MENTAL HEALTH AND PUBLIC POLICIES

UNDERSTANDING MENTAL HEALTH

 The term “mental health” encompasses a wide variety of conditions, issues and contexts.
 While illness represents individual suffering, disease implies structural and functional abnormalities
 The blurred disease–illness divide for mental disorders gives an illusion of specific brain pathology.
 The interchangeable use of these concepts is supported by academia and health, and insurance and pharmaceutical industries.
 Clinical presentations of individual suffering are viewed through the biomedical lens, leading to suggestions of disease and
recommendations of pharmacological therapies.
 However, social determinants of mental health (for example, poverty, gender, literacy, employment, social exclusion, etc)
are ignored
 The heterogeneity of the experience, disparity of contexts, and diversity of people make the task of employing a single
framework difficult.
 The stigma associated with mental illness further complicates issues.
NORMALIZATION AND ITS CRITIQUE

 “mental illness is like any other medical illness” implies that mental illness has a biological basis just like
other medical illnesses and should be treated in the public’s eye in a similar manner.
 It is important to examine the clinical and public utility of presenting a dominant neurobiological model of
mental illness to patients, their families and the public at large.
TYPE 2 DIABETES AND MENTAL DISORDERS

 Diabetes, is understood as the result of dysfunctional glucose metabolism related to absolute or relative insufficiency
of insulin signalling.
 This dysfunctional metabolism is the consequence of endogenous predispositions, such as hereditary and
environmental factors, including personal choices, such as poor diet and sedentary life style.
 By improving glucose metabolism, either through medication, insulin replacement or changes in lifestyle, positive
health outcomes can be expected.
 Diabetes is diagnosed by confirming high levels of fasting glucose and other related biochemical markers of glucose
metabolism.
 Further, the cascade of its effects on other systems (e.g., cardiovascular, central nervous system) are well explained
 They can also be prevented/treated by better and early control of diabetes.
 All through this, the patient is aware of the nature of their problems, including personal choices, and diabetes generally
does not affect their day-today thinking, behaviour or perception.
 The model of attribution presented to the patient is congruent with the scientific “facts,” thereby making it easier for
the person as well as society to accept the condition.
MENTAL DISORDERS – CORE OF ONE’S BEING

 Mental disorders, on the other hand, affect the very core of one’s being
 A range of experiences and phenomena of varying severity that alter the individual’s thinking, perception
and consciousness about the self, others and the world.
 This is seen to an extreme degree with more serious mental disorders, such as psychoses and bipolar
disorders, but to a lesser albeit significant degree with anxiety, mood, eating and other psychiatric disorders.
 Emotion, perception, thought and action are the essence of human identity and the concept of “self,” and
these are the prime domains altered in mental disorders.
 The factors involved in increasing the risk for mental disorders are endogenous (genetics is recognized as a
major contributor to most mental disorders) as well as environmental, much like most medical disorders.
 Psychological deprivation and trauma, social defeat and isolation, poverty and poor family environment are
but some of the environmental factors that have been reported to increase the risk for mental disorders.
 In addition to changes at the physiologic level, common to somatic and mental disorders the latter
encompass changes in one’s definition of “self,” and are not situated outside the “self.”
 It can even be argued that in the absence of any substantiated biological marker for mental disorders (only 1
has been included in the recent DSM-5: orexin change in narcolepsy), the hallmark defining features of
mental disorders, at least for now, remain the changes in how the patients feel, think and act and how these
changes affect their relation to themselves and to others.
MENTAL ILLNESS IS LIKE ANY OTHER MEDICAL ILLNESS: THE
AXIOMATIC STATEMENT

 In the last decade, biogenetic attribution of all mental disorders, having acquired a hegemoneous status
 It been used primarily to inform campaigns for reducing stigma and promoting better acceptance of mental
illness and the people with mental illnesses by society.
 Several studies now say that this strategy has not only not worked, but also may have worsened public
attitudes and behaviour toward those with mental illnesses.
 Investigations of stigma have shown that those who consider mental disorders as primarily attributable to
biological forces, just like other medical disorders,
 Absolved the mentally ill person of responsibility for their behaviour and actions,
 Tended to feel less optimistic about their ability to get better and function well, a
 Are less accepting of them and feel less positively toward them.
 Biogenetic causal theories and diagnostic labelling as illness are both positively related to perceptions of
dangerousness and unpredictability
 Leads to fear of and desire for social distance.
 The attitudes investigated in these studies are reflected in individuals’ responses to whether they would live next door
to, socialize or make friends with or have a close relative get married to a person described as being mentally ill.
 There is also evidence to suggest that biogenetic explanatory models may have negative consequences for those with
mental illness in terms of their implicit self concept and explicit attitudes, such as fear.
PSYCHIATRY AND SOCIETY

 While psychiatry argues that its diagnoses are based on empirical evidence, others suggest that they are a result of
value judgments.
 The “anti-psychiatry” movement has contended that mental illnesses are social constructs .
 They argue that mental illnesses are myths and should not be the concern of medicine and psychiatry, which
should focus on the body and disease
 They posit that deviations from societal norms are used by society, in conjunction with the medical profession, for
social control (for example, to stifle all social and political dissent in the Soviet Union).
CHALLENGE T0 BIO MEDICAL APPROACHES

 Activism by people with psychosocial disability has challenged the biomedical and psychiatric discourse.
 They have argued against the use of compulsory treatment for psychosocial conditions, including mental illness,
suggesting that such approaches are influenced by prejudice, and are a breach of the human right to equality and
non-discrimination.
 Such movements resulted in the United Nations Convention on the Rights of Persons with Disabilities
(UNCRPD),
 It argued that people with disability have rights equal to others, namely, rights to legal capacity, liberty, physical
and mental integrity, and the right to informed consent.
 While the broad structure of the UNCRPD does not explicitly ban the use of force in treatment of the mentally ill,
its logic clearly suggests prohibition of compulsion to treatment without consent.
RIGHT TO TREATMENT VS CONSENT

 Medicine focuses on the “right to health and treatment.”

 On the other hand, legal perspectives favour the individual’s autonomy, choice, and right to refuse treatment.
 Medicine in India prefers its paternalistic culture, while legal frameworks support contractual relationships
between patients and physicians.
 While psychiatry acknowledges that individual autonomy and choice are fundamental, they also support the
takeover of decision-making in certain situations.
 Most countries have mental health laws, which allow compulsory hospitalisation and treatment of people with
mental illness in specific circumstances
 These laws permit psychiatric interventions without patient consent in contexts where they are said to lack
decision-making capacity and when there is presumed risk of harm to self or to others.
USE OF FORCE

 While the use of force was delegitimised across many sectors and the provision of treatment for physical illness
without consent is seen as assault, the use of force remains problematic when employed for people without mental
illness.
 For those with such illnesses, mental health legislations and legal frameworks allow for coercion, compulsory
hospitalisation, and enforced psychiatric interventions.
MENTAL HEALTH ACT 1987

 The setting of unachievable minimum standards (for example, one psychiatrist for every 10 beds)
 The act did not cover other facilities where people with mental illness were involuntarily admitted (for example,
prison, juvenile homes, etc).
 The procedures for involuntary admission were considered difficult, arbitrary, and unreasonable.
 Silent on emergency psychiatric services and on the choice of treatments, particularly electroconvulsive therapy
without anesthesia
 Limited budget and resources also meant poor functioning of national and state mental health authorities, which
hampered its implementation.
MENTAL HEALTH ACT 2017 POSITIVES

 The new act replaces the Mental Health Act, 1987, which was essentially a custodial law.
 Its goal is the provision of humane and evidence-based care for people with mental health concerns.
 It puts the onus on the state for prevention of suicide, promotion of mental health, training mental health
professionals, and provision of care.
 It includes people with mental health conditions, caregivers, activists, and judges on its central and state decision-
making bodies and on review commissions.
 It attempts to provide for checks and balances to ensure the human rights and dignity of people with mental
illness.
MENTAL HEALTH ACT 2017: POSITIVES

 It attempts to foster reform within mental health institutions through review tribunals to protect human rights of
people.
 It mandates registration, licensing, inspection, and audit of mental healthcare institutions.
 It allows for involuntary hospitalisation in exceptional circumstances (for example, risk of harm to self and others)
with the provision of appeal to quasi-judicial mental health commissions.
 It allows the use of advance directives and nominated representatives.
 It mandates a range of services, including community rehabilitation.
 It de-criminalises suicide attempts.
 It bans the use of electroconvulsive therapy without anesthesia and prohibits its use in minors
CRITIQUE

 Many psychiatrists view the new reforms, including the use of advance directives, nominated representatives, and
mandatory oversight, as interference in clinical decision-making
 On the other hand, activists argue that the legislation only supports the biomedical model of mental illness and
does not comply with the UNCRPD
CONCLUSION

 Intertwined with scientific authority, the political economy of health, deeply rooted in capitalistic economic
systems, undergirds many medical and psychiatric formulations.
 The technical approaches of evidence-based medicine are not necessarily value-neutral nor above specific
interests.
 Medicine is politics and the health sector is a powerful player in national economies.