By Swetha Godavarthi, Shruti Muralidhar and Niranjan Kambi

The Mental Healthcare Bill was passed in the Lok Sabha this week. The legislation has been well-received and after 30 years, the discourse finally moves from treatment to the rights of affected individuals.

Classified according to codes outlined by the Diagnostic and Statistical Manual of Mental Disorders, mental illness is seen as a behavioral or psychological syndrome, or pattern, that occurs in an individual, the consequences of which are clinically significant distress (eg a painful symptom) or disability (ie, impairment in one or more key areas of functioning) or both. Many mental disorders, like bipolar disorder, depression, anxiety and addiction, show subtle, albeit debilitating changes. Although there are defined criteria for diagnosing mental illnesses, the tolerance thresholds to recognise specific symptoms and behaviour differ widely across cultures, societies and families. The difference in these thresholds dictate not just when an individual seeks medical attention, but also the societal response (stigma or support) to the patient’s mental illness. The bottom line is that mental illnesses are very much real illnesses that have devastating consequences on both the patient as well as their immediate family of caregivers.

A 2005 survey by Ministry of Health and Family Welfare shows that non-communicable diseases contribute 50 per cent of the disease burden in India.

Although the survey puts them under non-communicable diseases, injuries are technically not illnesses. This makes mental illness the second largest component among non-communicable diseases, next only to cardiovascular diseases. According to a 2016 survey by National Institute of Mental Health and Neurosciences (NIMHANS), mental disorders in the Indian population now comprise 10.6 per cent of the total disease burden, while a Lancet  study for the same period puts it at around 12 per cent. This means that approximately 150 million Indians need active intervention. This statistic is projected to increase to 23 per cent by 2025.

here are several misconceptions among the general public about mental illness and disorders. In rural India, the commonly-attributed causes of mental illness are either socio-economic factors (conflict with family or at work; not being married; bereavement; financial difficulties; poverty etc) or ‘tension’. Indian society views mental illness primarily as the ‘fault’ of the individual or lack of adequate ‘upbringing’ by the immediate family. Biological causes are not understood and many reject the idea of mental illness being a ‘real medical illness’. The myth that mental illness is caused by sorcery or supernatural forces is prevalent in both rural and urban areas. With this mindset heavily entrenched in the social psyche, changing viewpoints is imperative and well worth the time and effort.

The next hurdle is that of access to mental health services. Due to lack of adequate funding coupled with apathy of service providers, the success of District Mental Health Programmes (DMHP) has been extremely sub par. For its given population of 1.25 billion people, India has only 443 public mental hospitals. Six states, mainly in the northern and eastern regions of the country and with a combined population of 56 million people, do not have even a single mental hospital. Overall, there are 0·3 psychiatrists per 1,00,000 people in India, which is much lower than the average of 1.7 in China, for example.

This is the backdrop against which the Mental Healthcare Bill is being debated, and thus its importance. The bill proposes significant changes to the status quo of Indian mental health care (MHC). It guarantees the right of the patient to good quality, affordable and accessible MHC. More importantly, it assures the right to dignity of life and privacy and protects patients against inhumane treatments like forcible restraining, unmodified electroconvulsive therapy (ECT) and sterilisation. In a progressive step, it decriminalises attempted suicide and finally recognises that individuals attempting suicide need medical help and not incarceration.

Conversely, although it seems like the bill is a step in the right direction, there are grave problems concerning the way it deals with a lot of basic issues. A few among these include curtailing the role of the family in the treatment of the individual; lack of agreement regarding ECT and extreme shortsightedness in planning for elaborate mental health boards, licenses and treatments with no clear allotment of budget for basic infrastructure development.

In short, the bill is idealistic and not at all pragmatic.

With the current scenario in mind, as practicing neuroscientists, we put forth three major avenues of investment for the government:

1. Deinstitutionalisation of mental health care to increase access
2. Ameliorating mental health education followed by
3. Increasing investment in basic brain research.

Our current mental health care system centers around institutionalisation of the patient to dedicated psychiatric institutions for treatment. Not only does it make the patient population more difficult to handle by concentrating them in one place, but methods of treatment also promote maladaptive behaviours such as dependency and hopelessness. In an initiative to decentralise access to treatments, the bill mandates for the government to set up state-of-the-art mental health care facilities across the country, to provide good quality mental healthcare for all citizens of India. As an example, a similar deinstitutionalisation in 1970s’ United States of America brought about a sea change in the way patients were treated. Establishment of open hospitals allowing contact of patient with next of kin and supportive housing further helped create a better environment for the patient.

At the grassroots level, recognising and enabling primary health care providers such as counsellors and psychologists can spread awareness, especially in rural regions. Providing better mental health education to caregivers and village health care workers will show tangible benefits. A direct outcome will be an increased social acceptance of a recovering patient. The state of Kerala provides us with a good example where the impact of awareness, coupled with basic education, have shifted explanations for mental illness from “spirit possession” to “depression” and “tension”. Strong measures must be taken to educate the public with the scientific basis behind mental illness. For example, an attack of grand mal epilepsy in a patient cannot and should not be treated with prayers, potions and witchcraft. Mental health education must be introduced at the school level, along with physical health and education. Free and anonymous access to a counsellor will go a long way to both identify and help students in need. This is crucial, given the stress carried by students in the current Indian education system. Current health insurance policies for the working population must be re-designed to include coverage for regular mental health checkups.

Along with infrastructure and education, a basic understanding of normal brain function is fundamental to understanding abnormal brain functions. To this end, both the USA and Europe have sanctioned large monetary investments in research funding towards basic research in brain sciences. Comparatively, research into mental health and illness in India is highly underfunded and undervalued. It is imperative that our government start investing in fundamental brain research as soon as possible. For faster and better quality treatments, both academic and clinical researchers must work together on finding better therapeutics and translating them into valid cures. We will need all the help we can get to tackle the Himalayan burden of these devastating diseases of the brain and mind.