Happiness and Wellness Centre. “Sounds like a yoga centre or boutique spa, right?” quips a psychiatrist.
That, however, is the name the Kerala government recently suggested for its mental health centres.
The proposal came just days after the Kerala High Court delivered a damning assessment of the condition of mental health institutions in the state.
After personally visiting the centres in Kozhikode, Thrissur and Thiruvananthapuram, a division bench comprising Justices Devan Ramachandran and Basant Balaji found a system marked by appalling conditions and serious violations of human rights.
One of the institutions, the court said, was a “horror place”.
“The manner of violation of human rights – perhaps unintended and unwitting – is so rampant that no state can lose even a second to address it. However, this is not seen done!” the court observed.
“The so-called, I don’t want to use that name — Mental Health Centre. It is not a health centre. It is a horror place,” the bench added.
“No one knows what is happening there, not even the press… No transparency, no accountability, nothing. Worse than jail.
The bench noted that “every human right is violated in that system”.
Yet, somewhere along the way, the conversation shifted. To the name board.
The court-appointed amicus curiae had suggested that the term ‘Mental Health Centre’ itself carried stigma. While proposing the name ‘Institutes of Behavioural Management’, the amicus argued for a change in terminology.
The court, however, clarified that it was not recommending any particular name. “Since this is a matter of policy, it is for the government to initiate the first move and inform us,” the court said.
The government’s choice was ‘Happiness and Wellness Centres’.
For psychiatrist Dr C J John, the irony is hard to miss. “The issue here, if you go through the court findings, is definitely related to the poor state of these centres,” he says.
“Outdated architecture and infrastructure, lack of staff to run the centres in a more patient-friendly and productive manner, dearth of facilities…. lack of funding.”
These, Dr John stresses, are the problems that need fixing. “A name change will just distract from the actual issues,” he argues.
“There are systemic problems that need to be dealt with. As the judges visited these facilities themselves, they saw the glaring issues.”
But, he wonders, how have those glaring lapses now almost disappeared from the conversation, overshadowed by a debate over what the institutions should be called?
“This should not be a mere cosmetic change,” he says.
Dr John is not alone. Soon after the court welcomed the proposed new name, the Indian Medical Association (IMA) and the Indian Psychiatric Society (IPS) raised objections, questioning both the legality of the move and whether it would actually address the problems confronting Kerala’s mental healthcare system.
“The hospitals have to be upgraded as per modern standards,” says Dr Arun B Nair, professor of psychiatry at Government Medical College, Thiruvananthapuram.
And the list of what needs to be done is long. “Let’s start from the basics. We need to modify inpatient facilities. We need to provide rooms for extremely agitated and violent patients, rather than cell rooms. These should be padded rooms so that patients do not injure themselves,” he explains.
“There should also be family wards for patients whose illnesses are complicated by family conflicts. This will help treat the illness as well as the family dynamics that might be precipitating it.”
Then there is the question of the buildings themselves. “Most of the buildings are over a century old. They need definite revamping, along with new buildings,” says Dr Arun.
“Another important requirement is a separate block for child and adolescent treatment. The Mental Healthcare Act, 2017, clearly says that children under the age of 18 should not be admitted along with adult patients.”
All of this requires something more than a name change, says Dr Mohan Roy G, honorary general secretary of the Indian Psychiatric Society (Kerala).
“The court mandated a name change, suggesting stigma. Our laws call it mental health, the UN calls it mental health, insurance calls it mental health, and premier institutions around the country call it mental health,” he says.
“The stigma is not in the word, but within the people who have been mocking the term and the illness for ages.”
More importantly, he says, stigma has a physical form. “That stigma is rooted in visible structural issues like dilapidated colonial-era buildings with barred wards, severe understaffing, and the institutional abandonment of chronic patients,” says Dr Mohan.
The IPS made much the same argument in its publicly released letter.
“Replacing historical clinical terms with euphemisms does nothing to solve these crises. In fact, these new euphemisms will inevitably absorb negative social connotations if underlying patient care and facility conditions fail to improve,” the letter reads.
If a change in name is imperative, Dr Mohan adds, there are alternatives that comply with the law while retaining the clinical seriousness of the institution. The IPS has suggested two: State Institute of Mental Health and Wellness or Regional Institute of Psychiatry and Wellness.
The problem with ‘happiness’, psychiatrists argue, is more fundamental.
“Happiness is a state of mind. A person with or without mental health issues can be happy or unhappy. It is not something treatable,” Dr Mohan says.
“The patient needs further care after discharge. The centre and the doctors provide treatment, not happiness. It is a fundamentally wrong metric.”
Dr Mohan too calls for a “serious modernisation plan”.
“Allocating more staff for patient care, building modifications, exercise facilities, better treatment infrastructure, enhanced rehabilitation facilities, etc., are some urgent needs,” Dr Mohan says.
There is also the question of care after discharge. “This is vital,” he says. “Continuing care should be available through nearby PHCs and taluk hospitals.”
After hearing the objections raised by the IMA and IPS, the High Court asked the government to hear the concerns and suggestions of experts. This Wednesday, a panel representing the organisations will meet the health secretary to discuss the issues and their demands.
For psychiatrists, the debate returns to the question with which it began. What exactly is the state trying to fix?
“The ultimate goal is better patient care,” Dr Mohan says. “Both doctors and the state need to work together to provide that.”
Need modernisation
New infra: Many of the existing buildings have suffered decades of wear and tear and require urgent renovation and new treatment blocks.
Better design: Outpatient and inpatient facilities need to be redesigned to make patients feel safer and more comfortable. The image of a dark, closed institution must give way to spaces that are pleasant, patient-friendly.
Lifestyle support: Hospitals should provide adequate spaces for physical activity, nutritious meals and counselling on lifestyle modification.
Rehabilitation for chronic patients: Rehabilitation centres could be established within hospital campuses to provide accommodation, education, skill development and vocational training. Those willing and able could eventually be offered employment opportunities, including within the institutions themselves.
Training centres: Mental health centres could also be developed as centres for psychiatric education and training.
Staff crunch
On an average day, over 200 patients visit Kerala’s mental health centres for outpatient treatment. Yet, just four or five doctors, assisted by a handful of postgraduate students, are often left to care for them.
The most immediate requirement, experts say, is adequate staffing — including psychiatrists, psychologists and other mental health professionals, deployed according to their areas of expertise.
The available numbers paint a grim picture. Data from 2017 showed that Kerala had only 5.53 beds per 10,000 people seeking mental health treatment. The National Mental Health Survey (2015–16)* recorded an overall prevalence of mental disorders in Kerala at 11.36%. According to the survey, the state has only 1.2 psychiatrists per 100,000 population.
(*The next report is expected this year.)