An endless road to reintegration for mental health patients7 min read . Updated: 21 Jul 2015, 01:23 AM IST
The govt unveiled a mental health policy in 2014. But in a country where there is only one psychiatrist for every 343,000 people, that is just the starting point
New Delhi: It’s 6.30 pm. In 30 minutes, it will be dinner time for patients of Ward C, the women’s ward at the Institute of Human Behaviour and Allied Sciences (IHBAS) in Delhi. Pre-monsoon showers had brought down the heat in the national capital. So, many patients have stepped out. Some were sitting in the courtyard and some in the corridor.
A few like Shalini Mehra, however, chose to remain indoors. A slightly built woman, she will soon get busy helping the nursing staff serve dinner to other patients. “I have a hotel industry background. It is a good way to stay busy and involved," she says in a soft undertone.
Once upon a time, she used to be a news junkie, but not any longer. So, she has not heard of Partha De, the 44-year-old engineer who was found living with decomposed dead bodies of his sister and two dogs at his house in Kolkata’s Robinson Street. The sister had died in December last year and the dogs in August. If Mehra had read about it, she wouldn’t have missed the similarities with her case. Five years ago, Mehra too was found living with the four-month-old dead body of her mother in her Saket home.
Cases such as that of Mehra and De are not unique by any stretch of imagination. One such case has come to light every year for the past four-five years. In 2007, two sisters—Dolly and Poonam—were found living with the body of their sister Neeru in Kalkaji, Delhi. It was believed that Neeru died of starvation.
In 2011, Anuradha and Sonali Behl, two sisters, were found starving in their Noida home after neighbours complained of a stench from their flat. The sisters were living without any electricity or water supply. They too were starving and were suffering from acute depression and paranoia.
In 2014, a former Indian Air Force officer was found living with the one-month-old dead body of his brother in Meerut. When the police tried to remove the body, he said his brother was still sleeping.
Media coverage of the mentally ill have often been voyeuristic in nature. De’s house in Kolkata was dubbed the House of Horror. Mehra was interviewed extensively, in which she repeatedly denied that it was her mother’s body. She insisted her mother’s body had already been cremated and that the body found had been dumped there by a builder.
Comparisons to Norman Bates, Robert Bloch’s iconic creation from Psycho, are made. But all of these people are patients of mental illnesses, battling one form of schizophrenia or the other, unaware that they are ill and need help. Mehra was diagnosed with paranoid schizophrenia, while De is suspected to be suffering from psychotic depression.
“Very often, the people concerned (in such cases) suffer from mental illnesses; their decision-making ability is severely impaired," says Dr Sanjiv Jain, professor and head of the department of psychiatry at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru. To expect them to not just identify their illness but also seek treatment for it is a long shot. In cases like the ones described above, treatment is prescribed even against the patient’s consent with legal permission, said Dr Nimesh Desai, director of IHBAS.
It took the team at IHBAS nearly two years to make Mehra realize and accept that her mother was dead. Today, symptoms show that she is much better, with partial acceptance of the need for treatment. “She also has partial insight of her condition and there really is no requirement for her to be here (IHBAS) any more," said Desai.
But she still continues to be there. Last year, the institute approached a court for her rehabilitation and discharge after her ex-husband and daughter refused to take her home. A year later, after a round of discussions with her family, IHBAS is now seeking assisted community living for Mehra and protection of her economic rights. She herself wants to go back to her Saket home, but with no formal or even semiformal mechanism for reintegration of patients like her in society, the road is long and perhaps endless.
“There are five stages of treating a mentally ill person, which include their acceptance of the need for treatment. The last two steps of this process are social reintegration and living by oneself or in a group setting," says Desai. Both family and institutional support are needed to make the last two steps a reality. The institute wants Mehra to be constantly monitored if she were to live alone, with the area magistrate kept in the know.
“Once the patient accepts medical treatment, then within a matter of a week or 10 days, the situation shows signs of improvement. As the resistance reduces, there really is no need to keep the patient in the hospital," says Dr G.R. Golechha, senior consultant, psychiatry, at Kailash Hospital Noida. This is the stage where counselling and therapy can also accompany treatment. “It helps them to recover better, develop relationships, hobbies, socialize, perhaps even develop an insight into why they let happen what did happen. With a regular follow-up, even medication is tapered down, depending on the recovery," Golechha says.
During this stage, doctors, apart from assessing their progress, also keep a look out for telltale signs such as their moods, personal hygiene, daily activities and so on. “But if they follow their medication regime, then that is half the battle won," says Golechha. He was also the doctor who treated the Behl sisters and explains the particulars of that case.
“The older sister suffered from schizophrenia, went into a shell, and decided to cut off from the world. With her sister, it was a case of induced psychosis, when you develop a pattern of thinking in sync with that of the person you live with. She became the secondary person, who due to an emotional attachment with the primary person, in this case the older sister, follow whatever they say and their psychology changes."
If and when the primary source is taken away, the secondary person gradually becomes normal. Anuradha, the older of the Behl sisters, succumbed within a few days of being admitted to the hospital, but the younger sister’s tale has turned out to be a different one. Reconciled with her estranged brother, she was discharged and is now back to living in her old apartment. Golechha is loathe to share much details of the case as the patient has almost managed to get her life back on track. She was keen to return to her old job, but the constant media scrutiny was making things difficult for her.
This loss of privacy is a shared concern for both Dr Jain of NIMHANS and Ratnaboli Ray, founder of ANJALI, a Kolkata-based mental health rights organization. She is appalled at the coverage of De’s case and wants to know how he can ever hope to be reintegrated again. “Where will he go in the next three months? Who will discharge him?" Ray asks.
“Doctors cannot give him a competency or a fit-for-discharge certificate. He can’t open a bank account (in India, banks can refuse to start accounts for people with intellectual and psychological disabilities); look at the mess of his legal position; what are the mechanics to deal with any of this?" she says.
According to Ray, there is a large vacuum in our understanding of the services required to rehabilitate people like De. “You could begin by stressing on building institutions where they can be housed under supervision and with dignity, but from there to being reintegrated in society is a long way off. Access to doctors, alternate therapy, hostel facilities, community support where there is no family support, all of this has be looked at from a holistic point of view."
According to Dr Jain, India would do well to take a leaf out of the book of several European countries where there are community care programmes as well as supervised care after repeated intervals. “There is a strong network of community outreach doctors and nurses apart from counsellors who keep track of patients, drop in on them to check their progress, etc. In some countries, the government takes over the property of a mentally unsound person and then uses it to pay for the treatment of the patient. India needs to think along these lines. It is a situation that needs to be addressed on an urgent basis." says Dr Jain.
In 2014, the government unveiled a mental health policy, which included provisions for more institutions and trained professionals. It will also secure the right of a person to not be institutionalized. But in a country where there is only one psychiatrist for every 343,000 people, according to the World Health Organization, that is just the starting point. India spends only 0.6% of its total health budget on mental health. England spends nearly 11%. “There is insensitivity at the highest level towards mental illness. Any attempts to set up facilities get lost in red tape; their rights are not safeguarded," says Jain.
A sustained follow-up is the key to effective treatment of mental problems, but without any structures in place, it is very easy to slip through the cracks. And that’s why IHBAS wants Mehra’s discharge to be accompanied with safeguards. In the meantime, she waits in Ward C for the day she will leave and get to eat chicken, the thing she says she misses the most.