Mental health issue is a major global concern, accounting for 13 percent of the world's disease burden and causing 37 percent of lost healthy years. Unfortunately, individuals with mental illness in low and middle-income countries often face barriers to accessing necessary care and societal acceptance, even though effective treatments are available.
As a result, many of them end up spending extended periods in psychiatric facilities and rehabilitation homes, with 18 percent globally enduring stays of a year or more. In India, a concerning 32 percent of mental hospital beds are occupied by long-term patients, surpassing global and regional averages.
Long-term patients are individuals with mental health conditions who have stayed in psychiatric facilities far longer than necessary. They may have initially entered these facilities for acute care but remain institutionalised due to factors like social stigma, lack of support, fear of rejection, limited resources for ongoing care, and the absence of reintegration programs.
Deinstitutionalisation
Deinstitutionalisation in mental health means shifting from long-term, centralised care to community-based empowerment, aiming to eliminate stigmas associated with mental health. This approach promotes inclusivity, support, and full reintegration into society by prioritising community-based services. Deinstitutionalisation seeks to restore dignity, autonomy, and a sense of belonging for those dealing with mental health challenges.
Why is a shift required?
Traditional psychiatric facilities, reminiscent of historical asylums, often fail to provide rights-based and quality care. These settings can perpetuate separation and exclusion, inadvertently intensifying stigma and isolating individuals with mental illness. Living conditions marked by cramped spaces and limited privacy create discomfort and a sense of confinement. Most concerning is the disconnection from the broader community, hindering social development and skill-building.
While there have been some efforts towards deinstitutionalisation in India over the last decade, they remain limited in scope, primarily driven by individuals, and fall short of comprehensive community-based support.
Recognising these substantial shortcomings underscores the urgent need for a shift towards community-centred, person-centric care for long-term holistic and inclusive care.
However, this shift must still acknowledge that in addition to working towards deinstitutionalisation of long-term stay patients, there still remains a pressing need to bolster mental health institutions. It is simply that mental health institutions should be a temporary waystation to stabilise patients in their long-term journey towards a healthy life, rather than a permanent and final ‘stop’ for anyone.
Prolonged stays in these large institutions can lead to something termed ‘institutionalisation syndrome’, a set of adverse psychological and social effects that individuals may experience when residing in long-term institutional care. When a person lives the highly regulated and controlled life of an institutional setting for a long-time, no matter how well-meaning the intent, the experience can hinder or even diminish their ability to acquire essential life skills for independent living and makes it challenging for them to reintegrate into society. Moreover, the focus often leans heavily towards managing symptoms, which may hinder the development of vital coping mechanisms and life skills.
Larger settings can foster environments prone to abuse and neglect, harder to monitor and rectify and take corrective measures. Recognising these substantial shortcomings underscores the urgent and significant need for a shift towards community-centred, person-centric care for long-term holistic and inclusive care.
Inclusive Community-Based Care
Community-based mental health care shifts from institutional confinement to an inclusive, supportive environment where individuals can make their own choices. It acknowledges the importance of familiar surroundings and social engagement and connections in recovery. Quality care and socio-economic factors should be central to this effort, emphasising individual autonomy, dignity, and recovery. This approach is both ethically necessary and a practical requirement for transforming mental health care.
Families and parents play a pivotal role in de-stigmatising mental health by providing understanding, support, and open communication. However, families may also face stigma and resource limitations.
Therefore, providing them with education and access to mental health services is crucial for creating an inclusive environment and even prevent institutionalisation at all.
Strategies to adopt community-based care
Navigating the complexities of deinstitutionalisation in India requires a comprehensive framework based on global experiences. Instead of focusing on reducing bed numbers, it’s important to concentrate on improving living standards, care quality in institutions, and decentralising services. Gradually discharging long-term individuals, must be paralleled by concurrent substantial investments in community support and services.
Addressing prevalent schizophrenia-spectrum disorders in long-term patients requires acknowledging pervasive social disadvantages. This should be followed by sustained investments in community-based mental health services, working in collaboration with welfare sectors to address social disparities. Mere relocation from institutions to the community may not ensure lasting improvements in quality of life and social inclusion, so it's imperative to avoid replicating control dynamics and inconsistent care patterns in new settings.
Finally, prioritising outcomes like building relationships, facilitating work re-entry, and encouraging civic engagement will shape effective long-term care models and strategies. Collectively, these strategies form a detailed roadmap for India’s deinstitutionalisation journey, emphasising individual well-being and societal integration.
In India, where socio-economic disparities are significant, we need a robust mental health infrastructure. Deinstitutionalisation and reintegration are just the beginning; we must expand mental health Institutions’ capacities. This entails training healthcare professionals in culturally sensitive practices and establishing community outreach and mass awareness programs to demystify the stigma around mental health issues . By investing in mental health care, we ensure equitable access for all, regardless of their background, demonstrating our commitment to a more inclusive society.
—The author, Shweta Rawat, is Chairperson and Founder of The Hans Foundation. the views expressed are personal.
(Edited by : C H Unnikrishnan)
First Published: Oct 10, 2023 4:29 PM IST
