Mental health law in India: origins and proposed reforms

Socio-demographic development and burden of mental, substance use disorders, and self-harm: An ecological analysis using the Global Burden of Disease study 2019

OBJECTIVES

Whether a country's level of development is associated with an increased or decreased burden of mental and behavioural problems is an important yet unresolved question. Here, we examined the association between the burden of mental and substance use disorders and self-harm with socio-demographic development along temporal and geographical dimensions.

METHODS

We collected data from the Global Burden of Disease study 2019, which uses robust statistical modelling techniques to calculate disease burden estimates where data are sparse or unavailable. We extracted age-standardized Disability Adjusted Life Year rates as a measure of disease burden for 204 countries and territories, as well as the Socio-Demographic Index, a measure of development reflecting income per capita, fertility rate and level of education. We tested the association between Socio-Demographic Index and Disability Adjusted Life Years for mental and substance use disorders and self-harm, between 1990 and 2019, and across six geographical regions as defined by the World Health Organization.

RESULTS

The association between Socio-Demographic Index and Disability Adjusted Life Years was heterogeneous across world regions for all mental and behavioural conditions. For substance use disorders and self-harm, these regional variations were further moderated by time period. Our findings were robust to down-weighing outlier observations, as well as controlling for other socio-demographic variables, and the number of data sources available in each country.

CONCLUSION

Based on data from the Global Burden of Disease study 2019, we demonstrated that the association between mental and substance use disorders and self-harm with socio-demographic development is dependent on geographical regions and temporal periods. This heterogeneity is likely related to geographical and temporal variations in socio-cultural norms, attitudes towards mental problems, as well as health care and social policies. Better knowledge of this spatial and temporal heterogeneity is crucial to ensure that countries do not develop at the expense of a higher burden of mental and behavioural conditions.

Historic Precepts and Analysis of Mental Health Legislation in India: Implications for Health Management during Pandemic and Beyond

Mental health has become one of the growing concerns during the COVID-19 pandemic in almost all age groups. Further, the awareness and the facilities in regard to mental health issues stays limited to the privileged class of the society. It has further raised concerns to look for ways to effectively and equitably implement mental health legislation in India, where social stigma in approaching mental health services is also very high. This article analyses the historical precepts of mental health services in India and explores the implementation status of mental health legislation 2017 across different states. It also explores some of the issues related to social stigma which acts as a challenge in utilisation of mental health services. It recommends a need for expansion in mental health professionals’ numbers along with adequate infrastructure, especially in rural and remote areas, to make mental health services equitably accessible to all. Mental health awareness generation and therapeutic services for underprivileged class and for COVID-19 affected families should qualify as eligible initiative under corporate social responsibility funding. In this manner, corporates can supplement government efforts to ensure the implementation of mental health legislation in letter and spirit for the benefit of all the citizens.

India's Mental Healthcare Act, 2017: Content, context, controversy

India's new mental health legislation, the Mental Healthcare Act, 2017, was commenced on 29 May 2018 and seeks explicitly to comply with the United Nations Convention on the Rights of Persons with Disabilities. It grants a legally binding right to mental healthcare to over 1.3 billion people, one sixth of the planet's population. Key measures include (a) new definitions of 'mental illness' and 'mental health establishment'; (b) revised consideration of 'capacity' in relation to mental healthcare (c) 'advance directives' to permit persons with mental illness to direct future care; (d) 'nominated representatives', who need not be family members; (e) the right to mental healthcare and broad social rights for the mentally ill; (f) establishment of governmental authorities to oversee services; (g) Mental Health Review Boards to review admissions and other matters; (h) revised procedures for 'independent admission' (voluntary admission), 'supported admission' (admission and treatment without patient consent), and 'admission of minor'; (i) revised rules governing treatment, restraint and research; and (j) de facto decriminalization of suicide. Key challenges relate to resourcing both mental health services and the new structures proposed in the legislation, the appropriateness of apparently increasingly legalized approaches to care (especially the implications of potentially lengthy judicial proceedings), and possible paradoxical effects resulting in barriers to care (e.g. revised licensing requirements for general hospital psychiatry units). There is ongoing controversy about specific measures (e.g. the ban on electro-convulsive therapy without muscle relaxants and anaesthesia), reflecting a need for continued engagement with stakeholders including patients, families, the Indian Psychiatric Society and non-governmental organisations. Despite these challenges, the new legislation offers substantial potential benefits not only to India but, by example, to other countries that seek to align their laws with the United Nations' Convention on the Rights of Persons with Disabilities and improve the position of the mentally ill.

Policy development and challenges of global mental health: a systematic review of published studies of national-level mental health policies

BACKGROUND

Mental health policy can be an essential and powerful tool to improve a population's mental health. However, around one third of countries do not possess a mental health policy, and there are large disparities in population coverage rates between high- and low-income countries. The goal of this study is to identify the transition and implementation challenges of mental health policies in both high-income countries (HICs) as well as middle- and low-income countries (MLICs).

METHODS

PubMed, Cochrane Library and Campbell Library were searched from inception to 31 December 2017, for studies on implemented mental health policies at the national level. Abstracts and the main texts of papers were double screened, and extracted data were analysed through thematic synthesis.

RESULTS

A total of 93 papers were included in this study, covering 24 HICs, 28 MLICs and 5 regions. Studies on mental health policies, especially those of MLICs, kept increasing, but MLICs were still underrepresented in terms of publication quantity and study frequency. Based on the included studies, nine policy domains were summarized: service organizing, service provision, service quality, human resources, legislation and human rights, advocacy, administration, surveillance and research, and financing and budgeting. HICs incrementally enriched their policy content in all domains over centuries of development; following HICs' experience, mental health policies in MLICs have boomed since the 1990s and quickly extended to all domains. Implementation problems in HICs were mainly related to service organizing and service provision; for MLICs, more severe implementation problems converged on financing and budgeting, administration and human resources.

CONCLUSIONS

Mental health policy developments in both HICs and MLICs present a process of diversification and enrichment. In terms of implementation, MLICs are faced with more and greater challenges than HICs, especially in funding, human resources and administration. Therefore, future efforts should not only be made on helping MLICs developing mental health policies, but also on promoting policy implementation under MLICs' local context.

Mental health, mental illness, and human rights in India and elsewhere: What are we aiming for?

The Mental Health Care Bill 2013 was introduced to the Rajya Sabha (India's upper house of parliament) in August 2013 and following 134 official amendments, passed in August 2016. Properly implemented, mental health legislation such as this plays a key role in protecting the rights of the mentally ill, ensuring access to care, and promoting social justice for the mentally ill, their families and carers. In this context, the 2006 United Nations' Convention on the Rights of Persons with Disabilities (CRPD) presents a real opportunity to improve the position of people with disabilities and those disabled by long-term mental illness. The CRPD also presents many challenges to mental health legislators and service-providers, especially in relation to involuntary care, mental capacity, and substitute decision-making. Nevertheless, the CRPD has still generated strong incentive for reform and is an opportunity that should not be missed. Legislation along the lines of India's 2013 Bill offers much that is positive and progressive in terms of standards of care, revised processes for involuntary admission, and enhanced governance throughout mental health services. In this way, this kind of legislation, although imperfect in certain respects, promotes the principles of the CRPD (as outlined in the preamble to India's 2013 Bill). It is important that such initiatives focus not only on the right to liberty but also on rights to treatment, social care, social inclusion, and political empowerment of the mentally ill. Globally, the mentally ill have been neglected for far, far too long. It is time to fix this.