World Mental Health Day 2018 holds special significance for the stakeholders in India with the passing of the Mental Health Care Act. It is rights based, patient–centric , restoring legal personhood, and recognising mental capacity of the person with mental illness (PMI ) for informed consent. “Promoting Awareness”, the 2018 theme for World Mental Health Day, is an apt description of the Act to change public perception of the mental patient from ‘burden of care’ to ‘victim’ of an illness.
The objective of the Act is “…to provide for mental healthcare and services for person with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental healthcare and services and for matters connected there with or incidental thereto”. Implementation would involve reaching an “estimated 15O million persons in need of mental health interventions and care” (NIMHANS Survey 2016). Going by residential status alone , PMIs can be classified on five models of Care - Institutional Care, Community Care (Charities) ; Community Care(Commercial); Family Care; and Street Care of the wandering PMI. State is responsible for the protection and implementation of rights (Ch.V.18) across all the five care models. NSS ( 2002) 58th Round , National Statistical Survey (2016) on Disabled Persons and the Census of India 2011, concur that 65% to 70% of PMIs are under Family Care, the largest service provider in India. The 150 million needing care, together with 40 to 50 million in need of care, assuming that 14% of 1.3 billion Indians with Severe or Common mental disorders, presents humongous task before the Government. WHO cautions that India is in the grip of mental health emergency with 20% of its population likely to be declared mentally ill in 2020. Our policy makers, officials, mental health professionals, and even MHNGOs look upon Institutional Care and Community Care as major platforms for programs and interventions following the West. Family Care model did not have a distinctive identity of its own for introducing early intervention techniques. The trend is continued in the MHC Act and its repertoire of rights.
The Act mandates geographical proximity of mental health services. The question is does proximity alone ensure accessibility particularly for those living in families- rich and poor alike? Perfunctory references are made in ChV.18.4.c for “Provision for mental health services to support family of persons with mental illness” by assigning this as a duty of NR or Nominated Representative (Sec.17.e). Once again the question is can a mythical NR substitute the State for family support? The rights of abandoned PMI to family home called Supported Accommodation (Sec 19.2) and that of wandering PMI ( Sec 100 a &b in the Act) are given State backup. Similar support is missing for family based PMIs stopping medication, resisting first or follow up visits, suffering relapse and family upheavals. Many times, emergency is a cumulative outcome of mismanaged routines in families. It is not an exaggeration to conclude that Rights deficits in the Act affect 65% to 70% of PMIs and their families. “Vague, opaque language is however, used in certain contentious areas; this may represent arrangement-focused rather than realisation-focused legislation, and lead to inadvertent limitation of certain rights” (Duffy and Kelly, International Journal of Mental Health Systems, August 2017).
A robust Mental Health Program ought to prioritise investments in family outreach treatment, therapy, education etc. what may be called as Assisted Family Care. Using ‘family’ in an inclusive sense of care givers and Users , helps to have accessibility rights to AFC from one’s home. In the long run, this will prove far more rewarding than investing solely in understaffed, undertrained and under-utilised community centres.
The ten year timeframe permitted by the Act allows CMHA and SMHAs to design and implement AFC strictly on need basis. Further tweaking using PPP models is suggested to meet the needs of the middle class and migrant workers in urban metros. Demand for Supported Accommodation for OPMI (Orphaned PMI) is likely to go up among urban families as an upcoming challenge in the social landscape of mental health in India.
India’s persistent treatment gap of 80% to 90% is a worrisome trend. “686 Unlocking Program” in China was a door to door venture that reduced gap by 4% in 2005-15 is a case worth looking into. AFC can be used selectively for this purpose too.
The Act must be rolled out as a Right to Recovery in addition to granting right to treatment.