Right To Mental Health And The Barriers

Kamayani Bali Mahabal

Mental, physical and social health are vital strands of life that are closely interwoven and interdependent. Mental health is crucial to the overall well-being of individuals, societies and countries. Mental health includes subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualisation of one’s intellectual and emotional potential.

Health behaviour can affect physiology, while physiological functioning can influence health behaviour, resulting in a comprehensive model of physical and mental health, in which the various components are related and mutually influential over time. The health behaviour of an individual is highly dependent on mental health, individual psychological factors are also related to the development of mental disorders. Social factors such as uncontrolled urbanisation, poverty and rapid technological changes are also important. The relationship between mental health and poverty is particularly important: the poor and the deprived have a higher prevalence of disorders, including substance abuse.

The World Health Organisation (WHO) reports that 450 million people worldwide are affected by mental, neurological or behavioural problems at any time. They are also universal, affecting people of all countries and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. They have an economic impact on societies and on the quality of life of individuals and families. Around 20 per cent of all patients seen by primary healthcare professionals have one or more mental disorders. One in every four families is likely to have at least one member with a mental disorder. Furthermore, according to the WHO, most middle and low-income countries devote less than 1 per cent of their health expenditure to mental health.

In India, we do not have a separate mental health budget, but details are available for the state of Gujarat. The State’s total allocation towards mental health works out to Rs 82 million out of a total health budget of Rs 8,562 million. Of this Rs 82 million, Rs 37 million is spent on mental hospitals, Rs 34 million on medical colleges (presumably departments of psychiatry in medical colleges) and Rs five million on district hospitals (Mission Report, 2003). It appears that Rs 2.15 million under ‘central sponsored schemes’ is the only outlay on a community programme. About 67 per cent of the total expenditure is on salaries and 20 per cent on medicines and supplies.

The paradox is that although treatment is available and are relatively cheap, the problem continues to mount. A combination of relatively cheap medicines and family support can effectively handle the problem. The gap between the treated and untreated, between those reached and those not reached, is enormous.

This gap exists because there are barriers to implementation of the available knowledge. The first barrier is the stigma and the discrimination attached to those suffering from mental disorders. This prevents those affected from being properly treated because the family hides the patient from the health services. People believe that this happens only in developing countries. It is not so. Insurance schemes are not recognising the parity between physical and mental illnesses and they reimburse expenses on physical ailments but not mental ailments. This practice is prevalent in many countries.

The second barrier is the wrong public health choice in the matter of allocating money for mental health. In many countries, 80-90 per cent of the financial resources go for maintaining large, inhuman and outdated mental health institutions. There was a episode in Ervadi of an institution where basic human rights were violated by chaining mentally ill patients.

Money is being allocated to such institutions even when we know that the most effective interventions are community-based ones. Sometimes, this also explains why people do not seek treatment. If the only option is a psychiatric hospital, one that is poorly maintained, people will have no option but turn to quacks.

The third barrier is that we do not have enough specialists to deal with the problems of mental illness. There is also a need to mainstream the skills and knowledge of mental disorders, particularly in recognising and treating them. This means training primary health care doctors, nurses and social workers-people who are working in the community. We must use the few psychiatrists as multipliers so that mental illnesses are treated effectively in the communities.

To address the barriers, we need more awareness among politicians and policymakers that investing in mental health is better than non-treatment. Non-treatment is much costlier than treatment because the consequences of non-treatment are huge.

The public perception is that a mentally ill patient is a dangerous person and is best locked up. Ironically, doctors themselves strengthen this perception. They are delighted to remain in their offices instead of visiting communities where the disease is prevalent. They find the option of staying back in their hospitals more prestigious.

As a result, we tend to invest too much in hospitalisation, neglecting long-term care at the community level. Human rights and the full enjoyment of citizenship are the preconditions for any talk on mental disabilities.

Being a citizen is the best treatment for mental health problems. Isolation, separation and discrimination of patients lead to worsening of health from a mental health perspective. This is the first principle which was truly applied in the reform in Italy. Italy, the Nordic countries, Australia and Brazil were among the leading reformers in the area of mental health.

We need to combine civil passion, which recognises the rights of the patients, with the intellectual passion for science. Civil passion without science will be a disaster; and science without social commitment is a disaster as well. These two ingredients need to balanced to make a difference to mental health and well-being.

The writer is Senior Research Officer, CEHAT. Email- kmahabal@hotmail.com