For better mental health

The World Health Report 2001 recommends de-institutionalisation and advocates a change in the attitudes of governments, law-makers and the community towards mental health.

THE World Health Report 2001, titled Mental Health: New Understanding, New Hope, was released worldwide on October 4. In conjunction with two other documents - An Atlas of the Mental Health Resources in the World (2001) and Mental Health: A Call for Action by World Health Ministers, based on the proceedings at the 54th World Health Assembly and the Ministerial Round Tables held on May 15, 2001 - the WHR is an attempt to battle the neglect of mental health. Estimates suggest that "one in four families has at least one member currently suffering from a mental or behavioural disorder", and that about 450 million people are currently suffering from neuropsychiatric conditions. These are startlingly large figures, and provide the basis for the push to adopt a public health approach while dealing with mental health.

A paradigm shift is perceived as having occurred in mental health in the latter half of the 20th century. It is attributed to three factors: the strides made in psychopharmacology, with the discovery of new classes of drugs; the human rights movement, which became an international phenomenon under the sponsorship of the United Nations; and efforts to incorporate the mental component into the concept of health, spearheaded by the World Health Organisation (WHO).

Although the WHR spells out an intention to deal with the issue of mental health, it is the absence of mental health that constitutes its text. The focus is on depressive disorders, schizophrenia, disorders of childhood and adolescence, drug and alcohol dependence, Alzheimer's disease and epilepsy.

It is obviously difficult to provide a definition of mental health and, as the WHR admits, "from a cross-cultural perspective, it is nearly impossible to define mental health comprehensively". So the WHR confines itself to a "generally agreed" statement that "mental health is broader than a lack of mental disorders". There is an underlying acknowledgement of the stigma, discrimination and the inadequate services that are unvarying companions of the absence of mental health.

The WHR is essentially an effort in advocacy. It advocates, for instance, a recognition of the interconnectedness between physical and mental health, and seeks spaces in policy, law and resource commitments, which have been the near-exclusive preserve of physical health so far. It calls for an integration of mental health care into the primary health care system and makes a pitch for a public health approach. Emphasising the burden of mental and behavioural disorders, it advocates an altered paradigm of care. The principles of care pertain to diagnosis and intervention, continuity of care, provision of a wide range of services, partnerships with patients and families, the involvement of the local community and integration into primary health care. Pharmacotherapy, psychotherapy, psychosocial rehabilitation, vocational rehabilitation and employment, and housing have been identified as the ingredients of care relevant to those experiencing an absence of mental health.

The WHR makes out a strong case for de-institutionalisation. It appears that the accumulating evidence of the inadequacies of the psychiatric hospital, coupled with the appearance of "institutionalism" - that is, the development of disabilities as a consequence of social isolation and institutional care in asylums - led to the "de-institutionalisation movement". De-institutionalisation is a process that relies on the development of a grid of community services to displace the institutional framework of treatment and care. De-institutionalisation, it is stated, has not been an unqualified success because governments have not allocated resources saved by closing hospitals to community care, professionals have not been adequately prepared to accept their changing roles, and because the stigma attached to mental disorders continues to be strong. "In some countries," the WHR says, "many people with severe mental disorders are shifted to prisons or become homeless."

The Indian experience with institutionalisation has not been edifying. A report prepared for the National Human Rights Commission (NHRC) in 1999 after an empirical study of mental hospitals in the country made a damning indictment of the state of mental health institutions. "The findings reveal that there are predominantly two types of hospitals," the report said. "The first type do not deserve to be called 'hospitals' or mental health centres. They are 'dumping grounds' for families to abandon their mentally ill member, for either economic reasons or a lack of understanding and awareness of mental illness. The living conditions in many of these settings are deplorable and violate an individual's right to be treated humanely and live a life of dignity. Despite all advances in treatment, the mentally ill in these hospitals are forced to live a life of incarceration."

"The second type of 'hospitals'," the NHRC report continues, "are those that provide basic living amenities. Their role is predominantly custodial and they provide adequate food and shelter. Medical treatment is used to keep patients manageable and very little effort is made to preserve or enhance their daily living skills. These hospitals are violating the rights of the mentally ill persons to appropriate treatment and rehabilitation and a right to community and family life" [Quality Assurance in Mental Health (1999)].

In August 1993, hearing a public interest petition with regard to the large-scale incarceration of persons who had been branded mentally ill (and termed as non-criminal mentally ill, or NCLs), the Supreme Court said: "It is declared that admission of non-criminal mentally ill persons to jails is illegal and unconstitutional." Despite this order, in 1994 nearly 400 persons were found to have been kept as NCLs in jails in Assam; a commissioner of the court who investigated the matter found most of them fit enough to be released. In fact, there were cases where the persons had no mental illness to explain their being taken into custody. A 70-year-old woman, for instance, found herself in jail as an NCL because her landlord found this an easy way of taking back his house from her possession.

The WHR, which draws attention to the Netherlands-based Geneva Initiative of Psychiatry, founded in 1980 to combat the political abuse of psychiatry as a tool of repression, has not found a counterpart to contain the abuse of police laws that allow involuntary and unjustified incarceration. The WHR, however, recognises the encounters that people with mental disorders have with the criminal justice system, and suggests that "policies should be put in place to prevent the inappropriate imprisonment of the mentally ill and to facilitate their referral or transfer to treatment centres instead".

The Atlas highlights the dearth of mental health professionals. The figures are worrisome, especially given the pandemic proportions of the figures of the mentally ill that the WHR projects. About 52.7 per cent of the countries, covering 69.2 per cent of the world's population, have access to less than one psychiatrist per 1,00,000 population. All countries in the South-East Asian region and almost 96 per cent of the countries in the African region, accounting for 89 per cent of the population, have less than one psychiatrist per 1,00,000 population. India counts among them. The figures for psychologists working in mental health care is not too different, and there is a paucity of social workers too. The accent on community mental health care in the WHR makes sense for this reason.

The WHR makes 10 recommendations for action, which are as follows: provide treatment in primary care; make psychotropic drugs available more freely; give care in the community; educate the public; involve communities, families and consumers; establish national policies, programmes and legislation; develop human resources; link with other sectors; monitor community mental health; and support more research.

In the emerging patent regime, which grants privileges to the holder of the patent, the priority given to the provision of drugs more than raises eyebrows. "A synthesis of the available evidence indicates that while newer psychotropic drugs have fewer side effects, they are not significantly more efficacious, and they are usually more expensive," says the WHR. "...Patients in poor or developing countries should not be deprived, on economic grounds only, of the benefits of advances in psychopharmacology. It is necessary to work towards making available to all, the best drugs for the treatment of the condition. This requires a flexible approach to the essential drugs list." Yet, this is merely exhortative, with little in the international economic order to back it.

The impact of policies on the mental health of people is present more in the silences of the WHR than in its statements. The toll that globalisation is taking is reflected in the statements of Ministers who attended the Ministerial Round Tables. The Japanese Minister, for instance, said the competition inherent in a free market economy had resulted in rising incidence of stress, distress and mental disorders. The Mongolian representative observed that mental disorders were a problem particularly for countries in transition. He said that according to a recent study, 51 per cent of the adult population of Mongolia used alcohol and the suicide rate had risen five-fold between 1989 and 2000. The psychiatric morbidity of the Bhopal gas leak victims is still an unaccounted cost of that disaster, despite studies such as Against all Odds (December 1989), which found a prevalence of cases of post-traumatic stress disorder among the affected population. State and non-state violence remain on the periphery, as do war and the spread of large-scale conflict. But, as the Director-General of the WHO, Gro Harlem Brundtland writes, through the WHR the "WHO is making a simple statement: mental health - neglected for far too long - is crucial to the overall well-being of individuals, societies and countries and must be universally regarded in a new light."

Usha Ramanathan is a researcher in law based in New Delhi.