Mind the treatment gap

Vani S.Kulkarni, Raghav Gaiha
The Mental Healthcare Bill, 2016, which was passed in the Lok Sabha on March 27, 2017, has been hailed as a momentous reform. According to the Bill, every person will have the right to access mental health care operated or funded by the government; good quality and affordable health care; equality of treatment and protection from inhuman practices; access to legal services; and right to complain against coercion and cruelty. The Bill also empowers a mentally ill person to choose a treatment and her/his nominated representative, decriminalises attempted suicide, prohibits the use of electroconvulsive therapy (ECT) to mentally ill adults without the use of muscle relaxants and anaesthesia, and contains provisions for care, treatment and rehabilitation for those who have experienced severe stress and attempted suicide. While these are laudable and ambitious objectives as they address major concerns of mental health care, there have been some critiques drawing attention to the lack of funds, trained personnel, and insufficient emphasis on community care. The ground reality, however, suggests that these objectives are not just overambitious but an overkill.
Poor infrastructure, low funds
The Global Burden of Disease Study shows that in 2013, 50% of all disease burden in India was caused by non-communicable diseases, while mental disorders accounted for about 6% of the total disease burden. A third of this is due to depression, which also significantly contributes to suicide and ischaemic heart disease. Worse, suicide is a leading cause of death in people in India aged 15-29.
There are only 43 government-run mental hospitals across all of India to provide services to more than 70 million people living with mental disorders. There are 0.30 psychiatrists, 0.17 nurses, and 0.05 psychologists per 1,00,000 mentally ill patients in the country. The case of the Bareilly mental hospital – one of three major mental hospitals in Uttar Pradesh – is stunning. In this hospital, 350 patients can be admitted and around 200 patients can attend the out-patient department every day. But all these patients would be at the mercy of only one psychiatrist!
At the macro level, the proposed health expenditure of 1.2% of GDP in the Budget for 2017-18 is among the lowest in the world. In real terms, public health expenditure has consistently declined since 2013-14. Of the total health budget, a mere 1-2% is spent on mental health.
But this is a small part of the explanation of the inadequacy and abysmal quality of mental health services in India. Underlying this deplorable state of affairs is a pervasive perception that those with mental illnesses are pathological or even criminal; hence they do not deserve the type of rehabilitation given to those with physical ailments. Besides, the treatment gap (the difference between those suffering from mental illnesses and those seeking medical/psychiatric care) is widened because of the social stigma attached to such illnesses. In fact, many poor people hide their illnesses and endanger their lives. Others argue that it is not so much stigma but ignorance and lack of knowledge, myths, and supernatural beliefs that impede treatment. Women typically face larger treatment gaps as they are vulnerable to violence, sexual abuse and inhuman treatment.
Ethnographic evidence from the Human Rights Watch Report 2014 relating to women inpatients is gruesome. Deepali, a woman with a perceived psychosocial disability, said: “The nurse would sometimes forcefully put the pills in my mouth and stroke my throat to send them down, the way I feed my dogs… I woke up one night and I couldn’t move; my body was in intense physical pain. A nurse came and jabbed an injection into my body, without even taking off my clothes. You are treated worse than animals.”
Often, all women and girls were admitted without their consent and, as the team left, they cried out in despair, “send me home” or “take me home”. Unable to cope with mentally ill relatives, families often abandon them in mental hospitals and elsewhere. In one case, a woman who was declared “fit for discharge” in the 1990s was still in the institution as of August 2013 because of lack of alternative resettlement options for her.
Some women were not even informed that ECT was being administered. Psychiatric nurses admitted that ECT was administered not just on violent and suicidal patients but also on new admissions who tend to be
unmanageable.
Women and girls with psychosocial or intellectual disabilities in institutions are often subject to not just physical and verbal abuse but also sexual violence. Some women went to a hospital for three months and returned one month pregnant. Not a single FIR was filed.
Government hospitals refuse to admit “mentally ill” persons in the ICU on the grounds that this facility could be put to better use.
A woman suffering from breast cancer for two-three years was denied treatment and subsequently died.
Shift to community-based care
An emphatic case could be made for shifting from institutional care to community-based care for people suffering from mental disorders. A study published in The Lancet Psychiatry, 2017 offers corroborative evidence from VISHRAM (the Vidharbha Stress and Health Programme), which is a community-based mental health initiative. The reduction in the treatment gap was due to increased supply of mental health services through front-line workers and their collaborative linkage with the physicians and psychiatrists in the facilities, as well as increased demand for mental health services due to improved mental health literacy. The substantial reduction in the median cost of care resulted from availability of general as well as specialist services in the village itself.
Whether legislation such as the Mental Healthcare Bill help overcome supply and demand barriers seems highly unlikely, as the root causes lie in pervasive negative attitudes, massive neglect of mental health care, rampant abuse and unchecked inhuman practices, and weak redressal and enforcement
mechanisms.
The Bill seeks to address major lacunae in mental health care and is thus an important step forward. However, its implementation will require substantially larger public resources and, more importantly, restructuring of mental healthcare services with a key role for the community in their provision, rapid expansion of mental health literacy, effective monitoring and enforcement of the objectives envisioned in it. With limited awareness of these challenges, and with a slight risk of exaggeration, the Bill is an overkill.
Vani S. Kulkarni teaches Sociology at the University of Pennsylvania, and Raghav Gaiha is (Hon.) Professorial Fellow, Global Development Institute, University of Manchester.

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