Mental health in India

The Bhore Committee found that the position of mental health and mental healthcare in India was "extremely unsatisfactory".[10] Colonel Moore Taylor, I.M.S., Medical Superintendent, Ranchi European Mental Hospital, reviewed all the major mental health hospitals in the country, the findings of which were presented in the Bhore Committee Report. Colonel Taylor noted that "Every mental hospital which I have visited is disgracefully under-staffed" as well as run by unqualified staff, lacking experience and training.[10] However in certain cases such as the Child Guidance Clinic of the Sir Dorabji Tata Institute of Social Sciences, Col Taylor commented that he was "greatly impressed by the work".[11]

1980s onwards, public interest litigations (PILs) in India have been successful in bringing forward "horror tales of insane prisoners", "mental hospital (used as) dumping ground(s) for (the) unwanted" and the "callous conditions (that) plague (the) dustbins of society".[12] PILs have resulted in courts to investigate the dismal workings of mental institutions such as the government run Shahdara Mental Hospital (BR Kapoor vs. Union of India 1983 and People's Union for Civil Liberties vs. Union of India 1983) and Trivandrum Mental Home resulting in substantial improvements.[13][14] One of the first cases in this regard was Upendra Baxi vs. State of UP in 1983 concerning the human rights of the inmates of a Protective Home[lower-alpha 1] at Agra.[15][14] PILs subsequently raised issues concerning mentally ill prisoners (Veena Sethi vs. State of Bihar 1982) and the detention of those with mental retardation (Sheila Barse and others vs. Union of India and Ors 1986).[14]

In 1988, in the case of Rakesh Chandra Narayan v. State of Bihar, the petitioners wrote a letter to the Supreme Court in 1985 regarding the dismal working of a mental hospital in Ranchi, Bihar.[16] Following a court initiated review of the mental hospital by the Chief Judicial Magistrate as well as a later review by the Union Health Secretary, M.S. Dayal, the court held that the mental hospital resembled a "medieval torture house" and that a complete renovation was needed.[16] Importantly, the services of a psychiatrist were acknowledged by the Supreme Court.[17] This kind of judicial intervention has resulted in changes in the conditions of mental hospitals which were been brought before the court. Further, the Supreme Court decided to "keep the case(s) alive on its files so that the improvements which have emanated due to interest and supervision of the court are not wiped out once it withdraws its scrutiny".[18] However, while the courts gave direction to improve mental hospitals, it did not pronounce judgement on the laws that were in contradiction to the efforts of the courts, such as the Lunacy Act 1912.[19] In November 1997, in response to the PILs the Supreme Court directed the National Human Rights Commission (NHRC) to monitor specific mental hospitals across the country.[14]

Apart from the supervision of three mental hospitals across the country the NHRC supported an initiative on "Quality Assurance in Mental Health" undertaken by the National Institute of Mental Health and Neurosciences (NIMHANS) between 1997 and 1999.[14] This landmark report involved "37 government psychiatric institutions, 7 private psychiatric institutions, and 23 general psychiatric units" across the country.[14] The report revealed glaring deficiencies and violations. 7 hospitals were rated very poor, 8 poor, 11 average and 6 good.[14] The hospitals in the good category had adequate basic living conditions, but were nevertheless lacking in terms of service quality.[20] "Overall, mental health care in the mental hospitals was custodial rather than therapeutic".[20] Pratima Murthy from NIMHANS writes that the report was a landmark in "highlighting the state of mental health services in India. However, the report, like many others before it may have disappeared into oblivion, had it not been for the Erwadi tragedy".[14]

In 2008 a follow-up review was conducted of government run hospitals.[21] Overall, the report found that immense changes had been made in the last decade.[22] Positive changes included improved infrastructure, improvements in diet, greater integration of community activities and improved budgetary allocations. The positive changes were attributed to separate budgets for hospitals, monitoring by agencies such as NHRC, involvement of the leadership and raising awareness of the families related to patient care.[22] Poor progress had been made in the area of human resources including lack of adequately qualified staff and lack of post graduate training. This poor progress was attributed to various reasons such as social isolation of the institutions, large bed strengths and lack of state government involvement in areas such as release of funds and supporting change.[22] In 2013, the court formed another team to review the overall situation of mental healthcare in the country.[23][14] Observations from this included lack of information related to mental health and mental healthcare in many regions of the country, a bed ratio well below the global ratio and that there are more than 325 NGOs in the mental healthcare among other things.[14]

The National Mental Health Programme (NMHP) was initiated in 1982,[24] aimed at developing community based mental health services.[7][25] NMHP was operationalised in 1996 as the District Mental Health Program (DMHP) based on a pilot programme, later known as the 'Bellary Model', that had been conducted in 1980 in the district of Bellary, Karnataka.[25][26] Since its inception, the scope of the NMHP has increased, visible in the increase in its budgetary from ₹28 crore (equivalent to ₹115 crore or US$16 million in 2019) during the 9th Five-Year Plan (1997–2002) to ₹1,000 crore (equivalent to ₹24 billion or US$340 million in 2019) during the 11th Five Year Plan (2007–2012).[25] The aim was that DMHP would cover all the districts by 2025. By 2015, DMHP was present in 27% of the districts.[14]

An objective of the NMHP is to integrate knowledge of mental healthcare with general healthcare.[24][27] At the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Diseases, organised by the WHO and the Government of Russia in 2011 and attended by 162 countries,[28] following India's insistence, mental health was included in the list of noncommunicable diseases.[29][14]

Lunacy legislation in British India included the Lunatic Removal Act 1851, the Indian Lunatic Asylum Act 1858, the Military Lunatic Act 1877, and a bunch of others related to lunacy along with their amendments.[30] The first law to govern mental health in India was the Indian Lunacy Act 1912,[30] which itself drew heavily from the English Lunatics Act 1845.[31] The Indian Psychiatric Society suggested a draft in 1950, however it was only given assent by the President in May 1987, and implemented in 1993 as the Mental Health Act 1987. Criticism of the Mental Health Act 1987 led to the Mental Health Care Bill 2013, which was finally passed as the Mental Healthcare Act, 2017.[30]

India made efforts to align its disability and mental health laws with the UN Convention on the Rights of Persons with Disabilities, visible in the passage of the Rights of Persons with Disabilities Act, 2016 and the Mental Healthcare Act, 2017.[32] The Mental Healthcare Act states the rights of persons with mental illness, including the right to mental healthcare. Section 18 states that "Every person shall have a right to access mental healthcare and treatment from mental health services run or funded by the appropriate Government" and that "the right to access mental healthcare and treatment shall mean mental health services of affordable cost, of good quality, available in sufficient quantity, accessible geographically, without discrimination on the basis of gender, sex, sexual orientation, religion, culture, caste, social or political beliefs, class, disability or any other basis and provided in a manner that is acceptable to persons with mental illness and their families and care-givers."[1]

The Mental Healthcare Act addresses 96/175 (55.4%) of the WHO Checklist of Mental Health Legislation,[33] the concordance increases to 68% when other relevant laws are considered. Low concordance areas include the rights of carers, competence and involuntary community treatment.[34]

47 mental hospitals in the country account for a large proportion (18,307) of the total mental health beds available in the country.[14] Mental hospitals in India include:[39]

• Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH) Tezpur, 1876
• Central Institute of Psychiatry (CIP) Ranchi, 1918
• Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS) Ranchi, 1925
• Institute of Psychiatry (IOP) Goa, 1957
• Psychiatric Diseases Hospital (PDH) Jammu, 1964
• Institute of Human Behaviour and Allied Sciences (IHBAS) Delhi, 1966
• Gujarat institute of mental health (GIMH) Ahmedabad,1866