Psychiatric services, mental health law, & human rights

Mental illness is common, complex and costly. In June 2022, the World Health Organization (WHO) published its largest review of mental health since the turn of the century, in a report titled World Mental Health Report: Transforming Mental Health for All1. The WHO notes that almost one billion people around the world live with a mental disorder2. Suicide accounts for more than one in 100 deaths. Despite this, 71 per cent of people with psychosis (severe mental illness) do not receive the mental healthcare they need, according to the WHO2. Even in high-income countries, only one-third of people with depression access formal psychiatric treatment. Clearly, mental illness is a public health problem of the utmost gravity and urgency.

Since 1992, October 10 has been designated World Mental Health Day. The aim of the day is to increase awareness of mental health issues around the world and mobilize efforts in support of mental health3. World Mental Health Day is an annual opportunity for stakeholders working on mental health issues to discuss their work, identify what needs to be done and take steps to make mental healthcare a reality for people around the world.

Mental healthcare in India

The global challenges with mental illness and mental healthcare are as apparent in India, as they are in every country around the world. In 2015 and 2016, the National Mental Health Survey of India was implemented by the National Institute of Mental Health and Neurosciences, Bengaluru4. This survey was aimed to estimate the prevalence, socio-demographic correlates and treatment gaps for mental illness in a representative population of India. Conducted across 12 Indian States, trained field investigators completed 34,802 interviews with people aged 18 yr or above. The survey found that the weighted lifetime prevalence of ‘any mental morbidity’ was 13.7 per cent and the current prevalence was 10.6 per cent. The most common diagnoses were mental and behavioural problems due to psychoactive substance use, mood disorders and neurotic and stress-related disorders. Prevalence was higher among males, middle-aged people, urban-metro populations, less educated people and households with lower incomes. Perhaps, the most concerning finding was that, overall, the treatment gap for mental illness in India was 84.5 per cent. Given that almost 150 million people suffer from mental morbidity, this indicates a high level of unmet need across the country.

It is worth emphasizing that, like other countries, India has many dedicated mental health professionals working to a high standard of excellence across myriad disciplines: medicine, nursing, psychology, social work, occupational therapy, and various other areas. However, as in other countries, mental health services can be uneven in parts of India and virtually non-existent in others, as evidenced by the survey4. This has implications not only for individual suffering but also for families. The survey has shown that, on average, patients and their families spend ₹ 1500 per month on the treatment of common mental disorders5. There are also costs to communities and societies, as well as opportunity costs in terms of education, work and relationship opportunities that are missed due to mental illness. Overall, the cost of untreated mental illness is enormous.

Psychiatric treatments

In addition to highlighting the problems associated with mental illness, the World Mental Health Day also focusses on solutions. What can we do to alleviate the burdens of mental illness? How can we help those who suffer and the families who support them? What should we do in practice?

While our understanding of the biology of mental illness is still limited, we know that psychiatric treatments are just as effective as treatments in general medicine, and sometimes more so6. Treatment with an antidepressant, for example, is more effective in reducing relapse of depression (relative risk reduction: 58%) than low-dose aspirin in secondary prevention of serious cardiovascular events (19%)6. This makes antidepressant medications powerful tools for wellness, when these are used wisely. Antipsychotic medications also have substantial benefits. Not only do these alleviate symptoms of psychosis, but are also associated with reduced risk of early death in schizophrenia. One study followed up 62,250 patients with schizophrenia for up to 20 yr (median: 14.1 yr) and found that adjusted hazard ratios were 0.48 for all-cause mortality, 0.62 for cardiovascular mortality and 0.52 for suicide mortality during use versus non-use of antipsychotic medication7. This is very compelling evidence in favour of antipsychotic medication. To put these findings another way, the cumulative mortality rates during a median of 14.1 yr of follow up were 46.2 per cent for people with schizophrenia who were not on antipsychotics, 25.7 per cent for those on any antipsychotic and 15.6 per cent for those on clozapine. These are substantial benefits. As the authors conclude, the findings suggest that long-term antipsychotic use is associated with substantially decreased mortality in schizophrenia, especially among patients treated with clozapine7.

This is not to say that everyone responds equally well to antipsychotic medication: specific medications help some people more than others. Adverse effects also differ between medications and between people, as do individual judgements about the balance of benefits and risks. Reaching informed agreement on these matters requires good research information and strong therapeutic relationships between patients and health professionals. In addition, people change over time and so do their mental health needs. Sustained dialogue is vital if we are to use therapeutic tools such as medication to their best advantage. In addition to medication, there is growing evidence for psychological therapies such as cognitive behaviour therapy across multiple psychiatric conditions. This and various additional talking therapies offer substantial benefits to many people, often in conjunction with other treatment approaches, including social support and family education.

As a result, while we do not yet understand the biological underpinnings of most mental illnesses, psychiatry has treatments that help substantially with symptoms and are associated with longer life8. This is a somewhat unusual situation for any field of medicine. We have effective interventions for mental illnesses, but we do not understand the biology of mental illness itself. This places psychiatry in a decidedly complicated position: established but contested, useful but incompletely understood, necessary and still mysterious.

Mental health legislation

In addition to medication, psychological treatments and social supports, other interventions are also needed to provide better care to people with mental illness and their families. Often, these additional interventions are rooted in law and politics.

On May 29, 2018, India commenced its new Mental Healthcare Act, 2017, a notably comprehensive piece of legislation that seeks explicitly to comply with the United Nations Convention on the Rights of Persons with Disabilities9. India’s legislation introduces many changes, including a new definition of mental illness; revised considerations of capacity, advance directives and nominated representatives; revised procedures for independent admission (voluntary admission) and supported admission (admission and treatment without patient consent) and de facto decriminalization of suicide.

Perhaps most ambitiously, the 2017 Act creates a legal right to mental healthcare10. Section 18(1) 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’. This is a substantial commitment for any country to make, including India. Section 18(4) clarifies that ‘such services shall include (i) provision of acute mental healthcare services such as outpatient and inpatient services; (ii) provision of half-way homes, sheltered accommodation, supported accommodation as may be prescribed; (iii) provision for mental health services to support family of person with mental illness or home-based rehabilitation; (iv) hospital- and community-based rehabilitation establishments and services as may be prescribed, and (v) provision for child mental health services and old-age mental health services’.

The new legislation also specifies that mental health services are to be linked with general health services, because the Act requires ‘the appropriate Government’ to ‘integrate mental health services into general healthcare services at all levels of healthcare, including primary, secondary and tertiary healthcare, and in all health programmes run by the appropriate Government’ (Section 18(5)(a))10. There is no health without mental health, so linking all health services together makes sense: our minds are affected by our physical health, just as our bodies are affected by our mental health.

Advocating for change

The greatest challenge with India’s new mental health legislation and psychiatric care more broadly is resourcing and staffing mental health services and social support for the mentally ill. In India, as elsewhere, there is a constant need to focus the attention of politicians and policymakers on the requirement for better services that treat illness, protect rights and support families and communities, so as to make India’s new right to mental healthcare a reality in practice.

To make change happen, stakeholders can campaign for better services, advocate loudly, write to politicians, register to vote and ensure that all public representatives and decision-makers promote the rights of people with mental illness – the right to treatment as well as the right to liberty, with particular emphasis on social justice. People with mental illness and their families deserve no less.