Mental Health Policy in India: Unpacking the 'Right to Mental Health Care'

Item

Title: Mental Health Policy in India: Unpacking the 'Right to Mental Health Care'
Creator: Sudarshan Kottai
Date: 2015
extracted text: MENTAL HEALTH POLICY IN INDIA: UNPACKING THE 'RIGHTTO MENTAL HEALTH CARE'

SudarshanKottai
Research Scholar

Department of Liberal Arts

Indian Institute of Technology Hyderabad
This paper is an attempt to foreground the contradictions inherent in different policies related to mental

health and promotion viz., the NMHP, the UNCRPD, the proposed National Health Policy (NHP) and the
Mental Health Care Bill (2013). The paper is a call to shake this status quo by

examining critically the

continuing 'medicalisation' and 'individualization’ of mental illness whereby 'distress' is being
continuously diagnosed as 'illness' stripping the 'agency' of suffering individuals.

National-level policies in India: 'Right to mental health' or 'Right to mental health services'?

National Mental Health Programme (NMHP)

There have been various policies formulated at national and international levels with regard to mental

health and disability. The first one to be rolled out in India was the National Mental Health Programme
(NMHP) in the year 1982 with particular emphasis on community participation in the mental health
service development and to stimulate efforts towards self-help in the community.The policy objectives

of the NMHP have not been met because in practice it has become an administrative affair of
distributing medicines quite divorced from the community it is supposed to shake hands with by

nurturing collective adaptation and building social support systems. The NMHP has failed to address the

social determinants of mental health and illness through inter-sectoral engagements.There is little data
on community mental health from a community or developmental perspective.While 'prevention and

promotion' of mental health has always been a policy objective through the National Mental Health

Programme 1982, ground level practice has focused on mental illness and tertiary care treatments (Jain

&Jadhav, 2009).

United Nations Convention on Rights of Persons with Disabilities (UNCRPD)
The UNCRPD adopted on 13 December 2006 at the United Nations is intended as human rights

instrument with the aim of changing attitudes and approaches to the persons with disabilities.The
UNCRPD which was ratified by India in the year 2007 has been progressive in including psychosocial
disabilities under its umbrella. Article 26 of the UNCRPD states that,

"States

Parties

through

peer support,

maximum
and

full

Parties

take

shall

to

enable

and

participation

in

organize,

strengthen

and

inclusion

rehabilitation

persons

physical,

full

independence,

shall

effective

services

appropriate

with

disabilities

to

social

and

mental,

aspects

all

programmes,

and

measures,

and

extend

of

life.

and

maintain

vocational

ability,

end,

States

attain

that

To

including

comprehensive

and

habilitation

particularly

in

of

with

disabilities

to

their

families,

including

the

areas

of

health,

employment, education and social services".

Further, Article 28 states,
"States

Parties

recognize

adequate

standard

adequate

food,

living conditions,

and

right

living

for

and

housing,

of

clothing

the

shall

persons

themselves
and

take appropriate

and

the

continuous

steps to

safeguard

to

an

improvement

of

promote

the

and

realization of this right without discrimination on the basis of disability".
UNCRPD has thus brought about a social perspective about mental health replacing 'mental illness' with

a forward looking term of 'psychosocial disability' drifting away from the earlier biomedical model of

mental illness.Yet,how far it would be implemented in letter and spirit in India remains to be seen.

Mental Health Core Bill (2013)
The Mental Health Care Bill, 2013 piloted by the Ministry of Health and Family Welfare, Government of
India is intended to replace the Mental Health Act, 1987 to push forward reforms in the mental health

sector.Unfortunately, however, the Bill has narrowed down the scope of mental health care to merely

increasing access and availability of psychiatric facilities and medicines free of cost.Thisis far from what
is envisaged in the UNCRPD which exhorts mental health professionals to recognize and address the

social barriers to wellbeing and to design disability-sensitive mental health programs.
The clause of Right to Mental Health mentioned in the bill defines the right as access to mental health

services by integrating mental health services at all the levels of health care, namely, PHC and CHC close

to the residence and scaling up access to psychiatric drugs free of cost at the nearest vicinity. It reads as

follows: "Every person shall have a right to access mental health care and treatment from mental health
services run or funded by the appropriate Government. Nowhere is it mentioned that right to mental

health would go hand in hand in securing rights for the deprived sections of the society and improving
their quality of life.

The Bill further states that "Mental illness of a person shall not be determined on the basis of,—(a)
political, economic or social status or membership of a cultural, racial or religious group, or for any other
reason not directly relevant to mental health status of the person;

(b) non-conformity with moral, social, cultural, work or political values or religious beliefs prevailing in a
person's community."
Yet, it well-known that nonconformity to certain social norms (e.g. alternate sexuality) is often
pathologized and treated with anti-anxiety and anti-depressant drugs, without exploration of the social

cause of the anxiety/depression.

Draft National Health Policy (2015)

The draft National Health Policy, 2015 which is placed in public domain by the Ministry of Health for

feedback, comments and suggestions aims to improve performance of the health systems. A preliminary
survey of the proposed National Health Policy reveals that it has also not been able to conceptualize

mental health in its psychosocial aspects;it is silent about addressing the root problems of social
inequality, injustice and other deprivations that give rise to distress. The focus has been on telemedicine
linkages, integration with primary health care, easy access to follow-up medications and increasing

access to mental health care services by increasing the number of mental health professionals to fill the
gap.In a nutshell, there is a quest to equate mental health with that of physical health in every respect.

Medicalizationand individualization of distress
One of the awareness campaigns published in a national daily by the Ministry of Health and Family

Welfare, Government of India on World Mental Health Day a few years back read as follows: "Mental
illness is a brain disorder" which is an explicit recognition by the state that mental health care is nothing

but treatment of the brain and this would naturally entail extending and scaling up of medical services

for mental health problems.

At the same time, scholars have pointed out the limitations of the biomedical model with regard to
explaining historical and intergenerational trauma (Yankovsky, 2014). Even if a patient's distress is

rooted in extreme poverty that he doesn't have money for a square meal,the tendency among the

psychiatrists is to individualize the problem and term their distress as illness and treat with
pharmacological agents. The disadvantaged people's attention is deflected from the deprived socio
politico-situation in which they are in, towards their supposedly compromised brains. Thus, for example,

the governments of many states in India had sent a team of psychiatrists to prevent farmer suicides-a
knee-jerk response-without paying attention to the macro level agrarian crisis and consequent widening

of social inequalities (Mills, 2014).This exemplifies what Rose (2013) refers to as expansion of the scope

of psychiatric treatment to treat social problems and social deviance by posing that psychiatrists can
identify and ameliorate the miseries that plague society in various forms by drugs,Every distress arising

out of a person's compromised social environment is termed as illness and treated with psychotropic

drugsreinforcing the false notion that pills can cure life's ills

Disability scholars likeMehrotra(2013) have drawn attention to the need for a social paradigm ofmental
health that frames distress as not just rooted in one individual but as affected by the micro and macro
forces surrounding the person. Giving a diagnosis to a person beset by social problems would be akin to
symbolic violence which then legitimizes social order based on inequality.Reddy et al. (2013) state that

most strongly associated factors with mental disorders are deprivation and poverty. Reducing
discrimination against sex, caste, disability and socioeconomic status is an important aspect to reduce
mental disorders(Reddy,2013).They further state that national mental health policies should not be

solely concerned with mental disorders, but should also recognize and address the broader issues which
promote mental health which includes education, labour, justice, transport, environment, housing, and

health sector.

Rose (2014) has drawn attention to the expansion of psychiatric gaze which medicalises even common
life problems that are encountered by everyone on earth. As a trainee clinical psychologist in LGBR1MH,

Tezpurjwasa witness to such psychiatrizationofsocial distress.Half of the patients who thronged the
OPD were migrant Muslim women from Bangladesh's Sylhet district. Many of them experienced

constant, chronic trauma in multitude forms of illiteracy, poor nutrition and poor sanitation Most of
them were daily wage labourers engaged in manual work. These women often presentedthemselves in

the OPD with physical complaints such as aches. I was always struck when they were prescribed with a
bunch of antidepressants and anxiolytics (under the diagnosis of mixed anxiety and depressive disorder,

somatisation disorder, conversion disorder etc.) by the psychiatrists. They were also advised to come for
follow-up every month to replenish the supply of medicines handed out free of cost by the

Government.Talking to these women revealed many stories of resistance and struggles. But for the

psychiatrists, they were merely 'Sylheti psychosomatic' women to be prescribed with medications. Their
social problems becameessentialized asproblems within themselves, within their brains, consequently

depriving them of agency to act against injustices or improve their conditions by othermeans. This has
been referred to as the creation of "somatic individuality" by Rose (2006) whereby we are disguised to

think that all our states of mind are invariably caused by neuro-chemical imbalances and can be rectified
through medicines. Poverty and unemployment are both causes and effects of disability. Pharmaceutical
companies add to this by employing disease awareness programmes.

In fact, the diagnostic category of 'psychosomatic disorders' has become so common that it subsumes
every individual who seeks mental health care with presenting complaints of physical complaints

without a known physical etiology.Even I was a victim of this extreme form of psychiatrisationwhen I

was diagnosed as homesick ('adjustment disorder') as a student of clinical psychology when suffering
from high fever and weakness. Since the medical investigations turned out to be negative for TB,even

though my symptoms were indicative of TB, I was given a psychosomatic label by psychiatrists, who
commented on my introverted and withdrawn nature.I was later found to haveExtrapulmonary TB at
anadvancedstage.
Recent research has found that more and more people in India are on mood stabilizers.Ecks' (2005)

research in Kolkata found that India is one of the world's biggest producers of pharmaceuticals.The
spiraling of events stemmingfrom social demarginalisation to accessing of psychiatric medications is

explained in the article with a broader worldview based on the 'global monoculture of happiness' and

how the psychiatric medications travel to reach the marginalised citizens who yearn to make both ends

meet toiling hard with poverty and other social disadvantages.

All these studies draw attention to the need for a holistic approach which is rights based.For this to
materialize there is a dire need to shift the lens to asocial model of distress and to redefine mental
health as entirely different from physical health which cannot be simplyreduced to the brain.

REFERENCES

Ecks, S. (2005).

'Pharmaceutical Citizenship:

Antidepressant

Marketing and

the

Promise

of

Demarginaiization in India'.Anthropology & Medicine, 239 — 254.

Jain, S.,&Jadhav,S. (2009).Pills that swallow policy:Clinical ethnography of a community mental health

programme in Northern India.Tronscultural Psychiatry,46,60-85.

Kumar,A. (2002).Mental health

in

India: Issues and concems.Journal of mental health and

ageing, 8(3), 255-260.

Mehrotra,N.(2013) Disability, Gender and State policy:Exploring the Margins,Rawat Publications.

Mills,C.(2014).Decolonizing Global Mental Health: The psychiatrization of the majority wor/d.Routledge.

Reddy, V., Gupta, A.., Lohiya, A.,&Kharya, P. (2013).Mental health issues and challenges in India: A
review. International Journal of Scientificand Research Publications, 3, (2).

Rose,N.

(2006).

Disorders

Without

Borders?

The

ExpandingScope

of

Psychiatric

Practice.

Biosocieties, 1, 465-484.

Yankovsky,S.(2014).Mental Healthcare, Diagnosis, and the Medicalization of Social Problems in

Ukraine.Disability and the Global South, 1 (2), 302-318.

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