Mental Hospitals in India: Reforms for the future.

Mental hospitals are an integral part of mental health services in India. It is an interesting story how mental hospitals have responded to the challenges of contemporary period they were built in. It is beyond doubt that it is a progressive journey along with advances in mental health both in India and internationally. As in other countries, mental hospitals in India have responded to the social challenges, disparities, and poor resources of workforce and fiscal investment. Historically, there have been changes and three major reforms are needed, namely attempt to facilitate discharge and placing patients back into the family, introducing teaching and research in mental hospitals, and accountability to civil rights as per the requirements of the National Human Rights Commission. In this review, we explore the brief history of mental hospitals in India and examine the reforms in the clinical, administrative, and psychosocial areas of these hospitals and progress in teaching and research. We finally summarize and conclude the necessity and the relevance of mental hospitals in India akin to modern psychiatric practice. We believe that mental hospitals have an important and perhaps a central role in mental health services in India. Its modernization to address issues of long-term stay, burden on caregivers, stigma, research and teaching including undergraduate and postgraduate training, new curriculum, and training for nonpsychiatric professionals and primary care physicians are necessary components of the role of mental hospitals and responsibilities of both government and nongovernmental sectors. Last but not the least, it is obligatory for mental hospitals to ensure that evidence-based treatments are implemented and that the standard of care and respect of civil and human rights of the patients and families are provided while involving the people's participation in its functioning.

INTRODUCTION

Mental hospitals have been an integral part of psychiatric services in India over the years and for the past century. Mental hospitals stemmed in India from the era of lunatic asylums – a concept that was British and European in its conception. The whole purpose of the concept of a mental hospital was to segregate the mentally ill from the community and not treat them as normal but rather detention away from the community. Most mental hospitals in India were built in the British and pre-British eras when the emphasis was never on community-based treatments and in that era psychiatric patients were viewed as a danger and menace to the society. The present article aims to present a history of the development of mental hospitals in India and their role in mental health care, first in the past, and the manner in which they can influence and contribute to community mental health care in the present era. The article draws a plan wherein with judicious use of the infrastructure of a mental hospital, there can be an incremental rise in psychiatric services in cities where these hospitals exist and they can serve as a means to re-integrate the mentally ill rather than segregate them. The authors here propose a few ideas, some far-fetched yet attainable, while most of the suggestions in this article are highly implementable and will add to the already grim mental health infrastructure in our country.

CERTAIN HISTORICAL ASPECTS

The establishment of mental hospitals has played a significant role in the evolution of psychiatry to its present status. The prime objective of establishing mental asylums was to protect the community and not the insane and as a result, they were constructed away from cities, with high enclosures and often in military barracks from where escape was not possible. These mental asylums served as a means to isolate mentally ill persons from the society at large and provide treatments that were prevalent at that time. The whole idea of mental asylums was mainly that of British thought.[12] Mental hospitals have played a significant role in the evolution of psychiatry in our country right from the preindependence era to its present status. Postindependence, with an emphasis on health, there came in new concepts in the form of general hospital psychiatry units (GHPUs) and deinstitutionalization of the mentally ill. Along with the establishment of GHPUs, efforts started to improve the dilapidated conditions in the already existing mental hospitals.

The history of mental hospitals as they evolved is valuable in understanding the growth of psychiatry. As early as the 4th century AD, there was a witness of the establishment of institutions solely for the mentally ill in Byzantium and Jerusalem.[3] The treatment of mentally ill persons in asylums was started by the Arabs in the ancient city of Baghdad in 705 AD and then at Cairo in 800 AD.[4] The first major modern mental hospital to be established was the Bethlem hospital in London in 1247.[5] This was established primarily for isolation, treatment, and protection of mentally ill persons. During those times, urbanization was presumed to have an etiological role in mental illnesses and isolation served as curative.[6] It is noteworthy to mention that in India, there was a Chola Hospital antedating Bethlem Hospital which was treating the mentally ill along with the others. We can safely conclude, from history and epigraphy, that mentally ill in the medieval period were looked after in small hospitals, like the one at Thirumukkudal and hospitals situated mostly in the secluded parts of temples.[6]

In the 13th and 14th centuries, hospitals were established as there was the felt need to provide a human care for the mentally ill, but with time, the impact somehow was found to be missing and the outcome came up in the form of poor patient care. The conditions further prompted Pinel to liberate patients from these hospitals and propagate his moral treatment’ in the form of open wards, regular exercise, and a human approach.[7] Dorothea Dix in the 19th century again established hospitals for proper care of the large number of mentally ill. But, the condition in these hospitals too deteriorated, thus giving way to deinstitutionalization and community care.[8] During the same time, quite a number of professionals in the US and Europe have raised doubts about the efficiency of the community in taking care of mentally ill as well as concern has also been raised about the plight of deinstitutionalized and homeless mentally ill in many countries.[9] In India, mental hospital (or asylums) was entirely a British concept except for some ancient collections of curious humanity such as that of Shahdaula's Chauhas at Gujarat and in Punjab.[10] The earliest record of institutions for the care of mentally ill in India can be traced back to the reign of Md. Khilji in the 15th century. There existed at that time, such an institution at Dhar, near Mandu in Madhya Pradesh.[11] Even before this period, mentally ill persons have been described as being cared for in various temples and religious institutions in South India.[12]

The early development of mental hospitals in India reflected the needs and demands of European patients in India during the period. But later, the development and growth of mental institutions reflected both the interest and neglect by the colonialists who ruled India over 200 years. So also, the early mental institutions in India were greatly influenced by the ideas and concepts that were prevalent in England and Europe during those days.

PREINDEPENDENCE ERA AND MENTAL HOSPITALS

Sharma has described five phases in the development of mental hospitals in India in his book on mental hospitals.[13] Some evidence suggest that Portuguese first introduced modern medicine and hospitals to India during the 17th century in Goa. The history of modern psychiatry in the Indian subcontinent starts with the establishment of mental hospital by the British East India Company in 1600. They were constructed exclusively for the European patients in India.[14] These five phases were greatly influenced by the prevailing geopolitical situations at the time. The first phase extended from the last 18th century to the mid-19th century. The first asylum was established in Bombay in 1745 and the second at Calcutta in 1784, which were exclusively for Europeans. A surgeon named Dr. George M. Kenderline established the hospital in Calcutta, which was initially not recognized by the Medical Board as he was earlier dismissed due to negligence in service in 1777.[15] In 1774, Warren Hastings was appointed the Governor of Bengal by the Board of Directors of the East India Company with Calcutta as his headquarters. With this, the activities of the Government of the East India Company came under the direction of the “Board of Control,” following which systematic reforms and welfare measures were undertaken.[16]

In 1787, Dr. William Dick, a surgeon, established a private hospital, which was recognized and rented to East India Company. After his retirement in 1818, the hospital gradually deteriorated and was closed in 1821. At that juncture, in 1817, surgeon Beardsmore, the headkeeper of the hospital, had opened a private hospital at Bhowanipore, Calcutta. This hospital housed around 50–60 European patients with clean surroundings and a garden.[17] During this period, patients were treated with opium and morphia, were given hot bath, and sometimes leeches were applied to suck blood. It was believed that blisters were useful for controlling excited patients.[18] In 1794, Surgeon Valentine Connolly, who was the first superintendent and proprietor of the hospital, established the first hospital in South India at Kilpauk, Madras, for twenty patients. Later in 1799, the government took it on lease and Surgeon Morris Fitzgerald was appointed as medical superintendent. In 1807, surgeon James Dalton took in charge and expanded the hospital for 54 inpatients.[19] In 1795, another lunatic asylum in Monghyr, Bihar, about 400–500 miles north of Calcutta, was established by the British rulers, the remnant is still there at Shyamal Das Chakravarty Road and is known as “Pagal Ghar” building.[20]

Though the earliest mental hospital in India was started at Bombay in 1745, it is said that the beginning was made to construct a small lunatic asylum there. During the same period in 1855 in Dacca, which is now part of Bangladesh, another lunatic asylum was opened in Murli Bazar.[21] In the state of Bihar which was under the influence of the Englishmen, two hospitals were opened, one at Monghyr started in 1795 for insane soldiers and later in 1821 another lunatic asylum was opened at Patna.[22] The second phase in the development of mental hospitals extended from the mid-19th century to the late 19th century. After Lord Cornwallis rule (1786-1793) and until 1857, there was no further growth of any lunatic asylum in other parts of India except in the major cities of Calcutta, Bombay, and Madras. Later, suppression of the 1857 Revolution brought out some interesting changes and the power of the East India Company was directly taken over by the Crown in 1858. This period was significant for the enactment of the first Lunacy Act (also called act no. 36) in the year 1858.[23] This act gave guidelines for establishment of asylums as well as admission procedures. During this period, new asylums were built at Patna, Dacca, Calcutta, Berhampur, Cuttack, Waltair, Trichinapally, Colaba, Poona, Dharwar, Ahmedabad, Ratnagiri, Hyderabad (Sind), Jabalpur, Banaras, Agra, Bareilly, and Lahore. Colaba was mainly meant for Europeans with over 285 beds and Ahmedabad had 180 beds by 1872. The year 1874 is also important in Indian history as Assam was separated from Bengal and by 1876 a new asylum was opened at Tezpur. The similar expansion was also visible in Central Provinces where asylums were established in 1866 at Jabalpur and in 1866 at Elichpur in Brar. The hospitals at Jabalpur and Brar were constructed in 1912 and 1924, respectively. A hospital in Benaras was started in 1854, and at Agra in 1858 and later at Bareilly in 1862.[24] Despite establishing so many asylums, the number of lunatics admitted to these institutions was huge and increased further in the following years. Consequently, there was deterioration in the public health and hygiene of the hospital. By the end of the second phase, most of these buildings were in a bad state, in constant need of repair and renovation.[24]

This deterioration in the state of mental hospitals was a cause of great concern both in India and abroad. This heralded the third phase of development of mental hospitals lasting the first quarter of the 20th century. All asylums that were hitherto under the charge of the inspector general of Police were put under the charge of civil surgeons. The second change was in the recognition of specialists in psychiatry to be appointed full-time officers in these hospitals and the third significant addition was the intent of Government to have a central supervision of all lunatic asylums which was contemplated in 1906 and was brought out in the form of India Lunacy Act 1912. Furthermore, specialists in psychiatry were appointed to these hospitals. The year 1912 is significant as the capital of India was shifted from Calcutta to Delhi.[25]

Under a new legislation (Indian Lunacy Act, 1912) a central lunatic asylum was established in Berhampur for European patients, which was later closed after the establishment of Central European Hospital at Ranchi in 1918. The year 1918 saw the establishment of a Central European Hospital (now called the Central Institute of Psychiatry) at Ranchi by Col. Berkeley Hill for European mentally ill patients. It was the effort of Berkeley Hill that not only raised the standard of treatment and care in the mental hospital at Ranchi but it was his persuasion with the Government that the names of all mental asylums in India were changed to mental hospitals in 1920. The fourth phase extended from 1920 till the time of independence in 1947. During this period, efforts were made to raise the standard of treatment and care in mental hospitals. In addition, “asylums” were renamed as “mental hospitals” in 1920. The importance of occupational therapy and rehabilitation was stressed.[6] The “Bhore committee,” which was set up in 1946, surveyed mental hospitals and made appropriate suggestions for the future. At that time, there were at least 19 mental hospitals with a bed strength of 10,181. The Health Survey and Development Committee report submitted by Col. Moore Taylor in 1946 reported a numerical and professional inadequacy and suggested a focus on training of personnel and students in psychiatry, promotion of occupational and diversionary therapies, and separate child psychiatry units. Further, the report recommended that the “walls of ignorance, superstition, and suspicion be torn down so as to establish a friendly relationship with the community.” The committee suggested improvisation and modernization of most hospitals, attachment to medical colleges, and establishment of proper mental health.[26] The largest hospital in the Indian subcontinent at that time was in Lahore with 1408 patients followed by Ranchi (Indian) with 1380 and Poona with 1227 patients.[27]

POSTINDEPENDENCE DEVELOPMENT OF MENTAL HOSPITALS

The final phase of development of mental hospitals came after India's independence in 1947. In view of the poor conditions prevailing in most mental hospitals, along with inadequate resources, and a trend toward deinstitutionalization in the international arena, the Government of India has focused on the creation of general hospital psychiatric units rather than building more mental hospitals. The first two decades of independent India were devoted to doubling the number of mental hospital beds and humanizing the services at hospitals.[28] And during the last few decades, very few new mental hospitals notably at Delhi, Jaipur, Kottayam, and one in Bengal were added with greater emphasis on improving the existing hospitals. There has also been an emphasis on improving conditions in the existing hospitals while at the same time encouraging outpatient care through general hospital psychiatry units.[29]

Since independence, the numbers of mental hospitals in India have increased from 31 to 45.[29] The number of patients treated in these institutions has increased manifold as compared to before independence. Of late, there has been a surge of interest in community-based programs for managing mental illness on part of the Government of India. While hospital psychiatry units and community-based mental health initiatives are effective in identification and treatment of most minor and less severe forms of illnesses, there still exist a large number of patients who require long-term inpatient care (sometimes in restrained settings) in mental hospitals. These patients are mostly those with more severe forms of illness, poor social supports, and significant family and societal burden.[30]

Apart from the emergence of the mental hospital movement, there were other two major forces which influenced the evolution of psychiatry. The first was the development of specific drugs such as chlorpromazine for the treatment of mental illnesses–thus providing a ray of hope for their cure and the second was the rise of the antipsychiatry movement. These movements along with the economic recession prevailing at the time were motivating factors for deinstitutionalization of mentally ill persons and the evolution of the community psychiatry concept.[31] Attempts have been made to survey the functioning of mental hospitals by organizing a series of conferences/workshops of superintendents of mental hospitals. These were held in Agra (1960), Ranchi (1986), Bangalore (1988), Delhi (1995), and Bangalore (1999). The existing state of mental hospitals was reviewed in each of these conferences, and recommendations were proposed toward their improvement. The first conference in Agra highlighted the poor standards in most existing hospitals and suggested remodeling/modernization of buildings, improvement of treatment facilities, provision of adequate staff, development of psychiatric wards in all general hospitals, and a revised system of maintenance of hospital records.[32] The Ranchi workshop highlighted the large size, wide catchment areas, and paucity of funds and staff as contributing to mental hospitals functioning as “mere” custodial settings. Therefore, it recommended that the bed strength of the existing hospitals be restricted to 400, psychiatric training units (25–50 beds) be established at district level, no new mental hospitals be opened (unless minimum standards are met), and the roles of mental hospitals, psychiatrists, and other staff be redefined in keeping with the objectives of the National Mental Health Program.[33] It also recommended that daily outpatient services and 24 h emergency services, and special services for children and the elderly be established in addition to the provision of adequate and modern diagnostic facilities, establishment of detoxification centers, and community-based treatment programs to supplement occupational and rehabilitation services. Regarding the staffing pattern, the workshop suggested that there should be 8 psychiatrists, 20 medical officers/junior residents, 2 occupational therapists, 1 clinical psychologist, 2 psychiatric social workers, and 35 nurses for every 100 patients in addition to 20 attendants, 10 clerks, 8 records personnel, 1 dietician, 10 security staff, 3 drivers, and 5 pharmacists.[34]

The Bangalore conference in 1988 concluded that mental hospitals should function as active therapeutic centers providing mental health services and should become centers for community mental health services. Furthermore, service manuals, job descriptions, and periodic orientation courses were suggested so as to enhance the knowledge, skills, and the “right” attitude to mental health problems was also recommended.[35] The Delhi conference in 1995 also made similar recommendations as the previous ones and suggested the use of mental health-related nomenclature so as to reduce stigma.[36] The most recent of this series of conferences/workshops was held at NIMHANS, Bangalore, in 1999. Recommendations were drafted to ensure minimum standards of care in mental hospitals and are summarized and circulated at the National Workshop for Medical Superintendents for assuring minimum standards of care in mental hospitals held at NIMHANS, Bangalore, in 1999.[37]

There were about 10,000 beds in mental hospitals for a population of 400 millions at the time of India's independence. Over the last 50 years, the population has increased by nearly two and half times, while the number of beds had increased to only about 21,000. Thus, the psychiatric bed ratio has remained more or less constant at 1 bed for 5000 population. The prevalence of severe mental morbidity in India ranges from 3 to 10 per 1000, which is more than five times the bed strength available.[38]

ROLE OF MENTAL HOSPITALS IN INDIA

Mental hospitals in India are tertiary centers which specialize in the treatment of mental disorders. These hospitals may vary in their size and grading. Some of them specialize in short-term or outpatient treatment for low-risk patients while others specialize in the temporary treatment in the inpatient care for those who as a result of the disorder require routine assistance, treatment, or a specialized and controlled environment. The services which are being provided include indoor, outdoor, and rehabilitation services and psychological and psychosocial interventions along with liaison services as and when required.[39] The interventions mainly streamline at the various levels–individual, family, and the community at large. To each and every merit, there also lies a demerit in the form of institutionalization and its impact that falls on the individual. Looking back into history makes the things more clear, though previously when this concept of institutionalization came into being, it was in view of protecting the community from the pangs of the mentally ill, but as time passed by, there was more and more emergence in the concept and it also began to be looked at holistically with the inclusion of family members as well as the community at large into the frame in the treatment of the patients.[40] With the emergence of the outpatient care units, individuals opted as there was not much of distress associated in treatment in the way that they no longer had to stay away from their homes and relatives. Patients respond best to treatment when they understand and cooperate with it and trust the staff. At the same time, rehabilitation can be achieved best when the patient's interest in family, employment, and the community is sustained while undergoing treatment.[41]

Aftercare services are aimed to assist in the re-socialization of patients. One specialized aftercare facility is the halfway home which provides living arrangements and opportunities for re-establishing work, family, and social relationships on a gradual basis. Apart from these facilities, there is also the provision of certification that can be obtained from these centers.[42] The role of the psychiatrist in providing medicolegal opinion on the patient's behalf can be as important as a diagnostic decision or treatment recommendation. Certification may be required for many administrative purposes in which medical officers issue medical certificates stating the health of the patients. Occasionally, such certificates may be demanded in a court of law in relation to civil or criminal matters. Certificates that are issued by a psychiatrist assume more importance as it is from a government hospital/center. When they are declared of unsound mind, they are deprived of many of their civil rights. Nevertheless, there are special benefits for these persons given by the law in the recent years, for example, job reservation, loans for self-employment, travel concession, and for availing various schemes such as Uddyam Prabha, Gyan Prabha and Niramaya of National Trust which a disabled person can avail on production of these certificates.[43]

Certification in psychiatric practice is required in the following areas: involuntary hospitalization, employment, treatment certificate, and disability certificates. Then comes the issue of involuntary hospitalization, such situations often arise when patient becomes violent and threatens to harm to self or others because of mental illness. It is then that the patient may require involuntary commitment. Moreover, the admission of wandering mentally ill patients was also looked after.[44]

ISSUES WITH REGARD TO DETERIORATION IN SERVICES IN MENTAL HOSPITALS

When we look back at the Bhore Committee report of 1946, there was a clear mention of the lack of funds in the hospitals because of which steady functioning was not that possible. Moreover, there was a deficiency in the number of staff which could not cater to the number of patients who visited to the hospitals for treatment. Apart from this, there was stigma related to hospitalization in the form of terms for mental hospitals such as “asylum” and “pagal khana” during those times. By the mid-1960s, many people were concerned about the rising magnitude of drug abuse in India. Several research reports published in this period suggested the abuse of drugs by students, the general public, and clinical subjects.[45] Alarmed by this increased use, in 1977, the Ministry of Health and Family Welfare, Government of India, appointed an expert committee. The Committee had experts from various disciplines/organizations, namely the University, Excise and Customs Department, the Narcotics Commissioner, the Drugs Controller of India, the Indian Council of Medical Research, and the Ministry of Social Justice and Empowerment (earlier Social Welfare). This was one of the first major national efforts to assess the contemporary drug scene. The Committee reviewed the available literature extensively and concluded that though a large number of students were abstainers, there were sufficient numbers of college students as well as the general population who were habitual drug abusers. Abuse of alcohol and cannabis was most often reported among both these groups.[46] In addition, the abuse of other drugs such as amphetamines, pethidine, barbiturates, and tranquillizers by some was also reported. The Committee noted that (special) facilities to treat drug-dependent individuals were very few at that time and most were being treated in the psychiatric hospital or psychiatric department of some medical colleges. The Committee suggested several means to control drug abuse. Heroin abuse was reported from treatment centers in 1981 for the first time, and during subsequent years, it was perceived by many experts that drug abuse, including the abuse of heroin, was on the rise.[47] In 1985, the Narcotic Drugs and Psychotropic Substances Act was enacted and it provides the current framework for drug abuse control in India. On the basis of recommendations made by the expert committee in 1986 and the cabinet subcommittee in 1988, de-addiction centers in five central government institutes and two regional centers in two state capitals (Kolkata and Mumbai) were established. These seven centers initiated several activities toward the treatment of patients. In addition to the effort by the Ministry of Health, the Ministry of Social Justice and Empowerment (henceforth the Ministry of Social Justice) also became active. While the Ministry of Health carried out its functions through government organizations, the Ministry of Social Justice funded non-governmental organizations.[47]

During this period, more focus was put forth to the rising addiction, and as a result, there was not much of importance which was given to the already existing facilities. The year 2001 marks a horrific incidence which took place at Erwadi in which 26 persons with mental illness died in a tragic fire accident. During this time after the tragedy, The National Human Rights Commission called for a Report as well as the Supreme Court initiated action on the matter. As a result, many changes not only in Erwadi but also in the different parts of the country started taking shape, which proved to be a yardstick which revamped mental health services in the country.[48]

GOVERNMENT REVIEW OF MENTAL HOSPITALS AND THEIR SERVICES

The Supreme Court, shocked by the conditions and considering them a gross violation of the fundamental rights guaranteed under Article 21 of the Constitution of India, asked the National Human Rights Commission (NHRC) to survey all the 37 government mental hospitals (combined bed strength of 18,918) in the country. The conclusions of the well-documented NHRC Report of 1996 were echoed in just one sentence: “It was as if time had stood still.”[49]

Two reviews of mental hospitals were undertaken in 1998 and 2008 to identify the lacunae in these institutions and the changes that occurred over a decade. These evaluations illustrate the challenges these institutions present to mental health care. The situation of mental hospitals at the time of the first review was highly unsatisfactory – “38% of the hospitals still retain the jail-like structure that they had at the time of inception, nine of the hospitals constructed before 1900 have a custodial type of architecture, compared to 4 built during pre- and one post-independence, 57% have high walls, patients are referred to as ‘inmates’ and persons in whose care the patients remain through most of the day are referred to as ‘warders’ and their supervisors as ‘overseers’ and the different wards are referred to as ‘enclosures’.” Overcrowding in large hospitals was evident with the overall ratio of beds: patients being 1:1.4, indicating that floor beds are a common occurrence in many mental hospitals as seen in India. Patients are expected to urinate and defecate into an open drain. In public view, many hospitals have problems with running water. Storage facilities are also poor in 70% of hospitals, lighting is inadequate in 38% of the hospitals, 89% had closed wards while 51% had exclusively closed wards, and 43% had cells for isolation of patients. Leaking roofs, overflowing toilets, eroded floors, broken doors, and windows are common sights; privacy for patients was present in less than half of the hospitals, seclusion rooms were present in 76% of hospitals and used in majority of these hospitals, and only 14% of the staff felt that their hospitals’ inpatient facility was adequate. In most hospitals, case file recording was extremely inadequate, less than half of the hospitals have clinical psychologists and psychiatric social workers. Trained psychiatric nurses were present in <25% of the hospitals. Even routine blood and urine tests were not available in more than 20% of hospitals. Nearly 81% of the hospital in-charge reported that their staff position was inadequate. The report notes that “the deficiencies in the areas described so far are enough indicators that the rights of the mentally ill are grossly violated in mental hospitals.”[5051]

MENTAL HOSPITALS AND THEIR ROLE IN THE FUTURE

For the proper functioning of mental hospitals, it is mandatory that all the physical and clinical requirements for work be met. The current trends to show us that almost half of the patients continue to vegetate in a dehumanized manner within the hospital as relatives often do not want to take patients home. There are many long-stay patients who are being abandoned by their families in the mental hospitals. Mental hospitals serve as dumping ground which is convenient for relatives of unwanted mentally ill patients. There is also an uneven distribution of the available psychiatric services. Vast sections of the population and large geographical areas in many states lack even rudimentary mental health care. There is a need for rebuilding and revamping the existing infrastructure in these hospitals. The mental hospital of the past needs to be converted to a state-of-the-art tertiary psychiatry center with various subspecialty psychiatry clinics being available for the use of the common man.[52]

There is also a need for the term “mental hospital” being done away with and being replaced by words like “Institute of Mental Health.” The present form of treatment in most mental hospitals is basically custodial rather than therapeutic. There is a need to develop and cultivate outpatient services with the availability of counseling, psychotherapy, child guidance, and psycho-educational services. These mental hospitals with huge inpatient bed facilities can be converted into state-of-the-art tertiary centers for psychiatric care, and postgraduate training must be strived for in these centers. Presently, any form of postgraduate teaching is grossly inadequate or even absent in most mental hospitals. There is a need to develop psychology and social work training at these centers as well. The wealth of clinical experience available in our mental hospitals is not available in any other tertiary general hospital.[53]

While deinstitutionalization is an important part of mental health-care reform, it is not synonymous with de-hospitalization. Deinstitutionalization needs complex process of alternate network of community care. Closing down mental hospitals without community alternatives is as dangerous as creating community alternatives without closing mental hospitals. The community alternative model needs to be integrated within the infrastructure of the mental hospital. There is a need for mental hospitals to be re-integrated within an inclusion model rather than in an exclusion model as exists. A sound deinstitutionalization process has three essential components, namely (1) Prevention of inappropriate mental hospital admissions through the provision of community facilities, (2) discharge to the community of long-term institutional patients who have received adequate preparation, and (3) establishment of maintenance of community support system for noninstitutionalized patients.[54]

In community mental health care, empowerment of people with mental and behavioral disorders is to be sought for. It in turn will develop a wide range of services in local settings. The same protective function of the mental hospitals can be provided in the community itself in limited way. Service close to home including general hospital care for acute admission and long-term residential facilities in the community should also be built. There should be intervention related to disabilities as well as symptoms. Moreover, treatment and care specific to the diagnosis and needs of each individual should be there. Service which can be coordinated between mental health professionals and community agencies would prove to be important. Partnership with caregivers and meeting of needs with better legislation to support the above aspect of care is paramount.[55] There is a need for an optima mix of mental health services that need to coexist in order to serve the community [Figure 1].[56]

Figure 1

Pictures of certain old mental hospitals in India. (a) Government Mental Health Centre – Kozhikode (Estd: 1872). (b) Regional Mental Hospital – Thane, Maharashtra (Estd: 1901). (c) Reports on mental hospitals dated 1904 and 1938

There is also a need for mental hospitals to develop into long-term rehabilitation centers with large number of beds that shall cater to the needs of long-stay patients. There are very few committed and affordable centers in that area and this step shall go a long way in enhancing mental health of patients that are often not looked after by their caregivers and relatives. Mental hospitals can also be probably turned into training hubs for general physicians and family physicians where they are taught the early detection and referral of patients to psychiatrists. This shall help in patients seeking treatment early and preventing chronic mental illness while also serving to reduce stigma and clear some of the myths of mental illness in India.

CONCLUSIONS

While it is encouraging that psychiatry has come back to the fold of medicine, we must remember that more than any other specialty, psychiatry looks at the totality of a human being. No other specialty of medicine has such a special understanding of human distress as psychiatry has. This understanding of human suffering, both medically and psycho-socially, is our special double heritage and we must not give up one for the sake of the other. Mental health services must become more relevant for Indian cultural needs. Medicine and psychiatry do not develop in a vacuum, but they develop in a historical social context. Modern science, medicine, and psychiatry have all developed during the last few centuries, in a European setting. In the case of psychiatry, the influence of European philosophy is particularly striking. Various psychiatric terms, systems of diagnosis and classifications, and approaches to management are all based on European philosophical thoughts. This is not a very comfortable situation for a country like India, with its own rich philosophical heritage. Perhaps, no other civilization has considered understanding the functions of the human mind, psychopathology, and the management of various mental disorders, the way we have in India. Yet, we continue to blindly follow alien concepts and methods, even though these are often inappropriate in our sociocultural context. We need to deliberate on these issues and evolve as a truly indigenous approach to mental health. Operational strategies derived from such an approach will accord more closely with ground realties, particularly in respect of psychosocial therapeutic interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

The history of formal care for the mentally ill was linked to religious observance (at temples, mosques, and churches and poorhouses) for most of the human histories. The scientific renaissance, and the growth of “scientific medicine over the last 500 years, and its spread through colonialism and globalization had an obvious impact on psychiatry. Asylums proliferated in Europe in the 17th–19th century, as the riches from industrialism and colonial reach, were converted into social welfare, entwined as they were with notions of ‘progress’ and idealism. Roy Porter has described in great detail in “Mind Forg’d Manacles,” the asylums in the UK at least were built with a strong sense of reform and welfare, as were ostensibly those in the USA (where they were being built at exactly the same time as in India). In the Indian context, under colonial rule, the mental hospitals were seldom built with civic involvement, viewed as a burden by all governments, and professional involvement was sparse. However, asylums for the insane, which started with high intentions, usually ended in horror and neglect, mainly because, as Kay Jamison points out, “society's ideals deteriorate more rapidly than the structures built to facilitate them.” As the authors point out, with the advent of pharmacological treatments, treatment shifted to outpatient and community-based care, as discussed at various forums in the country. In countries that had a well-established public health-care system and civic engagement (like Europe and North America), services that covered the entire spectrum from institution-based care to community care could be discussed and planned. In India, with a paltry number of beds in institutions, and nonexistent public health, it is imperative, as the authors suggest, that both be strengthened, so that the entire range of services, by embedding the mental hospital within the community, are developed. As with other articles in this series, what does become clear is the need to critically examine what went before, to illuminate the way ahead.