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The Mental Health System in India
International Journal of Law and Psychiatry, Vol. 23, No. 3–4, pp. 393–402, 2000 Copyright © 2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0160-2527/00 $–see front matter
PII S0160-2527(00)00044-3
The Mental Health System in India History, Current System, and Prospects Vijay Ganju*
Introduction While policies and services for persons with mental illnesses in India are increasingly progressive and humane, the formal mental health infrastructure is minimal at best. The Mental Health Act (1987) represents an attempt to introduce the latest thinking in the field of mental health services, but the political will and the required resources to implement the legislation are lacking. Prodded by the courts, media attention, and a growing public awareness of issues related to mental illnesses, new services are emerging. Voluntary organizations, which provide crisis intervention, counseling, and rehabilitation services, are growing in urban areas. The National Institute of Mental Health and Neurosciences has evolved from a lunatic asylum established in the latter part of the 19th century to a premier service, training, and research institute. But the successes remain spotty and scattered, emblematic of what could be done with more consistency and commitment throughout of the country. Legislation and regulations—reflecting the underlying philosophy—are enlightened by any standard. The challenge is to implement these policies and ideas in a meaningful way. Administrative and Health Infrastructure India, with a population of approximately 900 million persons, has 25 states, 6 union territories, and 1 national capital territory, ranging in population from 406,000 (Sikkim) to 139 million (Uttar Pradesh). Ten states have more than 40 million people. The Indian constitution charges states with “raising of the level of nutrition and the standard of living of its people and the improvement of public health.” *Director, Planning, Research, and Evaluation, Texas Department of Mental Health and Mental Retardation, Austin, TX, USA. Address correspondence and reprint requests to Vijay Ganju, Ph.D., Texas Department of Health and Mental Retardation, P.O. Box 12668, Austin, TX 78711-2668, USA; E-mail: [email protected] 393
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Central (or federal) government efforts at influencing public health have focused on 5-year plans, on coordinated planning with states, and on sponsoring major health programs. Governmental expenditures are jointly shared by the central and state governments. Central government efforts, administered by the Minister of Health and Family Welfare, provide both administrative and technical services and manage medical education; states provide public services and health education. For administrative purposes, states are subdivided into districts. There are 476 districts in India: the average population of a district is 1.8 million persons. In general, health-care facilities and personnel have increased substantially in the 50 years since India achieved independence. India’s population growth, however, has resulted in a decrease in the number of licensed medical professional per capita: By the late 1980s, the number of licensed professionals had fallen to 3 per 10,000, from the 1981 level of 4 per 10,000. In 1991, there were approximately 10 hospital beds per 10,000 individuals. Primary health centers are the cornerstone of the rural health-care system. These facilities are part of a tiered health-care system that funnels more difficult cases to hospitals while attempting to provide routine medical care to the vast majority in rural areas. Primary health centers and subcenters rely on trained paramedics to provide most of their services. The geographic distribution of hospitals varies according to local economic conditions, and can vary considerably across states. Of the 7,300 hospitals, 4,000 are owned and managed by central, state, or local governments; 2,000 are owned and managed by charitable trusts, receiving partial support from government; and the remaining 1,300, many of which are relatively small facilities, are privately owned. There are also 128 medical colleges, which serve as educational facilities and provide hospital and ancillary services. Indigenous or traditional practitioners continue to practice throughout the country. The two main forms of traditional medicine practiced are the aryuvedic (“the science of life”) system, which emphasizes a holistic approach, combining mental, physical, and spiritual well-being, and the unani–herbal medical practice. It is within this administrative and health infrastructure that the mental health system is embedded. History While traditional Indian medical systems, such as ayurved and unani, identified mental illnesses as distinct disorders and necessary treatments were provided by medical practitioners. There was no separate, distinct setting or provider system for mental illness. Only with European colonization were services for persons with mental illnesses provided separately. The introduction of lunatic asylums—segregated and removed from population centers— was a British innovation influenced by the ideas and concepts prevalent in England and Europe in the 18th and 19th centuries. The earliest mental institutions were established to meet the needs and demands of European patients in India. Some records suggest that the first mental hospital was started in Bombay in 1745 (Sharma & Chadda, 1996). There is
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reference to a mental hospital in Calcutta in records dated 1787. A lunatic asylum was established in 1795 in Bihar for insane soldiers. A hospital in Calcutta in 1817 had “between 50 to 60 European patients with clean surroundings and a garden . . . excited patients were treated with morphine and opium, and were given hot baths and sometimes leeches were applied to suck their blood” (Sharma & Chadda, 1996). At another asylum in Dacca, music was used as a form of treatment to calm excited patients. In 1858, the first Lunacy Act was promulgated. The Act provided guidelines for the establishment of mental asylums and procedures for the admission and treatment of mental patients. These asylums were built “to segregate those who by reasons of insanity were troublesome and dangerous to their neighbors.” The 1912 Lunacy Act brought mental hospitals under the charge of Civil Surgeons instead of the Inspector General of Prisons; specialists in psychiatry were appointed full-time officers in these hospitals; and all lunatic asylums were brought under centralized government control. The 1912 Lunacy Act essentially remained in effect until the 1987 Mental Health Act was passed. Colonial conditions gave mental health policy a distinctive character in India. There were three significant deviations in practice from models in Britain: inmates were segregated by race; Europeans were not required to do manual labor; and Europeans were institutionalized much earlier than would have been the case in Britain, because they were seen as a special threat to the prestige of the ruling colonial class (Waltrand, 1991). In 1920, the names of all asylums were changed to mental hospitals. Occupational therapy was introduced and family units were established. During this period, an association of medical superintendents of mental hospitals was formed. In 1946, a health survey and development committee, popularly known as the “Bhore Committee,” surveyed mental hospitals. At that time, there were 19 mental hospitals with a bed capacity of 10,181. The committee reported that the hospitals were primarily designed for custodial care and detention rather than treatment. There was also recognition that there was “gross inadequacy” in medical personnel in all mental hospitals, both in terms of numerical strength and in specialized qualifications. Since independence of India in 1947, the emphasis has been more on the creation of psychiatric departments in general hospitals and medical colleges rather than the creation of new mental hospitals. In many ways, however, the inadequacies recorded in 1946 continue to characterize the system today. The National Mental Health Programmme As the Government of India embarked on an ambitious national health policy that envisioned “health for all by the year 2000,” mental health was not adequately addressed. The National Mental Health Programme was a set of recommendations developed to ensure that mental health care was explicitly included. Early drafts of the National Mental Health Programme were formulated by mental health professionals and then subsequently adopted by the Central Council of Health and Family Welfare, the highest health policy-making body
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at the national level. The major recommendations were that: (a) mental health must form an integral part of the total health programme and as such should be included in all national policies and programs in the field of health, education, and social welfare, and (b) strengthening the mental health component in the curricula of various levels of health professionals. These recommendations were in response to the recognition that mental health professionals alone would be unable to meet the growing mental health needs of the population. Even if training facilities for the mental health sector would be doubled or tripled, it would require several decades to meet such needs. Also, it was recognized that services beyond mental health institutions were needed. One of the more important elements in the delivery of health care in India is the primary health center. A major thrust of the National Mental Health Programme was to provide mental health care at and from these centers. The objectives of the National Mental Health Programme were: 1. To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population. 2. To encourage application of mental health knowledge in general health care and in social development. 3. To promote community participation in mental health services development and to stimulate effort toward self-help in the community. Since its inception, the efforts of the National Mental Health Programme have been directed at promoting and developing state-level programs, workshops for mental health professionals and voluntary organizations, evaluation of mental health care provided through primary health centers, the development of a model District Mental Health Programme, and the development of training materials and programs for practitioners and academicians. In addition, the Center for Advanced Research for Community Mental Health was set up for longitudinal research at the National Institute of Mental Health and Neuro-Sciences, Bangalore. Eleven medical colleges were selected as regional centers in the 8th Plan (in which national priorities are established and by which resource allocations are made). These centers were required to coordinate various mental health activities in their regions and to supply health education materials. The Mental Health Act, 1987 Even prior to independence in 1947, there was recognition that many of the policies and provisions in the 1912 Lunacy Act were outmoded and had outlived their usefulness. Initial attempts by the Indian Psychiatric Society to bring about change were unsuccessful. In 1959–60, reforms were considered but no consensus was reached. In the 1980s, there was a resurgence of activity resulting in the passage of the Mental Health Act in 1987. The rationale for the new legislation was that :it has become necessary to have fresh legislation with provisions for the treatment of mentally ill persons in accordance with the new approach” (Mental Health Act, 1987).
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The purpose of the bill was: 1. To regulate admission to psychiatric hospitals on psychiatric nursing homes of mentally ill persons who do not have sufficient understanding to seek treatment on a voluntary basis, and to protect the rights of such persons while being detained; 2. To protect society from the presence of mentally ill persons who have become or might become a danger or nuisance to others; 3. To protect citizens from being detained in psychiatric hospitals or psychiatric nursing homes without sufficient cause; 4. To regulate responsibility for maintenance of charges of mentally ill persons who are admitted to psychiatric hospitals or psychiatric nursing homes; 5. To provide facilities for establishing guardianship or custody of mentally ill persons who are incapable of managing their own affairs; 6. To provide for the establishment of Central Authority and State Authorities for Mental Health Services; 7. To regulate the powers of the Government for establishing, licensing, and controlling psychiatric hospitals and psychiatric nursing homes for mentally ill persons; 8. To provide for legal aid to mentally ill persons at State expense in certain cases. The bill is comprehensive covering the establishment, maintenance, and licensing of mental health facilities; the revocation of licenses; admission and detention policies on a voluntary and involuntary basis, powers and duties of police officers with respect to mentally ill persons, conditions of care for mentally ill persons receiving cruel treatment or improper care, the designation of at least five “visitors” (of whom at least one shall be a medical officer, preferably a psychiatrist and two social workers) to review conditions and services in psychiatric facilities, the transfer of mentally ill persons form one facility to another, judicial inquisition regarding property, the custody of his or her person, and the management of property, and the protection of human rights of mentally ill persons, including conditions by which a mentally ill person may participate in research. The Act proposed the effective start date as April 1, 1993. The bill was both comprehensive and progressive. Some of the key differences between the 1912 Lunacy Act and the Mental Health Act were: 1. Definitions and nomenclature: The bill provided definitions of a psychiatric hospital, a psychiatric nursing home and a psychiatrist. It also replaced outdated terminology such as “asylum” with more progressive language. The Act defines a mentally ill person as a person in need of treatment. For the first time a distinction was made between mental illness and mental retardation. 2. The bill required the establishment of both a central and state authority for mental health to advise the respective level of government on all matters related to mental health. The intention was to facilitate adequate supervision of psychiatric hospitals and to coordinate activities with the
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health infrastructure, which is a state responsibility (Subsequently, Central and State Mental Health Authority Rules were formed in 1990.) The new act simplifies procedures for both admission and discharge. Outpatient treatment facilities must be available at every psychiatric hospital and psychiatric nursing home. The Act provides clearer direction for the functioning of the Visitor’s Boards. “Visitors” now includes psychiatrists and social workers. Also, the new Act has a provision to cease the office of such a visitor if they do not participate in the joint inspection for 3 consecutive months. The Act incorporates new provisions governing the management of property of mentally ill persons. There are more safeguards and there are greater penalties for misuse of property by designated managers. Under the Act, the police can detain a person suspected of mental illness for up to 24 hours and are required to present the person to a Magistrate to obtain a commitment order. (This provision prevents undue or prolonged detention on the basis of the designation of mental illness.)
In conclusion, the Mental Health Act (1987) is a progressive, far-sighted attempt to incorporate the latest knowledge and experience related to the provision of mental health services in legislation so as to build on this platform a plan of action. The Act has taken several decades to evolve, reflecting the priority that the area has received. Even now, the Act represents an ideology and an approach rather than the reality. Even though the Act required implementation to be effective in 1993, many provisions of the Act still remain to be implemented uniformly across the country. The System of Care As the review of the historical development of mental health care indicates, the rate of movement toward the implementation of a “care” paradigm is painfully glacial. The colonial asylum system persists but, in parallel, there has been a growth of care provided through the medical colleges and voluntary organizations have initiated activities in the major urban areas. Overall, the formal mental health sector is skeletal at best where traditional systems of care co-exist with more medically oriented Western approaches. There has been no policy move to altogether close the colonial mental hospitals (Sharma & Chadda, 1996) despite their well-known problems of poor staffing; meager infrastructure, and health facilities; a greater dependence on physical restraint rather than therapy; the excessive use of electro-convulsive therapy (ECT); and meager healthcare. The users of the mental health facilities choose native healers, shamans and exorcists, as often, if not more often, than they choose professionals. . . . Therefore, in India, the “service sector” for mental health is structured into the mental health professionals, the medical professionals, the paramedicals and the non-professional healers, native or modern. Glaringly, the complexity of “services” available for the mentally distressed confounds and complicates is-
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sues about public monitoring and audits, consequently compromising any mental health policy that may be drawn up. Definitely, the issues facing those interested in establishing “consumer choice” and protection of user interests in this confounding scenario are innumerable. (Davar, 1999, pp. 149–150) Within this overarching framework, the various components of the mental health-care systems are described in the following sections.
Psychiatric Facilities The mental health institutional infrastructure consists primarily of 42 mental hospitals, with a total bed capacity of about 22,000 beds (In comparison, the cities of New York and Tokyo have more psychiatric beds than the whole of India.) Even this statistic does not reflect the status of bed capacity accurately. Approximately one third of the beds are in one state—Maharashtra— while there are several—Haryana and Himachal for example—that have no mental hospitals. While the modal number of beds is in the 200–500-bed range, there are still several institutions in the 1,000–2,000-bed range. The Regional Mental Hospital in Pune has 2,540 beds. There are also several hospitals with 100 beds or less. Over the last decade, the unsatisfactory conditions in mental hospitals have been subject of public interest litigation and conditions have improved as a result of court actions. But the lack of adequate care and support services in the community creates its own set of problems for the mental hospitals. In a recent study of three mental hospitals in the state of Keral conducted by the National Institute of Mental Health and Neurosciences, results suggested that at least 20% of the patients could be discharged but had neither support from families nor community organizations to help them leave the hospital and rehabilitation programs in the state “are virtually non-existent” (Condemned for Life, 1998). The lack of a comprehensive, coordinated system results in overcrowding in the facilities and substandard conditions. For example, the hospital at Thiruvananthapuram has a bed capacity of 507, but has 830 patients. Similarly the hospital at Kozhikade has 700 patients while there is room only for 400. The study notes that several recommendations made by various commissions to improve facilities remain unimplemented. Besides the lack of rehabilitation services and overcrowding, the hospitals were characterized by staff shortages and even the staff who are available often are not trained in psychiatry. These are conditions in Kerala, are of the more progressive states in terms of health and mental health care. Conditions elsewhere are likely to be similar if not worse.
General Hospital Psychiatric Units Since Independence, there has been a major growth of psychiatric units of general hospitals, especially those associated with medical colleges. While the first such unit was created in 1933, the major spurt of growth in this sector oc-
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curred in the 1960s (Wig, 1978). Currently, there are about 3,000 beds in 200 units across the country. These units vary in size but are typically 20–30-bed facilities. The advantages of this component are self-evident. They have provided greater public acceptance of psychiatric services because they do not have the associated stigma of the mental hospitals. They are situated in the community so access is easier and more convenient. Admissions are largely voluntary; family members typically stay with the patients and stays are of a short duration (the average is about 3 weeks). Most have associated outpatient services and the proximity to other physical problems. It is estimated that 75% of the research work being done is by professionals working these settings. Extensions of these units are the district hospital psychiatric units. Two states—Kerala and Tamil Nadu—have a psychiatrist in each district. These states are exceptional: in most states, general hospital psychiatric units are situated in large urban centers or state capitals.
Community Care The National Mental Health Program in India envisioned delivery of mental health care through primary health-care personnel. Initial research projects were started in Chandigarh, Jaipur, and Bangalore to study how this could be done. The focus of these projects was to develop and evaluate training to identify mental illnesses in health setting. In these pilots, a team consisting of a psychiatrist, a psychiatric social worker, and a psychiatric nurse conducted outpatient clinics three times each week at the public health center. Persons identified by community members were asked to come to the center. The study results indicated that most persons needing psychiatric services had consulted traditional healers. Most had chronic problems but did not make use of services at the general hospital units even through the hospital was less than 10 miles away. The majority accepted treatment while living at home. Such efforts are now being replicated in other parts of the country, including Baroda, Calcutta, Hyderabad, Lucknow, Trivandrum, and Gaubati. Community care in India is still in its infancy. The availability of day-care centers, half-way houses, sheltered workshops, foster care, etc. is limited. If available, such services would largely be confined to the big cities.
Private Psychiatric Nursing Homes/Hospitals Privately owned institutions that provide psychiatric care are also part of the system of care, with bed strengths that vary from 10–300. There are approximately 40 such facilities in the country.
Voluntary Organizations In India, public and voluntary organizations have also started to play a role in the delivery of mental health services and in public advocacy for improve-
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ments in the availability and quality of care. Some of the activities of such voluntary organizations include: • • • •
Mobilizing public support and demand for services; Provision of crisis intervention and rehabilitation services; Support for families of persons with mental illness and; Advocacy for research in mental disorders and their care.
The efforts of voluntary organizations have pressured the government to improve the quality of care in mental hospitals. Public interest campaigns have resulted in the creation of state-initiated review committees that have increased public awareness and accountability. Interventions by the Supreme Court While many of the progress changes and innovations have occurred as a result of the initiatives of mental health professionals, a strong lobby of lawyers and social activists have taken on issues related to the mental health care system. Their public interest petitions have produced several judgements by the Supreme Court that have had a significant impact on mental health care reform. These public interest petitions were related to issue, such as poor conditions in mental hospitals; the takeover of mental hospitals by autonomous bodies; the jailing of persons with mental illnesses; the human rights of psychiatric patients; suicide. These have resulted in reforms and more progressive policies in all these areas. Mental Health Manpower At the time of independence, there was no recognized facility for training psychiatrists in the country. Currently, there are approximately 40 centers that provide training in psychiatry and diplomas in psychological medicine. It is estimated that over 150 psychiatrists qualify annually and that there are about 1,500 psychiatrists in the country. Training facilities for clinical psychologists are available at Ranchi, Bihar, and Bangalore. There are 400 to 500 clinical psychologists in the country. The training facility for psychiatric social workers is in Bangalore: 12 professionals are trained each year. Psychiatric nurses are trained at Bangalore and Ranchi, which offer a 10month diploma course. Postgraduate courses in psychiatric nursing are also available in other locations. The total number of psychiatric nurses is estimated to be 500. Future Prospects for Mental Health Care in India Policies related to mental health care have made great strides to promote humanistic ideals and community care as a worthwhile goal. A major shift has occurred from the concept of custodial care to one that emphasizes care and treatment. The Supreme Court, in its judgements, has supported this shift.
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But a huge gap remains between the rhetoric of this new policy and its implementation. For example, though the government issued orders for the introduction of the Mental Health Act (1987) with effect from April, 1993, many states are still following the obsolete India Lunacy Act of 1912 and have not issued a gazette notification for the promulgation of the Mental Health Act (1987). The resource infrastructure for mental health care is rudimentary and systemic advances that have taken place are largely due to political will and commitment. Two states—Kerala and Tamil Nadu—have implemented mental health care systems so that a psychiatrist is available in each district. To a large extent, this has depended largely on the organization and progress in the general health sector. While illustrative examples exist, such innovation appears to be the exception rather than the rule. But these exceptions are trendsetters, paving the way for higher expectations throughout the country. The danger is that the rhetoric of community of care can also result in an abrogation of responsibility. While the mental hospitals may not be appropriate, community values and resources may not be prepared to provide the services that are needed. A well-meaning policy without the resources needed to back it up could mean that a person with mental illness could be on the street, bereft of all services. References Condemned for Life. (1998). India Today, December 14, 1998, p. 39–40. Davar, B. (1999). Mental health of Indian women: A feminist agenda. New Delhi, India: Sage Publications, India Pvt. Ltd. Mental Health Act. (1987). Mental Health Act 1987 with the State Mental Health Rules, 1990 and the Central Mental Health Authority Rules, 1990. Allahabal, U.P., India: Law Publishers (India) Pvt. Ltd. Sharma, S., & Chadda, R. K. (1996). Mental hospitals in India: Current status and role in mental health care. Delhi, India: Institute of Human and Allied Sciences. Waltrand, E. (1991). Mad tales from the Raj: The European insane in British India, 1800–1858. London: Routledge & Kegan Paul. Wig, N. N. (1978). General hospital psychiatric units—Right time for evaluation. Indian Journal of Psychiatry, 20.
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The Mental Health System in India History, Current System, and Prospects Vijay Ganju*
Introduction While policies and services for persons with mental illnesses in India are increasingly progressive and humane, the formal mental health infrastructure is minimal at best. The Mental Health Act (1987) represents an attempt to introduce the latest thinking in the field of mental health services, but the political will and the required resources to implement the legislation are lacking. Prodded by the courts, media attention, and a growing public awareness of issues related to mental illnesses, new services are emerging. Voluntary organizations, which provide crisis intervention, counseling, and rehabilitation services, are growing in urban areas. The National Institute of Mental Health and Neurosciences has evolved from a lunatic asylum established in the latter part of the 19th century to a premier service, training, and research institute. But the successes remain spotty and scattered, emblematic of what could be done with more consistency and commitment throughout of the country. Legislation and regulations—reflecting the underlying philosophy—are enlightened by any standard. The challenge is to implement these policies and ideas in a meaningful way. Administrative and Health Infrastructure India, with a population of approximately 900 million persons, has 25 states, 6 union territories, and 1 national capital territory, ranging in population from 406,000 (Sikkim) to 139 million (Uttar Pradesh). Ten states have more than 40 million people. The Indian constitution charges states with “raising of the level of nutrition and the standard of living of its people and the improvement of public health.” *Director, Planning, Research, and Evaluation, Texas Department of Mental Health and Mental Retardation, Austin, TX, USA. Address correspondence and reprint requests to Vijay Ganju, Ph.D., Texas Department of Health and Mental Retardation, P.O. Box 12668, Austin, TX 78711-2668, USA; E-mail: [email protected] 393
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Central (or federal) government efforts at influencing public health have focused on 5-year plans, on coordinated planning with states, and on sponsoring major health programs. Governmental expenditures are jointly shared by the central and state governments. Central government efforts, administered by the Minister of Health and Family Welfare, provide both administrative and technical services and manage medical education; states provide public services and health education. For administrative purposes, states are subdivided into districts. There are 476 districts in India: the average population of a district is 1.8 million persons. In general, health-care facilities and personnel have increased substantially in the 50 years since India achieved independence. India’s population growth, however, has resulted in a decrease in the number of licensed medical professional per capita: By the late 1980s, the number of licensed professionals had fallen to 3 per 10,000, from the 1981 level of 4 per 10,000. In 1991, there were approximately 10 hospital beds per 10,000 individuals. Primary health centers are the cornerstone of the rural health-care system. These facilities are part of a tiered health-care system that funnels more difficult cases to hospitals while attempting to provide routine medical care to the vast majority in rural areas. Primary health centers and subcenters rely on trained paramedics to provide most of their services. The geographic distribution of hospitals varies according to local economic conditions, and can vary considerably across states. Of the 7,300 hospitals, 4,000 are owned and managed by central, state, or local governments; 2,000 are owned and managed by charitable trusts, receiving partial support from government; and the remaining 1,300, many of which are relatively small facilities, are privately owned. There are also 128 medical colleges, which serve as educational facilities and provide hospital and ancillary services. Indigenous or traditional practitioners continue to practice throughout the country. The two main forms of traditional medicine practiced are the aryuvedic (“the science of life”) system, which emphasizes a holistic approach, combining mental, physical, and spiritual well-being, and the unani–herbal medical practice. It is within this administrative and health infrastructure that the mental health system is embedded. History While traditional Indian medical systems, such as ayurved and unani, identified mental illnesses as distinct disorders and necessary treatments were provided by medical practitioners. There was no separate, distinct setting or provider system for mental illness. Only with European colonization were services for persons with mental illnesses provided separately. The introduction of lunatic asylums—segregated and removed from population centers— was a British innovation influenced by the ideas and concepts prevalent in England and Europe in the 18th and 19th centuries. The earliest mental institutions were established to meet the needs and demands of European patients in India. Some records suggest that the first mental hospital was started in Bombay in 1745 (Sharma & Chadda, 1996). There is
THE MENTAL HEALTH SYSTEM IN INDIA
395
reference to a mental hospital in Calcutta in records dated 1787. A lunatic asylum was established in 1795 in Bihar for insane soldiers. A hospital in Calcutta in 1817 had “between 50 to 60 European patients with clean surroundings and a garden . . . excited patients were treated with morphine and opium, and were given hot baths and sometimes leeches were applied to suck their blood” (Sharma & Chadda, 1996). At another asylum in Dacca, music was used as a form of treatment to calm excited patients. In 1858, the first Lunacy Act was promulgated. The Act provided guidelines for the establishment of mental asylums and procedures for the admission and treatment of mental patients. These asylums were built “to segregate those who by reasons of insanity were troublesome and dangerous to their neighbors.” The 1912 Lunacy Act brought mental hospitals under the charge of Civil Surgeons instead of the Inspector General of Prisons; specialists in psychiatry were appointed full-time officers in these hospitals; and all lunatic asylums were brought under centralized government control. The 1912 Lunacy Act essentially remained in effect until the 1987 Mental Health Act was passed. Colonial conditions gave mental health policy a distinctive character in India. There were three significant deviations in practice from models in Britain: inmates were segregated by race; Europeans were not required to do manual labor; and Europeans were institutionalized much earlier than would have been the case in Britain, because they were seen as a special threat to the prestige of the ruling colonial class (Waltrand, 1991). In 1920, the names of all asylums were changed to mental hospitals. Occupational therapy was introduced and family units were established. During this period, an association of medical superintendents of mental hospitals was formed. In 1946, a health survey and development committee, popularly known as the “Bhore Committee,” surveyed mental hospitals. At that time, there were 19 mental hospitals with a bed capacity of 10,181. The committee reported that the hospitals were primarily designed for custodial care and detention rather than treatment. There was also recognition that there was “gross inadequacy” in medical personnel in all mental hospitals, both in terms of numerical strength and in specialized qualifications. Since independence of India in 1947, the emphasis has been more on the creation of psychiatric departments in general hospitals and medical colleges rather than the creation of new mental hospitals. In many ways, however, the inadequacies recorded in 1946 continue to characterize the system today. The National Mental Health Programmme As the Government of India embarked on an ambitious national health policy that envisioned “health for all by the year 2000,” mental health was not adequately addressed. The National Mental Health Programme was a set of recommendations developed to ensure that mental health care was explicitly included. Early drafts of the National Mental Health Programme were formulated by mental health professionals and then subsequently adopted by the Central Council of Health and Family Welfare, the highest health policy-making body
396
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at the national level. The major recommendations were that: (a) mental health must form an integral part of the total health programme and as such should be included in all national policies and programs in the field of health, education, and social welfare, and (b) strengthening the mental health component in the curricula of various levels of health professionals. These recommendations were in response to the recognition that mental health professionals alone would be unable to meet the growing mental health needs of the population. Even if training facilities for the mental health sector would be doubled or tripled, it would require several decades to meet such needs. Also, it was recognized that services beyond mental health institutions were needed. One of the more important elements in the delivery of health care in India is the primary health center. A major thrust of the National Mental Health Programme was to provide mental health care at and from these centers. The objectives of the National Mental Health Programme were: 1. To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population. 2. To encourage application of mental health knowledge in general health care and in social development. 3. To promote community participation in mental health services development and to stimulate effort toward self-help in the community. Since its inception, the efforts of the National Mental Health Programme have been directed at promoting and developing state-level programs, workshops for mental health professionals and voluntary organizations, evaluation of mental health care provided through primary health centers, the development of a model District Mental Health Programme, and the development of training materials and programs for practitioners and academicians. In addition, the Center for Advanced Research for Community Mental Health was set up for longitudinal research at the National Institute of Mental Health and Neuro-Sciences, Bangalore. Eleven medical colleges were selected as regional centers in the 8th Plan (in which national priorities are established and by which resource allocations are made). These centers were required to coordinate various mental health activities in their regions and to supply health education materials. The Mental Health Act, 1987 Even prior to independence in 1947, there was recognition that many of the policies and provisions in the 1912 Lunacy Act were outmoded and had outlived their usefulness. Initial attempts by the Indian Psychiatric Society to bring about change were unsuccessful. In 1959–60, reforms were considered but no consensus was reached. In the 1980s, there was a resurgence of activity resulting in the passage of the Mental Health Act in 1987. The rationale for the new legislation was that :it has become necessary to have fresh legislation with provisions for the treatment of mentally ill persons in accordance with the new approach” (Mental Health Act, 1987).
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The purpose of the bill was: 1. To regulate admission to psychiatric hospitals on psychiatric nursing homes of mentally ill persons who do not have sufficient understanding to seek treatment on a voluntary basis, and to protect the rights of such persons while being detained; 2. To protect society from the presence of mentally ill persons who have become or might become a danger or nuisance to others; 3. To protect citizens from being detained in psychiatric hospitals or psychiatric nursing homes without sufficient cause; 4. To regulate responsibility for maintenance of charges of mentally ill persons who are admitted to psychiatric hospitals or psychiatric nursing homes; 5. To provide facilities for establishing guardianship or custody of mentally ill persons who are incapable of managing their own affairs; 6. To provide for the establishment of Central Authority and State Authorities for Mental Health Services; 7. To regulate the powers of the Government for establishing, licensing, and controlling psychiatric hospitals and psychiatric nursing homes for mentally ill persons; 8. To provide for legal aid to mentally ill persons at State expense in certain cases. The bill is comprehensive covering the establishment, maintenance, and licensing of mental health facilities; the revocation of licenses; admission and detention policies on a voluntary and involuntary basis, powers and duties of police officers with respect to mentally ill persons, conditions of care for mentally ill persons receiving cruel treatment or improper care, the designation of at least five “visitors” (of whom at least one shall be a medical officer, preferably a psychiatrist and two social workers) to review conditions and services in psychiatric facilities, the transfer of mentally ill persons form one facility to another, judicial inquisition regarding property, the custody of his or her person, and the management of property, and the protection of human rights of mentally ill persons, including conditions by which a mentally ill person may participate in research. The Act proposed the effective start date as April 1, 1993. The bill was both comprehensive and progressive. Some of the key differences between the 1912 Lunacy Act and the Mental Health Act were: 1. Definitions and nomenclature: The bill provided definitions of a psychiatric hospital, a psychiatric nursing home and a psychiatrist. It also replaced outdated terminology such as “asylum” with more progressive language. The Act defines a mentally ill person as a person in need of treatment. For the first time a distinction was made between mental illness and mental retardation. 2. The bill required the establishment of both a central and state authority for mental health to advise the respective level of government on all matters related to mental health. The intention was to facilitate adequate supervision of psychiatric hospitals and to coordinate activities with the
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health infrastructure, which is a state responsibility (Subsequently, Central and State Mental Health Authority Rules were formed in 1990.) The new act simplifies procedures for both admission and discharge. Outpatient treatment facilities must be available at every psychiatric hospital and psychiatric nursing home. The Act provides clearer direction for the functioning of the Visitor’s Boards. “Visitors” now includes psychiatrists and social workers. Also, the new Act has a provision to cease the office of such a visitor if they do not participate in the joint inspection for 3 consecutive months. The Act incorporates new provisions governing the management of property of mentally ill persons. There are more safeguards and there are greater penalties for misuse of property by designated managers. Under the Act, the police can detain a person suspected of mental illness for up to 24 hours and are required to present the person to a Magistrate to obtain a commitment order. (This provision prevents undue or prolonged detention on the basis of the designation of mental illness.)
In conclusion, the Mental Health Act (1987) is a progressive, far-sighted attempt to incorporate the latest knowledge and experience related to the provision of mental health services in legislation so as to build on this platform a plan of action. The Act has taken several decades to evolve, reflecting the priority that the area has received. Even now, the Act represents an ideology and an approach rather than the reality. Even though the Act required implementation to be effective in 1993, many provisions of the Act still remain to be implemented uniformly across the country. The System of Care As the review of the historical development of mental health care indicates, the rate of movement toward the implementation of a “care” paradigm is painfully glacial. The colonial asylum system persists but, in parallel, there has been a growth of care provided through the medical colleges and voluntary organizations have initiated activities in the major urban areas. Overall, the formal mental health sector is skeletal at best where traditional systems of care co-exist with more medically oriented Western approaches. There has been no policy move to altogether close the colonial mental hospitals (Sharma & Chadda, 1996) despite their well-known problems of poor staffing; meager infrastructure, and health facilities; a greater dependence on physical restraint rather than therapy; the excessive use of electro-convulsive therapy (ECT); and meager healthcare. The users of the mental health facilities choose native healers, shamans and exorcists, as often, if not more often, than they choose professionals. . . . Therefore, in India, the “service sector” for mental health is structured into the mental health professionals, the medical professionals, the paramedicals and the non-professional healers, native or modern. Glaringly, the complexity of “services” available for the mentally distressed confounds and complicates is-
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sues about public monitoring and audits, consequently compromising any mental health policy that may be drawn up. Definitely, the issues facing those interested in establishing “consumer choice” and protection of user interests in this confounding scenario are innumerable. (Davar, 1999, pp. 149–150) Within this overarching framework, the various components of the mental health-care systems are described in the following sections.
Psychiatric Facilities The mental health institutional infrastructure consists primarily of 42 mental hospitals, with a total bed capacity of about 22,000 beds (In comparison, the cities of New York and Tokyo have more psychiatric beds than the whole of India.) Even this statistic does not reflect the status of bed capacity accurately. Approximately one third of the beds are in one state—Maharashtra— while there are several—Haryana and Himachal for example—that have no mental hospitals. While the modal number of beds is in the 200–500-bed range, there are still several institutions in the 1,000–2,000-bed range. The Regional Mental Hospital in Pune has 2,540 beds. There are also several hospitals with 100 beds or less. Over the last decade, the unsatisfactory conditions in mental hospitals have been subject of public interest litigation and conditions have improved as a result of court actions. But the lack of adequate care and support services in the community creates its own set of problems for the mental hospitals. In a recent study of three mental hospitals in the state of Keral conducted by the National Institute of Mental Health and Neurosciences, results suggested that at least 20% of the patients could be discharged but had neither support from families nor community organizations to help them leave the hospital and rehabilitation programs in the state “are virtually non-existent” (Condemned for Life, 1998). The lack of a comprehensive, coordinated system results in overcrowding in the facilities and substandard conditions. For example, the hospital at Thiruvananthapuram has a bed capacity of 507, but has 830 patients. Similarly the hospital at Kozhikade has 700 patients while there is room only for 400. The study notes that several recommendations made by various commissions to improve facilities remain unimplemented. Besides the lack of rehabilitation services and overcrowding, the hospitals were characterized by staff shortages and even the staff who are available often are not trained in psychiatry. These are conditions in Kerala, are of the more progressive states in terms of health and mental health care. Conditions elsewhere are likely to be similar if not worse.
General Hospital Psychiatric Units Since Independence, there has been a major growth of psychiatric units of general hospitals, especially those associated with medical colleges. While the first such unit was created in 1933, the major spurt of growth in this sector oc-
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curred in the 1960s (Wig, 1978). Currently, there are about 3,000 beds in 200 units across the country. These units vary in size but are typically 20–30-bed facilities. The advantages of this component are self-evident. They have provided greater public acceptance of psychiatric services because they do not have the associated stigma of the mental hospitals. They are situated in the community so access is easier and more convenient. Admissions are largely voluntary; family members typically stay with the patients and stays are of a short duration (the average is about 3 weeks). Most have associated outpatient services and the proximity to other physical problems. It is estimated that 75% of the research work being done is by professionals working these settings. Extensions of these units are the district hospital psychiatric units. Two states—Kerala and Tamil Nadu—have a psychiatrist in each district. These states are exceptional: in most states, general hospital psychiatric units are situated in large urban centers or state capitals.
Community Care The National Mental Health Program in India envisioned delivery of mental health care through primary health-care personnel. Initial research projects were started in Chandigarh, Jaipur, and Bangalore to study how this could be done. The focus of these projects was to develop and evaluate training to identify mental illnesses in health setting. In these pilots, a team consisting of a psychiatrist, a psychiatric social worker, and a psychiatric nurse conducted outpatient clinics three times each week at the public health center. Persons identified by community members were asked to come to the center. The study results indicated that most persons needing psychiatric services had consulted traditional healers. Most had chronic problems but did not make use of services at the general hospital units even through the hospital was less than 10 miles away. The majority accepted treatment while living at home. Such efforts are now being replicated in other parts of the country, including Baroda, Calcutta, Hyderabad, Lucknow, Trivandrum, and Gaubati. Community care in India is still in its infancy. The availability of day-care centers, half-way houses, sheltered workshops, foster care, etc. is limited. If available, such services would largely be confined to the big cities.
Private Psychiatric Nursing Homes/Hospitals Privately owned institutions that provide psychiatric care are also part of the system of care, with bed strengths that vary from 10–300. There are approximately 40 such facilities in the country.
Voluntary Organizations In India, public and voluntary organizations have also started to play a role in the delivery of mental health services and in public advocacy for improve-
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ments in the availability and quality of care. Some of the activities of such voluntary organizations include: • • • •
Mobilizing public support and demand for services; Provision of crisis intervention and rehabilitation services; Support for families of persons with mental illness and; Advocacy for research in mental disorders and their care.
The efforts of voluntary organizations have pressured the government to improve the quality of care in mental hospitals. Public interest campaigns have resulted in the creation of state-initiated review committees that have increased public awareness and accountability. Interventions by the Supreme Court While many of the progress changes and innovations have occurred as a result of the initiatives of mental health professionals, a strong lobby of lawyers and social activists have taken on issues related to the mental health care system. Their public interest petitions have produced several judgements by the Supreme Court that have had a significant impact on mental health care reform. These public interest petitions were related to issue, such as poor conditions in mental hospitals; the takeover of mental hospitals by autonomous bodies; the jailing of persons with mental illnesses; the human rights of psychiatric patients; suicide. These have resulted in reforms and more progressive policies in all these areas. Mental Health Manpower At the time of independence, there was no recognized facility for training psychiatrists in the country. Currently, there are approximately 40 centers that provide training in psychiatry and diplomas in psychological medicine. It is estimated that over 150 psychiatrists qualify annually and that there are about 1,500 psychiatrists in the country. Training facilities for clinical psychologists are available at Ranchi, Bihar, and Bangalore. There are 400 to 500 clinical psychologists in the country. The training facility for psychiatric social workers is in Bangalore: 12 professionals are trained each year. Psychiatric nurses are trained at Bangalore and Ranchi, which offer a 10month diploma course. Postgraduate courses in psychiatric nursing are also available in other locations. The total number of psychiatric nurses is estimated to be 500. Future Prospects for Mental Health Care in India Policies related to mental health care have made great strides to promote humanistic ideals and community care as a worthwhile goal. A major shift has occurred from the concept of custodial care to one that emphasizes care and treatment. The Supreme Court, in its judgements, has supported this shift.
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But a huge gap remains between the rhetoric of this new policy and its implementation. For example, though the government issued orders for the introduction of the Mental Health Act (1987) with effect from April, 1993, many states are still following the obsolete India Lunacy Act of 1912 and have not issued a gazette notification for the promulgation of the Mental Health Act (1987). The resource infrastructure for mental health care is rudimentary and systemic advances that have taken place are largely due to political will and commitment. Two states—Kerala and Tamil Nadu—have implemented mental health care systems so that a psychiatrist is available in each district. To a large extent, this has depended largely on the organization and progress in the general health sector. While illustrative examples exist, such innovation appears to be the exception rather than the rule. But these exceptions are trendsetters, paving the way for higher expectations throughout the country. The danger is that the rhetoric of community of care can also result in an abrogation of responsibility. While the mental hospitals may not be appropriate, community values and resources may not be prepared to provide the services that are needed. A well-meaning policy without the resources needed to back it up could mean that a person with mental illness could be on the street, bereft of all services. References Condemned for Life. (1998). India Today, December 14, 1998, p. 39–40. Davar, B. (1999). Mental health of Indian women: A feminist agenda. New Delhi, India: Sage Publications, India Pvt. Ltd. Mental Health Act. (1987). Mental Health Act 1987 with the State Mental Health Rules, 1990 and the Central Mental Health Authority Rules, 1990. Allahabal, U.P., India: Law Publishers (India) Pvt. Ltd. Sharma, S., & Chadda, R. K. (1996). Mental hospitals in India: Current status and role in mental health care. Delhi, India: Institute of Human and Allied Sciences. Waltrand, E. (1991). Mad tales from the Raj: The European insane in British India, 1800–1858. London: Routledge & Kegan Paul. Wig, N. N. (1978). General hospital psychiatric units—Right time for evaluation. Indian Journal of Psychiatry, 20.