Psychiatric practice in dire straits

Many psychiatrists fear the stringent provisions of the much-lauded Mental Health Care Act 2017 can harm their profession

Psychiatric  practice in dire  straits

SIndia’s Mental Healthcare Act of 2017, which came into force in May last year, has been hailed as a big leap forward in safeguarding the rights of people with mental illness.

The new legislation looks to empower persons suffering from various mental disorders by enabling access to healthcare and treatment from the government without discrimination.

Decriminalisation of attempts to commit suicide is a striking feature of the new law, which also declares an all-out battle against the stigma associated with mental illness.

The implementation of the MHCA 2017 has catapulted India into the league of the handful of countries that have well-structured policies to honour the rights of the mentally ill.

Leading psychiatrists have lauded the act as one of the best legislations on this subject anywhere in the world, and hopes it would bring about a sea change in India’s mental healthcare scenario.

Big gaps

However, even as experts extol the motives behind such an “ideal and aspirational” act, they rue the sorry state of affairs on the ground.

The gaps between available resources and the requirements are far too wide to be bridged anytime in the near future.

For example, the availability of trained manpower is abysmally low in comparison with the mind-boggling numbers of disease prevalence in a country where an estimated 10.6 percent of the adult population suffers from mental health issues.

Only about 7,000 psychiatrists are available to cater to a population of about 10-crore mentally ill people. Human resources in the public health sector is even lower. Going by these numbers, it might require another 20 years to live up to the commitments of the new, rights-based legislation.

According to a statement issued by the National Human Rights Commission (NHRC), there is a requirement for 13,500 psychiatrists. Against 20,250 clinical psychologists needed, only 898 are available. Similarly, the shortage of paramedical staff is also acute.

Coming to funding and infrastructure, a minimum of Rs 3,000 crore is required just for the treatment of the mentally ill in India. On the rehabilitation front, only a small number of such centres are operational in the public sector. There is a serious dearth of long-stay homes, halfway homes, sheltered accommodation, vocational rehab centres and day care facilities.

Old act, still

Since it is rights-based legislation, the onus of providing mental health care lies with the state governments. Only 19 of the 29 states have implemented the MHCA 2017 so far, says NHRC.

“MHCA 2017 is conceptually a very progressive and patient-centered act, which keeps the human rights of the mentally ill as a top priority. But it has a lot of practically difficult-to-implement suggestions. As a result, it has not been implemented fully in most states of the country,” says Dr Arun Nair, a consulting psychiatrist at Medical College Hospital, Thiruvananthapuram.

The new law emphasises the importance of setting up mental health establishments across the country — to ensure that no person with mental illness will have to travel far for treatment — as well as the creation of a mental health review board which will act as a regulatory body.

One of the probable reasons for the delay in getting the act implemented in most places is the expense of setting up mental health review boards at district levels, according to Dr Nair.

The budgetary allocation for the National Mental Health Programme (NMHP) for the year 2019-20 is Rs 40 crore, which is Rs 10 crore less than that of the previous year. 

Launched in 1982, the NMHP aims to ensure the availability and accessibility of minimum mental healthcare for all.

Even in many states where the State Mental Health Authority (SMHA) is formed, the so-called appellate authorities are not yet functional.

“The old Mental Act is still being followed in many places, because, as per the new law, the patient or a family member is supposed to approach the district review board first if they have a complaint on a deficiency of service etc. Since there is no such mechanism in place, where will they go,” asks Dr Indla Rama Subbah Reddy, Director, Indlas Vijayawada Institute of Mental Health and Neurosciences, Andhra Pradesh. 

The new law requires all review committees to have a retired judge and a psychiatrist on its board, besides several full-time members and staff. Since the budget for setting up these committees has not been provided for, the states are likely to encounter practical difficulties in the running of the board as well.

A lack of awareness about the new law is another major roadblock. Most people don’t know that MHCA 2017 has already been implemented.

This is compounded by confusion regarding the new admission procedures, because the police, doctors and judiciary are finding it difficult to adapt to some of the changes envisaged by the new law, especially the scrapping of judicial admission, part of MHA 1987.

If MHCA is implemented in its full spirit, it may be highly beneficial to patients, says Dr Nair, but widespread awareness programmes are needed for all the stakeholders involved as well as for the general public.

Impractical ‘mental health will’; limits on ECT

Even though it is intended to safeguard the rights of the mentally ill, some of the provisions in the new regulations seem to go against the essential spirit of the legislation and be counterproductive, clinicians point out.

The advanced healthcare directive is an example. In this legal document, a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. It specifies the patient’s preferences such as the system of medicine, method of treatment and even the medical facility and the doctor. If the person is afflicted with some mental illness, the family members or caretakers are supposed to act as per the document.

Dr Reddy sees it as totally impractical as no one would like to prepare and keep such a `will’. Many people in India don’t even bother to keep a will on their properties. Moreover, who would predict or like to develop a mental illness in the future,  asks this leading psychiatrist and a well-known social psychologist who has won accolades for his path-breaking work in rural Andhra Pradesh to reduce the stigma associated with mental illnesses.

Unlike the West, India, especially the hinterlands, is still steeped in myths and misconceptions.

Restrictions on the use of electroconvulsive therapy (ECT) is another point strongly protested by many psychiatrists.

With the objective to check the indiscriminate ECT practices, which has been found rampant in the country, the new law confines its use to cases of emergency, and only along with muscle relaxants and anaesthesia.

Administration of ECT after giving anaesthesia is, of course, more patient-friendly and a sophisticated way of doing it. That is how ECT is being administered in many centres, points out Dr Reddy.

On the other side, it should also be taken into account that ECT often works as a dramatic and magical form of therapy for certain group of patients, especially for the ones with suicidal intent. It is also an excellent treatment for some acute conditions and violently ill patients. In such situations, the rule that ECT should only be given along with anaesthesia could pose an impediment in delivering timely care. This is because district-level public mental healthcare facilities having a full-time qualified anaesthetist are far and few, especially in the small towns of India.

Additionally, the new law bans the use of ECT in patients below 18 years old.

Again, ECT has been found very helpful in certain highly disturbed youngsters below 18 years. Such cases are very rare. Still, the need may be there, he says.

In certain situations, ECT becomes the only option to manage violent, suicidal youngsters. With one or two ECTs, the patient becomes normal, whereas pharmaceuticals can take longer to act, Dr Reddy elaborates. 

The author of several books and a regular columnist in some of the leading local and national publications, Dr Reddy would like to describe the new law as patient-friendly legislation. Some of the proposals are really good for the patients, he says, while the others look good on paper, but are difficult to practice.

Exiting psychiatric clinics?

A big fallout of the new law is its undesired impact on clinical practice. In the olden days, taking up psychiatry as a career was much discouraged. Even the profession seemed to have been stigmatised. But things have changed in the recent past. Today’s youngsters are more enthusiastic about pursuing this branch of medicine, because they clearly see the need, and the potential, of this branch of medicine. However, all of a sudden, things are coming to a pause. Too many constraints and restraints in the new law are compelling these people to retract and rethink, particularly the newcomers.

“Only the psychiatric practice, among all branches of medical science, is governed by this type of special acts. Take any other specialty, whether it is cardiology, neurosurgery, paediatrics or ophthalmology; none of them have a separate legal act. They just follow the general healthcare act, even though some of these specialties are dealing with more serious, more complicated and more expensive conditions. Only the psychiatrists are bound to follow both the MHCA and the healthcare act,” quips Dr Reddy.

Moreover, psychiatric practice is also not as rewarding in monetary terms as some of the other specialties. Patients are willing to pay any amount to surgeons, but not to a psychiatrist, who they think does nothing, but talk and ask questions. Quite often, even the patients fail to realise the value of psychiatry.

Concurring with the view, Dr Nair says the lack of employment opportunities is another important hassle faced by mental health professionals in India. “It’s generally felt among the younger generation of professionals that MHCA 2017 has made it more difficult for them, as private hospitals are now contemplating the idea of doing away with psychiatry in-patient facilities due to the stringent provisions of the act, especially since psychiatry is not a high-income-generating specialty for the corporate hospital in the first place,” he observes.

It looks nothing but a paradox that clinicians go jobless even as the requirement of trained psychiatrists reaches an all-time high.

Oblivious of realities

Meanwhile, critics of the legislation maintain that the new rules are a blind copy of those that exist in the West and are totally oblivious of Indian realities.

Even though psychiatric conditions, their pattern, prevalence and treatment remain the same throughout the world, the Indian scenario is entirely different. Mental disorders often have a cultural context, and the Indian population is highly diverse from an ethnic view point. These factors should be taken into consideration while framing policies or offering psychiatric services.

The critics argue that psychiatric diseases represent social constructs peculiar to the social groups in which they are created. The diseased may be suffering due to specific causal factors rooted in local ontologies.

“Split personality disorders, like the one featured in popular Hindi film Bhool Bhulaiyaa, is an example. This is something that is very common in India and is not seen in the western countries,” says Dr Jateen Ukrani, consultant psychiatrist at the Lifestyle Clinic, Delhi.

Described variously in local terminology, this dissociative disorder usually has an aura associated with some cultural and religious beliefs. The victim of this disorder is suffering psychologically. She is being abused or facing some other issues from family members or in-laws. Since she is suppressed and not able to express her feelings, it comes out in this form. The sufferers are mostly uneducated, and they don’t know what to do. And this is how they express their grief, their worries, their stress. A lot of women suffer from this disease. When it occurs, these patients first go to faith healers, then to the physicians, then they go to gynaecologists and finally they end up in psychiatric clinics, he says.

Awareness about mental health issues has definitely increased in the last decade, thanks to proactive programmes initiated by psychiatrists and other professionals all over the nation. The number of patients seeking psychiatric help, too, has gone up in metros and cities. But psychiatric consultations are still largely driven by referrals in rural areas. “There are a lot of walk-ins in metros like Delhi. [But] if you look at smaller towns,
patients don’t come to a psychiatrist on their own. Someone has to send them, or someone has to bring them,” avers Dr Jateen, who also practices in his hometown of Mathura, a tier 2 city.

Though the attitude of the city dweller has changed for the better, awareness levels on mental illness has not improved much in the larger part of India. A significant section of Indian public is still groping in the dark.

Mental health at the bottom

Stigma continues to be the major hassle for the clinician. Attempts to destigmatize mental illnesses by offering a biological model hasn’t necessarily permeated into the awareness of the rural public of India, rues Dr Nair.

Certain sections of the public still prefer magical remedies and unscientific interventions for the treatment of mental illnesses. Despite higher levels of education, many still staunchly harbour superstitious beliefs, which hinder the delivery of effective healthcare, especially in rural areas.

Dr Nair, as someone who has conducted over 1,000 episodes of health programmes on TV, written over 800 articles and published 13 books on mental health, feels that we still have a long way to go in terms of creating the required awareness.

Mental health promotion strategies, like life-skills training, should form a mandatory component of the academic training of students. 

Problems like juvenile substance abuse is very common in India. These issues, however, are not widely discussed, alongside disorders like depression, schizophrenia, bipolar disorder, which are also on the rise.  

Nevertheless, mental health is not getting the kind of attention that it should from the government, and is yet to become a priority for administrators.

One of the ways to bring this about is through effective mental health advocacy. “If you observe the various marginalised sections of the society who have effectively got their demands met by the administrators, advocacy has been a key factor,” comments Dr Nair. Mental health professionals themselves should take the lead on forming advocacy groups and bringing their issues to limelight, he averred.

In healthcare, mental health is today considered the most insignificant sector, and comes at the bottom of the list of priorities in budgetary allocations. Who really is bothered about mental healthcare, asks Dr Reddy. 

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