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Mental Health For All

Ms. Snigdha Samantray

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The 10th of October is observed as the World Mental Health Day to raise awareness about mental health issues across the world and to mobilize efforts to support mental health. This year’s theme is “Mental Health in an Unequal World.” This article will talk about the existing legislation to ensure equality and the current barriers to equality.

Inequality due to race and ethnicity, sexual orientation and gender identity have always been a matter of social concern and a part of social stigma. Mental health problems are no exceptions as well. Discrimination based on mental health conditions & inequality in access to mental health services can happen to anyone, across any age and any location. The 2020 Pandemic has been the biggest example of this.

Although inequality pertaining to mental health existed even before the pandemic, it brought it to limelight. It highlighted how polarized access to mental health made the economically sound and technologically privileged access the services easily, while the underprivileged and technologically deprived remained ignorant & isolated.

Mental health is also affected by inequalities in other parameters like food insecurity, inadequate housing, unemployment, occupational health, inadequate mental health services, and conflict. These social and economic factors also contribute to widening inequalities, and negatively affect the poorer and more marginalised sections of society to a large degree.

Why does this matter?

Inequalities increase the likelihood of people having mental health disorders, affect the quality of care they receive, worsen existing mental health conditions, and makes recovery harder. It is important that we talk about these inequalities & discriminations as they not only affect the mental health of an individual but also affect their educational opportunities, job prospects, potential earning and overall well being.

Existing Legislations To Ensure Equality

In India, the 2017 Mental Health Care Act was passed on 7th April 2017 and came into effect on 29th May 2018. The Act aims to provide mental healthcare services for persons with mental disorders. It ensures that these persons have a right to live life with dignity and by not being discriminated against or harassed. The important clauses of the Act include:

Right to access mental health care (MHCA, 2017 Sec18)
a) Right to access in-patient & outpatient services, free essential psychotropic medication & rehabilitation services.
b) There should be awareness regarding these services, they should be affordable, acceptable, adequate & appropriate in quality.

Right to equality & non-discrimination (MHCA, 2017 Sec 21)
a) Every person with mental health disorder shall be treated as equal to persons with physical disorders
b) Persons with mental health disorder shall be entitled to the use of ambulance services in the same manner, extent and quality as provided to persons with physical disorders.
c) Emergency facilities & services for mental health disorders shall be of the same quality & availability as those provided to persons with physical disorders
d) Every insurer shall make provision for medical insurance for treatment of mental health disorders on the same basis as for physical disorders. They cannot have an exclusion clause stating non-incorporation of mental health disorders.
e) A woman with mental health disorder receiving care, treatment or rehabilitation at a mental health establishment shall not be separated from her child if the child is below 3 years. If separation is needed on grounds of safety of the child, then the consulting psychiatrist needs to certify that and in every 15 days he has to decide whether she continues to be a threat to the child. Even in that period of separation the mother should have access to her child under supervision.

Right to legal aid (MHCA, 2017 Sec 27)
This clause states that a person with mental health disorder shall be entitled to receive free legal services to exercise their entitled rights.

As mentioned, there are existing barriers that affect those diagnosed with mental health disorders. These barriers to equality is a big challenge when it comes to executing proper and discrimination free care to those that need it. Here are six barriers that should be understood so they can not only be eliminated but bring awareness to the issue.

(1) Unequal implementation of legislation
Despite the legislations and clauses in place, individuals with mental health conditions have often reported experiencing severe human rights violations, discrimination, and stigma. This is due to unequal implementation of legislation as there are no strict judicial actions taken against people violating them. A lot of people are either not aware about these rights or even if they are, they tend not to report them due to various reasons. Certain legislations also are not aligned with the principles of mental health. For example, in 2007 it was estimated by WHO that 4.4 percent of the global burden of disease was related to alcohol consumption. Despite this data, attempts to legislate against trade of substances harmful to mental health have been continuously questioned in the name of fair trade.

(2) Unequal distribution of resources
Mental health has been strongly correlated with the ability to provide the basics of life for oneself and one’s family. As the rich become richer & poor become poorer, the gap between haves & have nots never seems to bridge. The 2010 Human Development Report (II) estimates that the basic needs of 1.75 billion people in 104 countries are not met. How can mental health be assured when basic needs are not met?

The Global Health Watch (II) has reported on the substantial increase in suicides among small scale Indian farmers struggling to survive in a situation of unfair competition, rising prices, erratic weather, and heavy debt. How can mental health be assured when survival itself becomes a challenge?

Inequality is not just related to distribution of material resources but also to the value that people assign them. The predominant global economic system is built on the need for constant growth and profit, and hence is dependent on a high value being put on material possessions. The one who possesses most is the strongest & privileged.

When individuals live together in groups which are relatively unequal, it appears that their mental health can be affected due to the unequal standing in the wider society. The people belonging to a high proportion of ethnic or racial groups have better mental and physical health than those who live in areas where there are fewer people of their own ethnic or racial group, even if they are materially well off.

(3) Low awareness
Traditional healers have been the mainstay of mental health care in many low-income countries, but very few of those with mental health problems have awareness regarding mental health disorders and access to institutional mental health services.

According to a WHO report in the year 2010, it was estimated that 75–85 percent of people with mental health problems in developing countries do not receive institutional mental health treatment. It has been estimated that in India approximately 150 million people need therapy for their mental health disorders however less than 30 million people seek help.

Many mental health conditions can be effectively treated at relatively low cost. Yet the gap between people needing care and those with access to care remains substantial. This can be attributed to low awareness regarding the availability of these services.

(4) Global Inequalities in employment
Several studies have implicated that financial insecurity, low income, precarious employment opportunities such as no fixed term contracts, temporary contracts, and part-time employment are associated with poor mental health outcomes such as stress & work insecurity.

Global economic inequalities drive people to leave their homes in search of employment. According to a United Nations report from the department of economic and social affairs, there has been a steady increase in international migration over the last ten years, involving over 200 million people. These migrants ignore the human cost and the risk to mental health involved in leaving their homes, families and living in an unfamiliar, uncertain and hostile environment. Stress and depression can be caused by separation from family, difficult living conditions, dangerous working conditions, and an unwelcoming environment.

(5) Inequalities in mental health care
There is a huge global inequality when it comes to access to mental health care services. According to the World Federation for Mental Health between 75-95 percent of people with mental disorders in low- and middle-income countries are unable to access mental health services at all, and access in high income countries is not much better either.

Lack of investment in mental health and a disproportionate health budget contributes to the mental health treatment gap. According to the reports from the Indian Union Ministry of Health and Family Welfare there is a shortage of mental health professionals as per the population of the country. According to National Crime Records Bureau 2015, the entire mental health workforce currently stands at 7,000 whereas the actual requirement is around 55,000 mental health professionals.

Many Indian mental health professionals move abroad for better opportunities and working conditions. The number of seats available for professional courses in mental health is less and also the speciality of mental health is often overlooked. Additionally, the pay scale for mental health professionals in India is not adequately revised, hence it makes it hard for them to match up to other medical specialties, in terms of both income and acknowledgement.

Release of inadequate funds for mental health research, difficult working conditions for Indian mental health researchers, inadequate pay revision & irregular stipend are some of the major causes of researchers either opting to work abroad or choosing not to get into research in India.

(6) Role of media
The media may act as the primary source of information about mental health disorders and hence has the power to shape the perceptions and attitudes about mental health conditions among the general public. According to a study conducted at Rutgers University, media has played a role in contributing to the stigma associated with mental health problems by exaggerated, inaccurate, and comical depictions of persons with psychiatric disorders as well as providing incorrect information about mental health disorders.

Access to Equality: how do we bridge the gap

Effective measures to address mental health problems need to take place at all levels, local & global, and involve all members of society including health and mental health professionals. The following amends may help bridge the gap bought by inequality and neutralise mental health disorders.

Uniform implementation of mental health legislations & policies must be ensured. There must be surprise audits to check the uniformity in implementation of policies and judiciary action taken upon failing to adhere to these policies.
The global economic model needs to be reconsidered and revisited. Steps need to be taken to decentralise economic resources and ensure fair economic distribution which is not skewed.
Promising work opportunities, adequate pay and allowances must be facilitated for mental health professionals. More lucrative allowances must be provided especially for mental health professionals working in remote & high-risk areas. Community-level action and the integration of mental health treatment into non-specialist health care are key steps for ensuring better mental health outcomes.
Adequate funds must be released for quality mental health research and smooth release of funds must be ensured to retain good quality researchers in India.
The media needs to operate more responsibly, understanding their power of influence and portray mental health topics sensitively and rightfully using the help and advice of mental health professionals.
Any form of awareness begins in the family. Families, teachers, employees and in general, societies need to talk about mental health. In the same breath, individuals need to be educated on mental health and its conditions which will make them more confident in not only understanding them, but comprehending how to get help when needed.
Before we try to change our environment and other people, we need to assign equal status to mental health as that of physical health in our own heads first. Acknowledging our own mental health helps us acknowledge the mental health of another.

If problems related to mental health don’t discriminate between people, caste, creed, race, religion, domicile or geographic location, and if we agree they can happen to anyone, then why should access to mental health services not be for everyone. Mental health and inequality are interrelated. Mental health is not only affected by inequalities, but inequalities are also further deepened and exacerbated by mental health disorders. We all have a role to play in addressing the above disparities, spreading awareness and ensuring that people with mental health disorders are fully integrated into the mainstream in all aspects of life.

If you or a loved one needs help or are suffering in silence, you need to know that your story is valid. Please reach out to a mental health specialist who can guide you through your healing. Your mental health should be as much of a priority regardless the stigma attached to it. This World Mental Health Day, be kind to yourself and those around you.

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Written by

Ms. Snigdha Samantray

Ms Snigdha Samantray is a Certified Clinical Psychologist and Digital Mental Health Specialist, currently working as a Program Manager and Clinical Psychologist at MFine. She played a key role in the establishment of the Psychotherapy specialty at MFine.

Mental Health For All

Why does this matter?

Existing Legislations To Ensure Equality

Access to Equality: how do we bridge the gap

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