have to acknowledge that in rare circumstances, people lose capacity and to deny them on the grounds of choice is to condemn them.

Q: You were part of the of the mental health policy group responsible for developing India’s first national mental health policy. What unique challenges does India pose to treatment of mental health problems, given its social (specifically gender), economic (large rural population) and cultural— religious (for example, dependence on faith healers) realities?
A: It does and also doesn’t. These realities are true in most parts of the world. Cultural diversity is not unique to India. The fact that there is rural and urban, a mal-distribution of resources is not only true of India. That there is lack of access to evidence-based care is not only true of India. There are obviously certain things that are contextual. But there are many other things that are fairly universal. The point is, we could always adopt principles that are universal and adapt them to suit the Indian context. Rather than assume that it has to be entirely a local Indian initiative.

Q: What would you identify as the top five issues that need critical attention to meet India’s mental healthcare deficit?

First, it is to provide community-based care for people with severe and enduring mental illnesses such as dementia and schizophrenia. That means providing the whole range of residential day-care and home-based interventions. Basically, community-based interventions to support people who can live an independent life, either in their own homes or in some shelter facility.

Second would be to provide comprehensive primary healthcare for people with common mental health problems – depression, anxiety, stress-related and alcohol-abuse related mental health issues.
Thirdly, district-level in-patient units fully integrated with the district hospital for management of emergencies and acute mental health disorders. The fourth would be having specialised units, one in every district or one for every few districts, that caters to very specific sub-groups of people – for example, children with developmental disabilities and prison mental health services. Finally, strengthening the mental healthcare skills and training of all general health workers.

Q: Is there enough budgetary support for mental health?

A: Money used to be a problem. The planning commission has greatly increased the allocation for mental health. The big problem now is implementing the new plans. In fact, a lot of money allocated in the Eleventh Plan was unspent. So, the challenge is clearly not the money but poor absorptive capacity and implementation bottlenecks.

Q: How much does mental health get from the health budget?

A: My guess is it wouldn’t be more than one per cent. But that might change with the Twelfth Plan.

Q: How much should it be?

Lets’ put it this way. Ten per cent of the burden of diseases is mental health disorders. In an equitable world, it should be 10 per cent of the budget. There is a long way to go. But it is not the just the money. I don’t think we should get 10 percent of the budget right now. We don’t have any ideas about how to spend it. Unfortunately, we haven’t been able to spend even the little money that has been allocated so I wouldn’t rush into getting more money. I would rush more into getting more public health leadership in the mental health programme.

Q: Mental, neurological and substance-use or MNS disorders account for 12 percent of the disease burden in India. Could you break down that statistic for us? What are the leading disorders in these categories?

A: Of the three groups, the mental disorders account for the largest group. And all three are united by one thing – some form of dysfunction of the brain.

The leading disorders are depression, followed by anxiety disorders and lastly, schizophrenia. In certain age groups you have “key disorders”. In older people it is dementia and stroke; in children, development disabilities such as mental retardation, autism; and in certain groups like men, alcohol-use.

Q: You were part of a recent study on suicide mortality in India that showed suicide death rates in our country were among the highest in the world. A disturbingly high percentage of suicide deaths are among young adults. What are the reasons for this?

A: Why are young people more likely to commit suicide? The first thing to remember is because they are actually in a phase of neuro-development that makes them more prone to impulsive behavior. And in India, the problem is young people are turning to lethal methods such as pesticides. Since pesticides are so toxic, suicide attempts lead to death. Whereas in the West, most young people who attempt suicide would use medicinal substances which are not so toxic.

In urban areas, there would be less use of pesticides and more of other methods. Don’t forget that rural India has double the number of suicides than urban India. The reason for this could be that there is better medical care in urban India.

Q: Do young people face added social pressures in India?

A: I think so. There is potentially also a generational conflict. Say, you are a young woman aspiring for equal opportunities with young men. You might find yourself in a social or family system where you don’t have the same opportunities, you are not allowed to choose your partner or your job. And that is why one of the most shocking things about the Indian suicide data is that there is markedly higher suicide risk in women compared to young men. And the rate of suicide in young women is much higher compared to the rest of the world.

Clearly, there must be something about the lives of young women that makes disappointment more frequent. And I think the most likely explanation is domestic abuses.

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