Institutional inadequacies

Print edition : September 16, 2016

A view of the Institute of Mental Health in Chennai, a 2009 picture. Photo: M. Vedhan

A place to dump “mad” people: that was the Institute of Mental Health (IMH), Chennai, when it was first conceived. Much has changed since then in the world of psychiatric care, but the 1,800-bed institute, one of the largest mental health facilities in India, has barely kept pace.

For sure, the semantics around it have undergone a huge transformation: In 1793, Valentine Conolly, a British doctor, acquired 45 acres (18 hectares) of land in a Chennai suburb to build a place to “confine the mad”. About a decade and a half later, the place came to be known as “Dalton’s Mad House”, after Dr Dalton. Just over half a decade later, the name changed once again, this time to Lunatic Asylum. The first doctor trained in psychiatric care at the asylum took charge in 1922, Dr H.S. Hensman. This resulted in another change of name, this time a more acceptable one—the Government Mental Hospital.

Most government-run mental health institutions in India are colonial relics, and the living conditions in them have come under scrutiny repeatedly. They have been found wanting in almost all cases, particularly their custodial nature—more like jails than therapeutic facilities—and glaring human rights violations and abysmal facilities.

A series of exposes in the late 1980s and the 1990s did have a significant impact in terms of improving the basic standards in many hospitals. But ever so often a numbing story comes to the fore, such as the collective neglect that resulted in the Erwadi tragedy in Tamil Nadu in 2001 or the expose in early August of the appalling conditions in which inmates live at the Berhampore Mental Hospital in West Bengal—to highlight the manner in which mentally ill people are treated.

Mental Health Status Report

The 2016 Mental Health Report Vol-1 (Report of the Technical Committee on Mental Health, Constituted by the National Human Rights Commission to evaluate mental health services in India; its members include Pratima Murthy, Sudhir Kumar, Nimesh Desai and Balbir Kaur Teja) notes that the “concerns raised in the 1998 Quality Assurance Report of the NHRC/NIMHANS really saw the light of day only following the 2001 Erwadi tragedy, where 26 mentally ill persons who were chained in a dargah tragically died in a fire accident. The Supreme Court took suo motu notice of the incident and issued notices to the Union of India and the State of Tamil Nadu (Writ petition (Civil) No. 334 of 2001). The apex court directed the Union government to conduct a survey on an all-India basis to identify registered and unregistered facilities and check if the NHRC recommendations had been followed.”

Apart from the lack of facilities, public-run mental health institutions are being weighed down by destitute patients; an unacceptably long duration of treatment in confined spaces, which often leads to physical ailments; and widespread abuse.

At the IMH, this translates into patients not being given beds for “safety reasons”, patients being locked in wards after 6 p.m. with no access to food for the diabetic and the hypertensive, many sleeping on wet floors at night because water overflows into the wards from leaking pipes in bathrooms, and non-functional recreation therapy units. One informed source spoke about male warders being placed in charge of female wards, leading to multiple problems, including sexual harassment.

The 2014 Human Rights Watch report “Treated Worse than Animals: Abuses against Women and Girls with Psychosocial or Intellectual Disabilities in Institutions in India”, details the problems that arise from inadequate monitoring and oversight. One key concern is the lack of adequate monitoring of both state-run and private mental hospitals and residential care institutions for women with psychosocial or intellectual disabilities. It is essential that State mental health authorities and independent bodies such as the NHRC regularly monitor residential care institutions as well as community-based services such as the District Mental Health Programme to ensure quality of care and informed consent. States that have passed the Clinical Establishments (Registration and Regulation) Act (2010) can also leverage it to regulate and monitor mental hospitals.


At the IMH, the average inpatient strength is 1,650, and outpatient, 370. According to the hospital, the duration of stay is between three and six months for most patients. Some patients who have no family stay on longer. The hospital did not have a record for the longest stay, but this correspondent had chronicled in The Hindu in the mid 1990s the life of a patient, Tirupurasundari, who was abandoned and, after treatment, stayed on at the IMH for over 50 years.

According to the 2016 Mental Health report Vol-1, the IMH has 733 inmates who have been there for more than a year, which is the highest for that period among all mental hospitals in India. As many as 551 patients have been staying at the IMH for more than five years, and as many as 100 have nowhere to go.

There are many methods public-run hospitals employ to keep track of a patient’s relatives. Dr S. Mohan Raj, a consultant psychiatrist, spoke of his experience when he used to work at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. The hospital, he said, took three times the bus fare from the patient’s family at the time of admission, and once treatment was completed the patient was sent home with an escort if his/her relatives did not turn up.

Doctors who have worked at the IMH said relatives of patients often gave wrong addresses or dumped the patient on the campus and left, and the institute did not have resources or the requisite manpower to track down families. An NGO was involved in transit care and rehabilitation until 2010. For a variety of reasons these associations invariably collapse over a period of time, and this one was no exception.

On record, the staff strength at a mental health facility in India is usually one person per ward of 20 patients. But this could be lower on any given day. In its report on “Care and Treatment in Mental Health Institutions: Some Glimpses in the Recent Period, 2012”, the NHRC quotes the 1990 rules, which define minimum staffing requirements. The minimum staff requirement for every psychiatric hospital or psychiatric nursing home with 100 beds as laid down in Rule 22 of the State Mental Health Rules, 1990, which was framed in pursuance of the requirement under Section 14 of the Mental Health Act, 1987, are as follows: medical officer having MBBS degree: 1:50, GDMO: 1:25, psychiatrist: 1:100, assistant clinical psychologists: 1:100, psychiatric social worker: 1:100, occupational therapist/staff nurses: 1:10, sweepers: 1:10, and attendants: 1:5 (page 108). Most hospitals do not meet this standard.

The 1996 NHRC-NIMHANS report on infrastructure clearly outlines staff training parameters. It states that attendants need to be trained, sensitised and brought under the nursing administration to ensure better evaluation of patient rights and recommends in-service training for mental health professionals. More nurses need to be deputed for psychiatric nursing training and more doctors must be available after 2 p.m., it says.

Eight years later, in his interim observations in 2004, the Directorate General of Health Services notes about the IMH: While the number of psychiatrists is adequate, the strength of other mental health professionals is below the sanctioned level.

The 2016 Mental Health report, Vol-1, states that Tamil Nadu has no substantive courses for training psychiatric social workers and that there were 30 deaths at the IMH last year. This is next only to Maharashtra, which has more than three times the number of beds in its mental health institutions than the IMH.

Former Union Health Secretary Keshav Desiraju told Frontline that every level of government was aware about the state of mental health institutions, though they might not know the exact details. Officials at various levels, including his office, have received multiple inputs from a variety of sources on the problems in these institutions. “You can’t say that no action was taken because there was no information [on the state of the institutions].”

Not institutionalised

Desiraju added that the notion that most of the mentally ill in India were institutionalised was nowhere near the truth because all the institutions put together had a bed strength of only about 25,000. And the numbers who need treatment are in the millions. The Macroeconomic Report 2005 (the first meta-analysis formed part of the burden of disease in India report commissioned by the National Commission on Macroeconomics and Health in 2005) put the number of persons with mental illness in 2001 at 67 million, which increased to 70 million in 2005, was projected to be 76 million in 2010 and 81 million by 2015. “What is true is that most of the mentally ill are simply in their homes. Most of these people, who are in their own homes, are probably badly off…. The Erwadi incident attracted attention to the issue of mental illness, and the Supreme Court directed that State governments should do something. This was interpreted by many State governments as creating more institutions,” Desiraju said.

While the debate on mental health issues rages on, the fact is that government-run mental health institutions are still strapped to their colonial legacies and ethos and continue to be at least half a century behind in patient care. But that can change only when the patient is in a position to demand his or her rights.

R.K. Radhakrishnan

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