One area that the public health sector in the country needs to address urgently is mental health. Currently about 32 per cent beds in psychiatry institutions are estimated to be occupied by long-stay patients, many of whom should ideally have been rehabilitated into the mainstream years ago. India has roughly a 150 million population with mental health concerns, a sizeable number of them come from rural districts and are brought to facilities located in State capitals or small towns.

Take Mehzabin’s story. She is 50 and diagnosed with bi-polar disorder. From Maharashtra, she had been in a mental health institution for the last seven years despite there being no resurgence of symptoms. The hospital staff has failed to trace her family though she remembers her small house and her days as a domestic worker. She says her episode of mental illness and homelessness was triggered by persistent disruptions in her marriage and her alcoholic husband. She believes she can start anew and support herself if she is discharged. But right now, there seems no light at the end of the tunnel.

To address the issue of long-stay patients in state mental hospitals and to find inclusive community-based alternatives, Delhi-based The Hans Foundation set up a national level multi-stakeholder task force and undertook a study across 43 state psychiatric facilities in 24 States. Titled, National Strategy for Community Based Living for persons with Mental Health Issues ,’ the study offers insights into addressing this concern.

Confined for a long time

The plight of those who languish in psychiatric institutions is heart-rending. During the study, the team met Hema, who is in her late twenties. She has been in solitary confinement for seven years, almost since she came to the mental health institution. The only time she is taken out of the small space she lives in is to eat and take her medication. The staff says that she has been confined “in the best interest of the client” because she has the habit of drinking water from a drain close by. There is hardly any chance of Hema leaving the institution. Like her, many who are checked in hardly ever check out. The study revealed that among long-stay inmates, 11.4 per cent had been there for over quarter of a century. In fact, the team identified 40 who had been confined for as many as 50 years.

The findings of the study indicate that in the 43 state mental hospitals surveyed, 4,935 inmates had been living in a facility for one year or more, which translates into 36.25 per cent of the total number of people living in these institutions. Women formed a larger proportion of the long-stay inmates in 14 of the States surveyed.

Uttar Pradesh had the highest, at 70.31 per cent women.

The survey found that of the long-stay patients, 33 per cent were brought to the hospitals by their families and 55.4 per cent were referred by the police or magistrates, indicating that they were homeless.

As Hans Foundation and its partners in the government, educational institutions and not for profit entities are looking for a national strategy for inclusive and community-based living for persons with mental health issues, the study makes some key recommendations and action plans. These include the following:

National and State steering committees work in tandem to de-institutionalise mental health facilities.

Strategies must include person-centred plans that have a flexible range of support and services, including a choice of housing options and community participation.

Setting up of an expansive community care system that helps people to build lives outside the institution.

Designating investments with accompanying legislative and policy support to help set up community living alternatives.

Promoting inclusion by ensuring that social entitlements like a disability allowance, ration card, banking access and voting right are provided to each person. It is only when these measures are put in place that de-institutionalising can happen for those who have recovered from mental illness.

In the meantime, The Hans Foundation has been giving support to some partners for community mental health interventions and to build models on how people with mental health issues can live independently in the community. Some of these include organisations such as Ashadeep in Assam, Bethany in Meghalaya, Anjali in West Bengal, and Sri Dakshinya Bhava Samity in Andhra Pradesh. Going forward, it plans to foster partnership with Swyamkhrushi in Andhra Pradesh, The Banyan in Tamil Nadu, and Tata Institute of Social Sciences to run similar interventions.

But this effort would only be touching the tip of the iceberg. The Hans Foundation delegates met Thawar Chand Gehlot, Minister of Social Justice and Empowerment, to present the study report last month. They are pinning their hopes on the Centre initiating action based on their recommendations to help usher in broader and far-reaching changes.

Published on March 20, 2020