Every year the World Mental Health day is marked on 10th October. The theme of this year's World Mental Health day is ‘Dignity in Mental Health'. Worldwide, various organisations including WHO, celebrate the day to raise awareness to fight stigma. As per the World Health Organisation, millions of people with mental health conditions are deprived of their basic human rights. Apart from being discriminated and marginalised they are also subject to emotional and physical abuse in their own homes, community and even mental health facilities. This is further worsened by the lack of infrastructure, dilapidated facilities, poor quality of staff or lack of an adequate number of professionals. Failure to treat people with respect and dignity often worsens their condition further, by having a negative impact on the recovery and long-term prognosis.
In Kashmir, the number of people suffering from psychological problems has increased exponentially. With the ongoing conflict, mass exposure to trauma, worsening socioeconomic conditions and the prevailing day to day uncertainty, people are more prone to develop psychological problems. Psychiatric Diseases Hospital, Srinagar is the main facility catering to all the districts of Kashmir, Ladakh and adjoining areas like Banihal, and Kishtwar. The hospital has been under tremendous pressure over the years catering to huge demand due to the absence of other psychiatric facilities in the region. The department has expanded and developed over the years and has become one of the Centres of Excellence in the country, meaning that increased number of doctors and allied staff are being trained. This was only possible due to the sustained efforts of doctors working in the hospital, who at times spent money from their pockets to attend meetings around the country, to get the funding and upgradation status, without any help from the State administration. The psychiatry department has its own facility at the SMHS Hospital, which provides daily OPD services and treatment to drug abuse patients. Lately, many psychiatrists have joined at various district hospitals though there are still no inpatient beds available.
The attitude of young doctors has changed towards psychiatry and even toppers in the entrance examination are choosing to become psychiatrists. This is surely progress when it comes to the acceptance of psychiatry as a career by doctors in spite of opposition from families and society at large. Mind you, they could easily join other specialities like medicine or surgery. It is worth noting that psychiatry has improved academically in the Valley compared to many other parts of India.
When it comes to the stigma and general treatment of people suffering from mental illness, we are not doing any better, both in the community and at the professional level. There is huge stigma related to any kind of mental illness and often people find it difficult to even talk. There are various myths and stereotypes associated with it and people prefer to take advice from anyone but a psychiatrist. People would often go to neurologists and cardiologists and undergo multiple unwarranted investigations and end up on a cocktail of unnecessary medications. Faith healers are often the first port of call, where few find respite and most get into further trouble. I am not blaming common people here, it is due to lack of awareness and more so because of the stigma.
Although stigma is inherent with mental illness in most societies, the delivery of care has made the problem worse in Kashmir. The Psychiatric Hospital at Kathidarwaza originally a part of the central jail was initially started as an asylum. Later, it was converted into a Mental Hospital and ultimately became part Medical College Srinagar. Recently, it was renamed as Institute of Mental Health and Neurosciences. But when it comes to the perception of common people, probably the status of the place has not changed much and is still considered merely as a mental hospital and often called by derogatory names. Often, young women would request if the prescription is written on a paper which does not say Psychiatric Hospital. Sometimes they will carry an additional prescription slip from SMHS to show to their family, fearing stigma, shame, being judged or even fearing that visiting here may cost them their marriage. Most people are usually comfortable to see a psychiatrist at SMHS OPD but would refuse to go Psychiatric Hospital citing obvious reasons.
Once accompanying a young man from downtown Srinagar, his old mother innocently narrated how she tried to bribe a policeman to get him arrested, explaining that it is more respectful to be in prison than to be admitted to this hospital. Sadly, such cases are not rare. Many believe that by receiving treatment from this place, the prospects of future relationship and marriage could be bleak for both boys and girls.
There are families even from well-educated background who lock up their loved ones, fearing stigma and shame. We still see incidents when people are being chained and treated inhumanely. There are also some patients who have been admitted to the Psychiatric Hospital decades ago, but for various reasons have never been claimed back.
With the opening up of new wards at SMHS and open ward at Psychiatric Diseases Hospital, the care and treatment for many patients has improved. Unfortunately, same cannot be said about the patients treated in the closed wards. The wards are not in good condition and remain locked without any direct nursing supervision. The hospital has a limited area of land, where ongoing construction has meant that it has lost the only garden space and looks more like a construction site. There is no place for patients to have some free air or get any physical exercise.
The Mental Health Act 1987 is in force in Jammu and Kashmir to safeguard the care and treatment of mentally unwell. Sadly, the Act is on paper only and none of the state machinery including the medical fraternity abides by it. When admitting or treating patients against their will, no consideration is given to their basic human rights and end up essentially locked up. Sometimes people are admitted under court orders without a review date meaning prolonged admission. Police has an integral role in the care and safeguarding of mental health patients, but most families have to either beg or bribe the cops to get help for transferring an uncooperative patient to the hospital. With no training and knowledge of the mental health legislation, patients are transported in very inhumane conditions, often tied and bundled up.
The Jammu and Kashmir State Legal Services Authority has published guidelines in 2010 for the care and treatment of the mentally ill persons, which if followed would have greatly improved the services. It argues that as India is a signatory to the UN Convention on the Rights of Persons with Disabilities (CRPD), 2008, making it obligatory for legal system to ensure the human rights and fundamental freedoms of people with mental illness and mental disabilities are protected on equal basis with others. It also advises to ensure that they get equal recognition before the law and equal protection of the law. The Convention further requires ensuring effective access to justice for persons with disabilities on an equal basis with others. But again this has remained limited to paper.
There is a need for education and awareness of the general public and particularly of professionals involved in care and treatment of mentally unwell. This would include the health professionals, police and legal services. Mentally unwell people should be treated with dignity and respect as anyone else in the society. This includes treatment of both mental and physical health. Those who have been abandoned by their families or have no families need to be rehabilitated in the community so that they don’t live a life of imprisonment just because they have a mental illness.
Finally the government should relocate the Psychiatric Diseases Hospital to a suitable location and allocate adequate land so that a world class Institute of Mental Health is developed with appropriate space and wards manned by psychiatric nurses, and separate wards for children and old age patients. Many like-minded psychiatrists tried to get the hospital relocated after it was granted the status of the centre of excellence, but no headway was made due to red tape and unending bureaucratic apathy. A new hospital will surely ease the stigma and improve the basic facilities so that people are not treated in asylum-like conditions anymore.
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