Expert Speak Young Voices
Published on Dec 13, 2019
Examining the progressive and archaic elements of the Mental Health Care Act

The Mental Health Care Act (MHCA) was unanimously passed by the Lok Sabha on 7 April 2017 and came into effect on 29 May 2018. The act has been hailed as a major step towards destigmatising mental health disorders and is a major improvement over the archaic Mental Health Act of 1987 that failed to take a patient-centric approach to mental health care.

Policies and the legal framework aimed at mitigating the nation-wide crisis of mental health has been long overdue. According to a World Health Organization (WHO) report, 7.5 percent of the Indian population suffers from some form of mental disorder. India accounts for 15 percent of the global mental and neurological disorder burden. The report also revealed gross asymmetries in provision of mental health services. The report found that there are merely three psychiatrists and even lesser psychologists for every million people in India, which is 18 times lesser than the Commonwealth norm of 5.6 psychiatrists per 100,000 people. The grim state of affairs regarding mental health in India reinstates the need and importance of the Act passed last year.

Against this backdrop, the MHCA seems to address some core concerns of the mental health ecosystem. Providing more agency to the patient on the issue of treatment choices, decriminalising attempted suicide and prohibiting the use of electro-convulsive shock therapy  being some of the  landmark amendments. Nonetheless, if one looks closer, the Act still leaves many questions unanswered and some of the terminology used to describe and categorise mental health disorders leaves a lot to be desired. Moreover, it begs the question whether the discourse informing the legal amendments to the Act are in accordance with the standards set by the American Psychological Association or the widely-accepted DSM 5 manual that is considered the sacrosanct text categorising  mental illness.

The first set of concerns with the Act pertains to the notions of mental health informing the laws. The MHCA has a provision for an Advanced Directive that allows the patients to determine their course of treatment along with choosing a nominated representative. Unlike developed democracies in the West, the awareness regarding mental health disorders and warning symptoms that may signal the onset of such disorders is low. This lack of awareness, coupled with the existing deficiency in adequate mental health professionals, increases the probability of people in India to be in denial about their mental state. Moreover, the prevalent notion in India that confuses concepts of insanity with seeking psychological care stigmatises help-seeking. The Act has certain provisions towards destigmatising mental health, but one must realise that this requires a systemic change in a societal mindset that has been indoctrinated over generations. When patients may be in denial over their own mental state, an Advanced Directive may work against their interests – at least in the short-run. The Act also has certain provisions under which the Advanced Directive can be revoked. The Mental Health Review Board (MHRB) established under the Act may review claims by the caregiver to overturn an Advanced Directive on the following grounds:

  • If free will of patient is under dispute
  • If patient was not well informed to make the directive
  • If patient did not demonstrate capacity for basic decision making.

It must be noted, that the aforementioned criteria seem to only safeguard patients with some form of severe psychosis from providing a counterproductive Advanced Directive. However, in many cases of mild mental health issues, the capacity for decision-making and comprehension of basic information may not be compromised, yet, that does not guarantee the patient to not be in denial about their mental state. Thus, how the Act accounts for people lying on the mild end of the spectrum of mood and anxiety disorders is left to be seen.

Another concern is the definition of “mental illness” as stated in Section 1(s) of the Act. Mental illness is defined as “a substantial disorder of thinking, mood, perception, orientation, or memory that grossly impairs judgment or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs”. This definition of mental health seems to include substance abuse as a part of the diagnosis of a mental illness rather than a symptom of the same. Moreover, the word “associated with abuse of alcohol and drugs” seems vague. What does the term “abuse” constitute? How does the Act differentiate between abuse and use? Furthermore, is the use of substances inextricably linked to mental illness? If not, and since the Act seems to only deem it an “association”, why is it included in the definition? These are some questions that evade common understanding which is a cause for concern.  It must also be noted that the DSM 5 has replaced the term “abuse” with the term “dependence”, citing the latter to be less stigmatising. Moreover, the DSM recognises substance use as a separate disorder but does not include it as a descriptor of the larger construct of mental illness.

As established earlier, the Act, in principle, has made many important amendments in service of improving the state of mental health care in India. That being said, some notions about mental health and the liberties in defining some of the terms like “mental health professional” seem to be lacking falsifiable scientific research. According to the inclusion criteria for a “mental health professional” as laid down in the Act, anyone with a postgraduate degree in  “Mano Vigyan Avum Manas Rog, homeopathy, Ayurveda or Unani medicine will be considered as a legitimate mental health professional. The inclusion of Ayurvedic or Unani practitioners as mental health professionals having a pivotal role in diagnosis and treatment decisions is an unnerving reality. The scientific research supporting the validity of these techniques is dubious. Moreover, the exact research informing this policy decision is unexplored. Although there are numerous studies linking alternative forms of treatment like Ayurveda with improved mental health outcomes, the research is highly unregulated. For instance, all pharmaceutical antipsychotic medication like Prozac or Lithium had to meet FDA regulations before finding shelf space. With such forms of alternative medicine, the regulatory oversight is compromised and can also fuel misinformation among the public regarding its efficacy. These concerns were echoed by Dr Sumaiya Shaikh, science editor at Alt News, “A lot of times many of these medicines are not being tested properly, and are marketed as ‘ancient science’ and assume that our ancestors must have established its efficacy”.  However, even if one takes an optimistic view of alternative medicine’s efficacy, it is unfair to assume that practitioners of alternative medicine are also equipped with the skills and insights to deliberate about diagnosis and treatment trajectories for mental disorders. Section 18, sub section 3 of the Act has also made an “essential drug list” that would be given free of cost to patients. This list would also include alternative medicine like Ayurveda and Unani if the mental health establishment in question has appropriate professional help to dispense the treatment. Although the decision to provide essential mental health medication for free is a noble idea, including alternate therapy as free may fuel its purchase in spite of the fact that the scientific community is still skeptical about its effectiveness.

Irrespective of these shortcomings, the Act has indeed shown promise. Especially with respect to safeguarding the rights of the patient and providing equal care to all. Clause 2 of the Act states that, “All people with mental illness shall be treated equally as people with physical illness”. This statement encapsulates a major shift in how policymakers seek to understand mental health and this change in outlook is a positive sign for the future of mental health care in India. Thus, it is safe to say that the MHCA is a progressive law that serves public interest. Nonetheless, the loopholes of the Act and some of the notions informing its understanding of mental health that diverge from globally-recognised bodies like the APA and the DSM 5 manual must be addressed to ensure its promised efficacy.

It must, however, be noted that implementation of the Act is riddled with financial hurdles. A recent study estimates its nation-wide implementation cost to be Rs. 94,000 crore a year. This does not include the costs of hiring and training more mental health professionals to meet the country’s health demands. Such prohibitive cost of implementation has resulted in poor financial support coming from states. Till such time that adequate budget allocation is made for this purpose, the real benefits of MCHA will continue to remain elusive.

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Prithvi Iyer

Prithvi Iyer

Prithvi Iyer was a Research Assistant at Observer Research Foundation Mumbai. His research interests include understanding the mental health implications of political conflict the role ...

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