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Psychiatric hospital reform in India

Tasneem Raja, the Senior Program Officer at Sir Dorabji Tata Trust provides an overview of the issues facing India in reforming psychiatric hospital care.

India accounts for 2.4% of the world’s surface area and for 17.5 % of the world’s population. Just in terms of sheer numbers, India is also home to one of the largest population of people living with a severe mental disorder. The country has a population of 1.21 billion (1) this translates to about 78 million people living with a severe mental disorder. Though mental illnesses account for a higher Disability Adjusted Life Years DALYs lost than some other diseases such as cancer, tuberculosis, HIV/AIDS and malaria, (2) it receives far less attention from government, public health system as well as philanthropy

Severe and enduring mental disorders (SMDs) contribute hugely to global burden of disability and mortality (3) (4). In low and middle-income countries (LMIC)

SMD sufferers face impediments to their clinical and functional recovery, protection of their human rights, social inclusion and participatory citizenship (5). There are major barriers in access to appropriate care, limited resources leading to large treatment gaps, and heightened vulnerability and disadvantage due to stigma and discrimination (5) (6) (7) (8). Many languish in large hospitals, abandoned by family and forgotten by policy makers. The emerging field of global mental health has also relegated the exposure of abuses in mental hospitals to media, non-governmental organizations and human rights commissions. Hospitals and long stay institutions are not mentioned in any of the top 25 Grand Challenges in Global Mental Health (9).

Mental health care in India is largely provided by institutions operating within a legal framework inherited from British colonial rule, with 43 psychiatric hospitals set up 100 - 150 years ago (10). These constitute 80% of all available psychiatric beds and 14% of admitted patients have been there for more than five years (11), some for 3-4 decades. The infrastructure and standards of care are poor. There are no clear pathways to discharge and successful integration into the community, especially for women and those abandoned by families (8).

Global mental health reforms emphasise the development of community-based and primary care mental health but are silent about SMD patients in large institutions. Given the lack of feasibility of closing down psychiatric institutions in most low and middle income countries,
‘Uddan’ is a collaborative program of Tata Trusts with the Government of Maharashtra addressing institutional reform in the Nagpur Regional Mental Hospital in the state of Maharashtra in India. The program aims to demonstrate a feasible an evidence based process of reform that has implication not just across all the 43 mental hospitals of India but also for other low and middle income countries.

This participatory reform process is being modeled based on the experience of Tata Trusts partnership on institutional reform through the INCENSE program in two large hospitals of the country and the framework of QualityRights by the World Health Organization.
The mental hospital in Nagpur was started in 1884 and was originally called the lunatic asylum. Over the years several additions and alterations have been made and in 1959 the Out Patients Department (OPD) was added. (12). The hospital was subsequently named as mental hospital and further as Regional Mental Hospital.

The hospital has a capacity of 940 beds and an out patient department with a foot fall of 50,000 a year.

In its first quarter of the first year, Udaan has established itself within the hospital and formed a core reform group from within the hospital staff. Third party facility assessment using the QualityRights tool has been completed and the first 10 areas of reform have been identified with reform plans being developed and auctioned by the core group.

Works Cited
1. Government of India, Ministry of Home Affairs. Population Enumeration Data, 2011 Census; http://www.censusindia.gov.in/2011census/population_enumeration.html. 2011.
2. Training and National deficit of psychiatrists in India - A critical analysis. hirunavukarasu M, Thirunavukarasu P. Indian J Psychiatry 2010;52, Suppl S3:83-8, 2010.
3. Time for a Global Commission on Mental Health Institutions. A. Cohen, S.Chatterjee, H.Minas. s.l. : World, 2016, World Psychiatry Vol 15, N0 2, pp. 116-117.
4. The burden of mental, neurological, and substance use disorders in China and India: a systematic analysis of community representative epidemiological studies. Charlson FJ, Baxter AJ, Cheng H, Shidhaye R, Whiteford H. May 18, 2016, Lancet, Published online http://dx.doi.org/10.1016/S0140-6736(16)30590-6.
5. Evaluation of a community-based rehabilitation model for chronic schizophrenia in rural India (2003). Chatterjee S, et al:. 2003, Br J Psychiatry, 182, pp. 57-62.
6. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study. Collaborators, Global Burden of Disease Study. 2013, . Lancet, Vol:386; no:9995, pp. 743-800.
7. The treatment gap in mental health care. Kohn R, Saxena S, Levav I, Saraceno B. 2004, Bull World Health Organ; 82:, pp. 858–66.
8. NHRC. Care and Treatment in Mental Health Institutions; Some glimpses in the recent period. India : National Human Rights Comission, 2012.
9. The magnitude of and health system responses to the mental health treatment gap in adults in India and China. Patel V, Xiao S, Chen H, et al. s.l. : Lancet. Published online http://dx.doi.org/10.1016/S0140-6736(16)00160-4, May 18 2016.
10. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. . Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO study group. 2009, Lancet; 373: 408–15.
11. WHO. Mental health action plan 2013–2020. Geneva : World Health Organization, 2013.
12. Gazetteer, Nagpur District. Historical background. s.l. : http://nagpur.nic.in/gazetteer/gaz1966/final_gazettee/med1.html, Accessed from the World Wide Web on 15th Sept 2016.

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