MENTAL HEALTH CARE DURING COVID-19: REVISITING THE MENTAL HEALTHCARE ACT, 2017
Updated: Aug 10, 2020
- Co-authored by Archi Jain & Parnika Mishra
India has been declared the most depressing country by the WHO[i]. According to the National Mental Health Survey[ii] conducted in 2016, nearly 150 million Indians need mental healthcare service while only 30 million seek for it. Mental health assumes greater significance amid the corona pandemic with the country witnessing a spike in mental illnesses such as depression and anxiety. The stigmatization of mental disorders has added insult to injury and also contributes to suicides in India. At present, India spends only 0.06% of its health budget on mental healthcare and desperately lacks the requisite infrastructure.[iii] The current circumstances are a wake-up call to warrant immediate attention to mental health and take necessary measures to tackle it. This article discusses the copious mental health issues that have birthed in Covid-19. It also critically analyses certain provisions of the Mental Healthcare Act, 2017, and their urgent need to cohabit with the quarantine measures which are in force.
THE CHANGING CONTOURS OF MENTAL HEALTH IN A PANDEMIC
Mental health issues have aggravated owing to the current pandemic resulting in new mental health problems or exacerbation of existing ones. The pandemic has resulted in acute phase issues which include stress-related disorders and even relapse from pre-existing mental health issues as well as long term issues that range from grief survivor’s guilt and depression to post-traumatic stress disorder and somatization disorder.
The pandemic has affected people of all age groups. Depression among students has increased due to lost opportunities and restricted access to mental health services. The lack of professional counseling during quarantine has increased psychological symptoms and student’s risk for suicide and substance abuse. Pregnant women are also at an increased risk of postpartum depression. The health of the mothers and their newborn baby during the pandemic cater to a great sense of anxiety. There have also been increased cases of domestic violence during the lockdown which triggers the mental health issues of the people.
The individuals who suffer from mild substance abuse, a sudden stoppage of the use of alcohol can lead to withdrawal symptoms. These symptoms can range from mild anxiety to various life-threatening complications like seizures. Social isolation, widespread dissemination of fake news over various social media platforms, recession, and financial stress has led to increased levels of stress and anxiety consequently increasing risks of suicides.
THE CURRENT MENTAL HEALTHCARE REGIME: EXIGENCIES AND EXHORTATIONS
In 2017, the Parliament had enacted the Mental Healthcare Act (hereinafter ‘MHCA’ or ‘Act’) to align itself with the Convention on Rights of Persons with Disabilities, thereby declaring the right to mental health a statutory right. Notwithstanding that it has received both bricks and bouquets from stakeholders, the MHCA has assumed more seriousness now, than ever. The Act does come with its own shortcomings but in these trying times, there is an urgent need to suit the provisions keeping in mind the pandemic.
Mental illness is determined as per nationally and internationally recognized medical standards such as the International Classification of Diseases (ICD).[iv] What is problematic at the outset is that the use of the term “substantial” [v]is too restrictive thereby excluding panic disorders, phobia, personality disorder, etc. which are recognized as mental illnesses under ICD 10.[vi] Moreover, section 2(r) of the Act excludes psychotherapists and psychoanalysts from the definition of mental health professionals. In a rather regressive approach, it presumes all mental illness to be a ‘disease’ that can only be treated through medicines. Research shows that medical intervention occurs at advanced stages and preliminary counseling, psychotherapy, and cognitive behavioural therapy are largely efficacious. Some studies even suggest that psychotherapy may prove to be a better option for the treatment of disorders like depression and anxiety. Expansion of these definitions becomes imperative during Covid-19 when mental health issues are on the rise and medications are not easily accessible.
The government is also mandated to set up mental health services in each district of the nation[vii]. India desperately lacks the requisite infrastructure as there are only 40 mental institutions and fewer than 26,000 beds[viii], 9,000 psychiatrists[ix], or one doctor for every 100,000 people. The desirable number of psychiatrists is three for every 100,000 people.[x] The District Mental Health Programme, wherever available can however serve as an important vehicle to deliver mental health care to local communities. They can undertake steps such as fever screening of patients, popularizing norms of social distancing, suggesting activities for well-being at home such as exercising, meditation, and reading books.
There is also an urgent need to give insurance covers to persons with mental illness. Although section 21(4)[xi] of the MHCA mandates the insurance companies to provide medical insurance covers for mental illness just like physical illness, this provision has never seen the light of the day. Insurance companies were also directed by the IRDAI to comply with the legislation in a circular[xii] issued in August 2018 but in an RTI response, it was agreed by the IRDAI that no action has been taken to check this non-compliance by insurance companies. Recently in June 2020, a writ petition[xiii] was filed in the Supreme Court seeking action on this aspect. It is also the case of the petitioner that health being a state subject, every state has failed to design and implement public health programs under Sections 29, 30, and 115 of the Act.[xiv]
The Act disallows electro-convulsive therapy[xv] (ECT) without the use of muscle relaxants and anesthesia and completely prohibits it for minors. Guidelines[xvi] on specialized mental health care settings issued by the Department of Psychiatry suggested that ECT for patients during Covid-19 should be minimized as much as possible and must be resorted to only in emergency cases. This is because ECT with bag and mask ventilation and suction to clear secretion to involve aerosol production. The COVID-19 virus is known to be present in aerosols. ECT should be used after a careful analysis of community spread and available resources to protect the patient. Thus, this calls for judicious use of PPE kits and adequate precautions for the medical personnel.
There is an urgent need for concerted efforts to reduce suicides in India and in furtherance of this aim, the Act decriminalizes suicide. Furthermore, it proposes methods like rehabilitation to be taken to minimize the recurrence of such attempts. Rehabilitation is an important process for a person with a psychiatric disability because it enables the patient to socialize, boosts their self-confidence, and trains them for requisite skills. Closure of rehabilitation centers has worsened their psychiatric symptoms causing them to relapse due to boredom and frustration.[xvii] Section 18(4)(c)[xviii] of the MHCA provides provision for home-based rehabilitation. Efforts must be taken to facilitate telecommunication such as group meetings to give the patients a sense of togetherness, reassurance must be given and medicines must be timely provided.
On a positive note, the government published the Telemedicines Practice guidelines, 2020. The guidelines legalized the teleconsultation between the doctor and the patient. It permits the registered doctors to provide teleconsultation for prescribing medicines, providing specific instructions, and imparting health education during the pandemic. Since India does not have a great doctor-patient ratio, it is a vital step to increase the reach of health care services in the country. The government also started the National Mental Health Programme and the District Mental Health Programme to ensure the availability and accessibility of mental healthcare services and promote community participation in such programmes. The National Institute of Mental Health and Neurosciences has also launched a 24*7 toll-free number for the purpose of providing psychosocial support and mental health services during disasters. Furthermore, India also entered into an agreement with the US to deal with mental health issues through innovative measures. The agreement would enable India to learn from the US’s research and experience in tackling mental health issues.
CONCLUSION AND SUGGESTIONS
Mental health is not given the attention it deserves. If the current pandemic has taught us anything, it is that the medical infrastructure of a nation should be given prime importance. India spends only 1.2% of its GDP[xix] on public health which is among the lowest in the world.[xx] Apart from focusing on the clinical issues, prevention, and promotion of mental well-being should also be attended to by the government to burst the prevailing narrative around mental health. Inclusive policies that are focused on under-resourced communities such as daily wage workers need to be enacted. Concomitant measures must be taken for a reorientation of workplaces which recognizes employee’s mental health as essential especially in the prevailing circumstances of pay-cuts and job losses. Online counseling and therapy should be facilitated, meditation apps should be popularized, radio programmes for those who cannot access online therapy, and yoga programmes should be broadcasted on national television to inspire people especially in these difficult times.
As has been said: we are all in the same storm, but we are all not in the same boat. In this time of crisis, we must do our part by avoiding the dissemination of fake news, providing psychological support to friends and family, and showing empathy towards all. It is only if we adopt a public health and prevention approach, we can emerge as a healthier nation.
[i] World’s ‘most depressing country’ is facing a mental health epidemic, National Herald India (Jul. 22, 2020, 10:36 PM) https://www.nationalheraldindia.com/opinion/worlds-most-depressing-country-is-facing-a-mental-health-epidemic,. [ii] National Institute of Mental Health & Neuro sciences, National Mental Health survey of India, 2015-16, (Jul. 22, 2020, 10:39 PM) http://indianmhs.nimhans.ac.in/Docs/Summary.pdf, [iii] Nina Kler, Mental health and Budget 2020: Here’s what is needed, She the people TV (Jul. 22, 2020, 10:42 PM) https://www.shethepeople.tv/mental-health/mental-health-budget-2020-needed/. [iv] S. 3(1), The Mental Healthcare Act, 2017. [v] S. 2(s), The Mental Healthcare Act, 2017. [vi] World health organisation, The ICD-10 classification of Mental and Behavioral Disorders (Jul. 22, 2020, 10:50 PM) https://www.who.int/classifications/icd/en/bluebook.pdf?ua=1. [vii] S. 18(5)(e), The Mental Healthcare Act, 2017. [viii] Abhishek Mishra & Abhiruchi Galhotra, Mental Healthcare 2017: Need to wait and watch, (Jul. 22, 2020, 10:56 PM)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5932926/#ref21, [ix] Kabir Garg, C. Naveen Kumar and Prabha S Chandra, Number of psychiatrist in India: Baby steps forward, but a long way to go, (Jul. 22, 2020, 11:06 PM)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341936/?fbclid=IwAR1NidiuLemz9B11IzCjT593ZjfQK0v6S7gm6kh78kW7NLOwAZzdTUZCXNE. [x] Harshita Rathore, How committed is India to Mental Health, The Diplomat, (Jul. 29, 2020, 10:42 PM) https://thediplomat.com/2020/03/how-committed-is-india-to-mental-health/#:~:text=Further%2C%20India%20has%209%2C000%20psychiatrists,of%2018%2C000%20mental%20health%20doctors. [xi] S. 21(4), The Mental Healthcare Act, 2017. [xii] Insurance and regulatory development Authority of India, circular dated 16th August 2018, (Jul. 22, 2020, 10:36 PM) https://www.irdai.gov.in/admincms/cms/whatsNew_Layout.aspx?page=PageNo3555&flag=1 [xiii] Gaurav Kumar Bansal v union of India and ors., writ petition (civil) No.__ of 2019. [xiv] S. 29, The Mental Healthcare Act, 2017; S. 30, The Mental Healthcare Act, 2017; S. 115, The Mental Healthcare Act, 2017. [xv] S. 95(a), The Mental Healthcare Act, 2017. [xvi] National Institute of Mental Health & Neuro sciences, Mental Health in the times of COVID-19 Pandemic guidelines for general medical and specialized Mental Health care, (Jul. 22, 2020, 11:16 PM) https://www.mohfw.gov.in/pdf/COVID19Final2020ForOnline9July2020.pdf. [xvii] Sidharth Arya, Rajiv Gupta, COVID-19 outbreak: Challenges for addiction services in India (Jul. 31, 2020, 11:39 PM )https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194862/ [xviii] S. 18(4)(c), The Mental Healthcare Act, 2017. [xix] Vishal Bali, View: good health is good governance, (Jul. 22, 2020, 11:18 PM) https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/view-good-health-is-good-economics/articleshow/75695101.cms?from=mdr. [xx] Vivek Tiwari, Budget 2020 expectations for India’s healthcare sector, (Jul. 22, 2020, 11:24 PM), https://www.financialexpress.com/budget/budget-2020-expectations-for-indias-healthcare-sector/1842519/.