10 October is World Mental Health Day – a day first celebrated in 1992, designed to bring awareness and understanding of mental illness and disability and its effects on people worldwide.In the UK, it is estimated that in any one year, 1 in 4 people will experience a mental health problem. So, out of every 1000 people, 300 will have a mental health problem, 230 will visit a GP, 201 will be diagnosed as having a mental health problem, 24 will be referred to a specialist psychiatric service and 6 will become inpatients in psychiatric hospitals.[1] Whilst well-known personalities such as Stephen Fry, Alastair Campbell and Ruby Wax who have suffered with mental illness, have done much to publicise and de-stigmatise the issues, many people still suffer without receiving the help they need for fear of adverse reactions from family or employers.
Mental illness is a type of disability – sometimes referred to as a ‘psychosocial disability’ [as opposed to a learning, or other kind of, disability]. Disability has long been characterized according to a ‘medical’ model, seeing the person with a disability as flawed and vulnerable and therefore in need of medical treatment, service provision or charity to give needed social protection. Disability is therefore individualized and classified as a deviation from the norm. Campaigners such as Mike Oliver[2], however, have argued for a social model of disability, which locates any limitations experienced not in the individual but in society.
Mental health legislation in the UK has undergone an overhaul in the last 8-10 years, resulting in the amended Mental Health Act 1983 (MHA) in 2007 and the introduction of the Mental Capacity Act in 2005. While some new safeguards were introduced in the MHA 2007 (such as for treatment with ECT or psychosurgery), much of the legislation was left intact, with the focus on detention and treatment (by force if necessary) of mentally ill people in order to protect either themselves or the public. There continues to be huge publicity over violent criminal acts committed by people with mental illness (such as the recent stabbing of Christina Edkins on a bus in Birmingham) and while these cases are shocking and tragic, they are fortunately very rare. Figures from the UK Royal College of Psychiatrists help to put this into perspective: for every citizen killed by a mentally ill person, 10 are killed by corporate manslaughter, 20 by people who are not mentally ill, 25 by passive smoking and 125 by NHS hospital acquired infection (2004 figures).
If mental health issues in the UK are underfunded and stigmatised, the situation in India is worse. Whilst in the UK, many are concerned about over-treatment, and the right to refuse treatment (for example if sectioned in a psychiatric hospital), the emphasis in India is more about the right to access and receive appropriate treatment. In May this year, the BBC reported about a man who had been incarcerated for more than a decade in southern India. The man, Keshava, had suffered with mental health problems and for years his family tried to get him some help. Eventually they could not cope, so took to hiding him in a room when people visited and then bricked it up, imprisoning him in there with only a tiny opening for ventilation and through which to serve food. Eventually, the authorities heard about the case and broke into the room – to discover Keshava still alive, but who seemingly had not washed or had a hair cut for a decade.[3]
Of course these cases are extreme, but it does serve to highlight the lack of help or resources. A 2005 report in India by the National Commission on Macroeconomics and Health estimated around 65-70 million people in India have a mental illness, and this excludes common mental disorders. There was an estimated 70-80% treatment gap for mental disorder. There is only one psychiatrist for every 400,000 people in India – one of the lowest ratios in the world and there are thought to be more Indian psychiatrists working in the US and the UK than in India. Psychiatry is still very much the poor relation in medical career choices, with doctors saying it is often treated as an after-thought in medical education with very little time devoted to psychiatric undergraduate teaching.
There are reports also of a large increase in suicide rates in India in recent years – worldwide suicide is among the top three causes of death among younger people. From 1980 to 1990, there was an estimated 41.3% increase in suicide rates in India – although the data must be treated with caution. Suicide is still a criminal offence in India which may lead to under-reporting and registration of death and causes of death are not that efficient or accurate in rural areas. Nevertheless, there does seem to be a high rate of suicide among young people, farmers[4] and married women (elsewhere marriage is a protective factor against suicide, but seemingly not in India. Domestic violence and / or forced marriage may be a key factor here). It is also more common in urban areas – possibly because of greater stress factors and pressure to succeed in the job market.[5]
Mental health legislation in India largely reflects the UK legislation. The current Indian law is the Mental Health Act 1987 and is based on the same medical model of mental illness, focused on the detention of people with mental illness in psychiatric hospitals.
In 2008 the UN Convention on the Rights of Persons with Disabilities (UNCRPD) came into force. This was hailed as a paradigm shift, finally treating people with disabilities as rights holders, rather than charity or medical cases. It aims to give all disabled people (which includes those with psychosocial disabilities, or mental disorder) equality of opportunity, freedom from any discrimination based on the disability, autonomy including legal autonomy to make their own decisions and participate fully in society. As well as guaranteeing liberties for people with disabilities, it also places obligations on States to enable their exercise of these rights. Both the UK and India have signed and ratified the UNCRPD and both countries are now obliged to comply with this international law.
India, to its credit, has recently drafted a new Mental Health Care Bill which was introduced to the upper house of India’s parliament in August this year. This new legislation aims to make India’s mental health laws UNCRPD compliant with a new emphasis on the rights of people with mental disorder. New provisions include the welcome decriminalisation of suicide, an improved definition of mental illness, non-discrimination in the exercise of legal capacity, autonomy in decision making, restrictions on the use of ECT and psychosurgery as well as the introduction of advance directives to specify in advance the treatment a patient might accept in case they are incapacitated and unable to give consent. In fact it seems to go further than current UK law in s.4 where it states that every person, including a person with mental illness shall be deemed to have capacity to make decisions regarding his mental health care or treatment. Under UK mental health law at present, people who are ‘sectioned’ in a psychiatric hospital can potentially be treated for their mental illness without their consent, using reasonable force if necessary. This includes those who still have ‘capacity’ – ie. the ability to make their own decisions - as well as those lacking capacity. Many, including myself, would say this is not UNCRPD compliant – although the UK government does not seem to have addressed this anomaly as yet.
Dr Sushrut Jadhav (UCL, Senior Lecturer in Cross-Cultural Psychiatry), however, argues that mental health theory and practice in India still remains a ‘watered down’ version of Western psychiatry. He maintains there needs to be more awareness of the local cultural context of mental disorders, and how the understanding of mental disorders is shaped by cultural factors. For example, how does the stigma of Dalit caste contribute to suffering or well-being? Does this change on conversion to other religions (from Hinduism) and is the stigma of caste similar or different to the stigma of mental illness?
On this World Mental Health Day, so much more needs to be done to help those suffering with mental illness in India, the UK and across the world. Let’s hope the new legislation in India will go some way towards strengthening the dignity and rights of those with mental illness, more resources are made available to promote effective treatment and those needing help able to have treatment without fear of stigma or discrimination.
[4] A high suicide rate among farmers in India has been widely reported, thought to be caused by economic conditions, introduction of GM crops and debt. A BBC report though (23 Jan 2013) questions these statistics, saying they are no higher than other groups (and may be lower) but seem high because agricultural workers make up a large proportion of the Indian population.
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