Due to the rising global awareness about mental health among people, mental illnesses in the elderly population have become a cause of concern in the recent years. The rise in the elderly population of India has brought forward the issue of geriatric mental health care. Chronic mental health disorders such as dementia and depression, coupled with socio-economic problems such as financial dependency, neglect and abuse, makes the elderly a special class of citizens, with unique needs that need to be addressed satisfactorily. Hence, it becomes imperative for the Indian government to recognize the needs of the elderly and address their problems accordingly, by means of passing legislations and policies.

This paper aims to anatomize the existing problems with the geriatric mental health care system, by means of conducting a comparative analysis of mental health laws of India, Japan, and Malaysia. Through this comparative analysis, this paper aims to understand the shortcomings of the existing legislations and policies. Furthermore, this critical analysis will help in understanding the changes that need to be brought about, for the betterment of the geriatric mental health laws.

This paper was written in the midst of the COVID-19 pandemic, due to which, the authors could not go out publicly to conduct research of their own. Hence, this paper follows the doctrinal research methodology.

Geriatric mental health is a problem spoken about rarely- with majority of a state’s focus on the working population of the nation since it’s the one that majorly contributes to GDP. The issues faced by the elderly in our country are normally brushed aside, and even when considered, the focus is on their physical health. Society expects the families of the elderly to take care of their needs, but those who suffer neglect from their own families have nowhere to turn to for help. They often do not even have the necessary information about the legal rights they have, to necessitate help from the state.

With the huge rise in the average ages in countries, the elderly is becoming a larger part of the population and it is pertinent to understand the needs of the elderly to provide them with the adequate help they require, while also understanding the gaps in our current mental health laws. This can be done by comparing our current laws, with mental health regulations of countries like Japan and Malaysia which have high aging population rates. Geriatric care is often expensive, and with the majority of the elderly being retired, their savings are limited, which makes geriatric care inaccessible to most of the population.

With the COVID-19 pandemic, the older population are more likely to be hospitalized or succumb to the virus. They might suffer from more severe breathing difficulties and have a higher risk of developing severe illnesses due to underlying health conditions as well. Most of the deaths from COVID-19 occurred in the elderly, especially those with diabetes, hypertension, or cardiovascular diseases. The elderly during this time have been prone to stress and anxiety, depression, and other mental-illnesses due to the issues faced by them and those around them.[i]The lockdowns have also made it difficult for them to meet their family, and those going through isolation are at a risk of depression as well. They face difficulties in accessing healthcare channels due to the rapid digitalization of service booking. The average counselling session in India with a mental-health professional ranges from Rs.800 – Rs.2500, which when added up, makes mental healthcare for the elderly a pressing and expensive issue.[ii]

The impressive growth of the Indian society, fueled by industrialization and globalization, has led to an increase in the life expectancy of the people. The unprecedented demographic changes have also resulted in an increase in the number of elderly citizens. According to the Census conducted in 2011, the percentage of the population above the age of 60 accounted to around 9%, with nearly 104 million elderly people. It has been estimated that by 2050, the number will rise to 319 million, as the gradual annual increase is seen at 3%. An ageing population, in any country, is a burden on the natural resources and especially for a country like India, where its population explosion has already caused a severe scarcity of resources, such a population boost has led to concerns being raised at many levels for the government. With the demographic pattern differing across various states, its unevenness and the complexities are reflected on the levels of socio-economic development, cultural norms, and political background in the state.

Although there has been a significant progress in medical sciences, the elderly still suffer from social, economic, and psychological issues, which are yet to be resolved. The care for the geriatric population requires the understanding of their needs and problems as they vary significantly according to age, socio-economic status, health and living standards and most importantly necessitates the need to underline the social issues that they continue to face in the current society. The elderly population face challenges that range across various aspects of human life.

Problems related to health form a major concern for the elderly as they are more prone to diseases and physical disorders than the younger generation. Lack of physical infrastructure such as old age homes, purpose-built care homes or public ramps has become a major deterrent in providing ease to the elderly. With increasing longevity and enervating chronic diseases, the access to better infrastructure at home and in public spaces for the older people is highly necessary. Due to an inaccessible healthcare system, the older people face the issues of unattended chronic diseases, ill-developed emergency response infrastructure, high cost of treatment and medicine, and malnutrition. There are only a few geriatric services in the public health care system that emphasize on the geriatrics, addressing their requirements and concerns. The public health system also lacks in infrastructure, manpower, good quality of healthcare and proper facilities due to deficient focus on the care of the older people[1]. For a significant portion of the country's elderly, deteriorating health is worsened by the lack of good quality and age-sensitive health care. Furthermore, limited access to health services, lack of information, and high disease management costs put reasonable elder care out of reach for most seniors, particularly the poor and vulnerable.

According to the National Sample Survey Organization (52^nd round), it was found that nearly half of the aged people were entirely dependent on others for their economic needs, while those who were partially dependent estimated to around 20 percent[iii]. Around 85 percent of the elderly depended on their relatives or children for their daily maintenance. The dependency ratio is increasing and is said to gradually increase, with larger share from rural areas than the urban areas. In the report released by National Sample Survey Organization in 2006, it was observed that the percentage of older males fully dependent for their financial needs in the rural areas (32 per cent) was higher compared to the urban areas (around 30 per cent). The situation pertaining to elderly females is much worse[iv].

The social security provisions and other financial protections like pension are not made easily available for the elderly if they do not have a work background in the public sector or organized industries sector. The elders living with their families are contingent on the economic capacity of the family for their welfare and security. The welfare of the older people living in poverty, is one of the most pressing concerns as it raises the risk of abuse and harassment[v]. Moreover, there exists a void in insurance schemes for the older people as they have very low reach, along with poor pay out. Due to the lack of financial dependence, the elderly have a low priority for their health, making them more susceptible to chronic and infectious diseases. The relevancy of old age homes has become more prominent in the Indian society due to the breakage of the joint family, migration of the younger generation for job opportunities, unaffordable housing, economic challenges, and lack of proper care in the family.

The fast-changing socio-economic demographics, advancement of technology, evolution of the modern society, improved levels of education and establishment of new forms of organizations have rendered the knowledge and wisdom of the elderly as obsolete. According to research, it was noticed that individuals at the age of 60 years were unable to realize that they have reached old age. This portrays their reluctance to accept their declining age (Singh, 2015)[vi]. After retirement, the feelings of loneliness, loss of status and worthlessness dwells upon the aged as their social life is narrowed down by the death of their relatives, friends or spouse, loss of work and poor participation in social activities due to their weak health. They tend to confine themselves within their homes, centering their social life to the interpersonal connections of their family members, resulting in isolation and depression, due to the loss of the social roles they once performed.

The geriatric population of the country is on a steady increase. In 2001, the elderly population accounted for 7.1% of the total population and it is speculated that by 2021, the share is to increase by more than 10%[vii]. Along with the challenges associated with social and economic facets and physical health, the rapid change in demographics as well as family systems have exerted a psychological burden on the elderly. The psychiatric morbidity in the geriatric community varies from 8.9 to 61.2%[2]. The disorders most encountered by the Indian geriatric population includes depression, dementia, mood and anxiety disorders, delirium, alcohol, and drug abuse, to name a few. The mental health issues in older women, especially in the rural areas, is higher compared to that of men, as they are susceptible to greater emotional and financial uncertainties, health problems and social insecurity[viii]. The mental health issues facedby the elderly population can be effectively diagnosed and prevented if sought early. However, it is erroneously dismissed on the assumption that it is the process of ‘normal ageing’[ix].

The infrastructure of hospitals, in the private and the public sector, are not well equipped with geriatric units and most often, the cases of elderly are treated at the general ward or the psychiatric ward. There is an inadequate number of medical professionals catering to the mental needs of the elderly, with around 4000 psychiatrists for an aged population of 21 million[x]. Inequitable distribution, shortage of staff, unaffordable medication, and equipment, are some problems faced by public hospitals, while the private hospitals are largely unregulated, with severe complaints about poor quality of service and unethical behavior. Moreover, there are no provisions for insurances that cover mental illnesses in India, while less than 20% of Indians have any form of insurance[xi].

The impact of COVID-19 on the healthcare system of India, as well as in other countries, has had a devastating effect due to its high infection and mortality rates. However, the most vulnerable sections of the society, who have been majorly affected by the pandemic are the older adults. According to the report from the Centre for Disease Control and Prevention (CDC), the chances of the elderly being hospitalized is around 31-59 percent while the risk of death is around 4-11 percent. Due to the high risk of acute respiratory problems caused by COVID-19, the elderly face a major threat as it increases their chances of hospitalization or need for ventilatory support, resulting in greater anxiety, stress, and various other mental health challenges. Social distancing and isolation has led to depression, loneliness, feeling of imprisonment, anxiety about the uncertain future, and other psychological disorders among the elders. They are least likely to be well-versed with technology, which has become the only way to maintain a social contact in the current age. The elderly are more likely to have difficulty in accessing essential medical services and medication if they live separately from their children or relatives. This is especially the case if they have worsening pre-existing medical and psychiatric diseases due to the strict enforcement of Covid restrictions[xii].

The major drawback faced by the Indian mental healthcare system is the acute shortage of fund. The Financial Year of 2019 saw a dip in the allocation of budget for the National Mental Health Program (NMHP), from Rs. 50 crores in FY2018 to Rs. 40 crores, with only Rs. 5 crores each being spent during the years[xiii]. In the Union Budget of 2021-22, the Healthcare budget was increased by 7 percent but out of the total funds allocated, only 0.05 percent was allotted towards mental health. The NMHP received only 7 percent of the total budget allotted for mental health, while the majority was distributed between two institutions, i.e., the National Institute of Mental Health and Sciences (NIMHANS) in Bangalore and Lokpriya Gopinath Bordoloi Regional Institute of Mental Health, based in Tezpur[xiv]. The overall budget for NMHP remained to be Rs. 40 crores, like the previous year, which is very nominal as the country continues to crumble under the pandemic.

The pandemic has brought the realization to people that mental wellbeing is as important physical wellbeing. In the report by the National Institute of Mental Health & Neuroscience[xv], it was observed that 1 out of every 20 Indians suffer from some form of mental health issue, and the numbers have risen significantly during 2020. As there has been greater discussion and awareness about mental health, the Insurance Regulatory and Development Authority of India (IRDAI) has instructed insurance companies to align mental health insurance policies into their insurance schemes[xvi]. This allows for psychological illnesses, mental ailments and stress, and neural diseases to be covered under insurance policies, like any other physical ailment. The steps taken by IRDAI are very crucial towards the development of a healthcare ecosystem where people suffering from a mental illness are relieved of the burden of huge financial cost that are required for their healthy treatment and wellness[xvii].

Over the past few decades, the Indian government has passed the following legislations and policies for geriatric mental health care.

Traditionally, in the Indian society, the elderly are cared for, by their children or other family members. Geriatric care, be it mental or physical, was provided in the homes of the elderly or of their children. However, there has been a steady decline in the care of the senior citizens by their children, due to the development in socio-economic norms and the fast-paced lives that their children now lead.

The need for mental health laws began to be recognised globally, and countries, including India, started drafting their own laws for the betterment of the mental health of its older citizens.

The Act of 2017 has taken many landmark steps for the advancement of mental health laws in India. First and foremost, the Act defines mental illness as “a substantial disorder of thinking, mood and perception, orientation, or memory that grossly impairs judgment, behaviour, capacity to recognize reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.”[xxvii]

Firstly, on a legal front, tribunals should be set up to specifically deal with cases of elder abuse or neglect. Although regular Courts do deal with such cases, it may take a long time for the matter to be resolved, which would ultimately cause the aggrieved senior citizens to be in constant anxiety and stress. The establishment of such tribunals would ensure fast-tracking of these cases to provide relief to the elderly in the quickest way possible.

Secondly, elderly helplines should be established, whereby the senior citizens can acquire knowledge about the law, which would help them understand their rights.

Thirdly, mental health institutions, which specialise in geriatric care, should be established. All the personnel in these institutions should be specifically trained in managing and treating elderly patients. Furthermore, the facility of “Ageing in Place”[xxxi]should be made available to the senior citizens, as a means to sustain dignity of living in old age.

Additionally, provisions for establishment of elders associations should be made, whereby senior citizens can come together and discuss their problems more openly. These associations should be formed at district levels to ensure that all the elderly citizens can access them. These associations should also specifically aim to help the elder citizens, who  fall below the poverty line. These associations must aim at making the elderly comfortable enough to share their problems. This can be done by creating a buddy system where two adults are assigned to each other, to talk about the problems that they might be facing. This would encourage socialisation and would also shed light on other issues that the elderly might be facing, be it physical,

mental, or legal. This, in turn would help the concerned authorities take necessary actions to solve these problems.

Furthermore, geriatric mental health care should also be extended to other oppressed groups of the society, who have been ridiculed and subjugated for ages. For instance, before decriminalisation of homosexuality, queer people were subjected to violence from the society, the police, at the hands of doctors as well as their own families. This problem of non-acceptance, queer-phobia and trans-phobia can cause long-lasting psychological problems in people such as depression, anxiety disorders and in some extreme cases, suicidal thoughts[xxxii]. Similarly, there are other groups of people in India who have been subjugated throughout history. An example of this would be the historical mistreatment of minority groups such as Dalits, Scheduled Castes, Scheduled Tribes, etc. These groups have been at the centre of many incidents of hate crimes over the years. So, there is a need for focussed efforts to improve the mental health conditions of the elders of these minority communities. [xxxiii]

This section of the paper focusses on the international comparative analysis of the Indian geriatric mental health law with the laws of Japan and Malaysia.

Due to its high life expectancy, Japan has one of the highest elderly populations in the world. According to the World Population Prospects 2019, published by the United Nations Populations Division[xxxiv], 28.2% of Japan’s population is over the age of 65. The population of the elderly has been steadily growing over the past few decades, with the 1970s reporting that only 7.1% of the population was over the age of 65.[xxxv]

With the increase in the elderly population, there has also been an increase in the National Medical Expenditure, which forms a part of the GDP. In the 1970s, the National Medical Expenditure was calculated at 3.3%, which increased to 7.9% in 2016[xxxvi].

As compared to Japan, in Malaysia, only 7% of the population is over the age of 65[xxxvii], due to the high life expectancy and reduced birth rates. While 7% seems to be less in comparison to the other developed and developing countries, this statistic is expected to grow further. It is estimated that by 2040, 14.5% of the Malaysian population would be over the age of 65[xxxviii]. Hence, it is of extreme importance to discuss geriatric health care in Malaysia.

It is vital to note here that Malaysia, in 2018, witnessed a historic change in its government. In Malaysia’s 14^th general elections, Barisan Nasional, the party which had formed the government for the past 62 years, was voted out. The appointment of the new Prime Minister, who was 93 years old at the time of his appointment in 2018, brought up the topic of ageism and geriatric care[xxxix].

Mental health reforms kicked off earlier in Japan than it did in most nations, with the Law of Confinement and Protection of the Mentally Ill (1900). Though it was a massive step forward in recognizing mental health issues in the country, it also made it legal to confine mentally ill people at home. Only after the Mental Hygiene Law of 1950 did the practice of home imprisonment of the mentally ill end. It necessitated medical treatments for people with mental disorders in hospitals. This was followed by a revision of the Mental Hygiene Law in 1965 which focused on community based mental health services and required each prefecture/district to have at least one community mental health center. The Mental Health Act of 1995 was

the first act to recognize that mental illness is a disability and it provided for stricter criteria for involuntary hospitalization, which was done to give people with mental disorders, the same treatment as those with physical disabilities.[xl]

The National Health Insurance Act was then passed in 1958, which entailed that every Japanese person can be covered by health insurance, including both physical and mentalillnesses.[xli]

Act on Mental Health and Welfare for Mentally Disabled Persons (1950, Law no. 123) was enacted to provide mentallydisabled people with proper medical care, ensure proper social rehabilitation is done and to facilitate their participation in society. It provided for measures such as the establishment of mental health & welfare centers in all districts, as well as mental institutions and private hospitals. It also made it necessary for the establishment of rehabilitation institutions for mentallydisabled people, which would contain training facilities and workshops to adjust them back to their daily lives, as well as provide welfare homes and industries. It also enabled medical fees to be partly covered by government funds and designated promotion centers for social participation.

The Law for the Welfare of Mentally Retarded Persons (1960. Law No. 37) further made it necessary for counselling to be provided by social welfare and rehabilitation centers as well as the provision of technical aids, living space and specialized facilities. It also contained provisions for in-house services like helpers, short stay programs and more. People suffering from mental disabilities are also provided handbooks from welfare centers that enable them to easily access these services. [xlii]

The 1973 Amendment of the Act on Social Welfare for the Elderly made health care free for almost every person aged 70 and above, which was later changed in the 1982 Public Aid for the Aged Act, which made insurers also liable to cover the fund along with the government. The 1990 amendments to the eight welfare acts made municipalities obligated to create healthcare plans for the elderly. The Long-Term Care Insurance Act of 1997 also covered care for the elderly and reduced caregiver burden.  The 2006 Health Care Reform Act then established a brand-new medical care system only for people aged 75 and above, making it easier for them to access healthcare.[xliii]

Despite all these measures, the COVID-19 pandemic led to worsened mental health in the elderly with an increase in depressive moods and apathy.[xliv]

The Malaysian Mental Health Act, 2001 which came into effect after the Mental Health Regulations of 2010 is the most important mental health act in the country, which lists out the framework for the delivery of comprehensive care, rehabilitation, treatment, protection, and control of those suffering from mental disorders. It deals with the establishment of government and private psychiatric hospitals, nursing homes and community centers.[xlv]

This Act encourages treatment in community centers rather than in institutional settings and prompts the private sector to aid more in providing mental health care.  The Malaysian Mental Health Framework of 2002 helped implement mental health services in the country by describing comprehensive services for every age group such as mental health promotion, treatment, and prevention of mental disorders as well as rehabilitation of the mentally ill in hospitals and community centers.

The National Operational Plan of Action for Comprehensive Integrated Community Mental Health Services of 2002 required the formation of a national technical committee consisting of health, labor, welfare, and housing directors to implement strategies, strengthen community mental health services, and to transfer services from mental hospitals into community centers.

The National Mental Health Policy was formed back in 1998, and also focused on advocacy, prevention, rehabilitation, and treatment, and stated that accessibility, human resource training as well as community participation were necessary for mental health development.[xlvi]

The laws still fail to properly deal with all geriatric mental health issues, guardianship of the elderly, determination of mental capacity, treatment centers and more.[xlvii] Further, with the pandemic, depression, anxiety, and a higher mental health burden have become major cause for concern amongst the elderly.[xlviii]

In India and Malaysia, senior citizens or the elderly are defined as people over the age of 60, whereas in Japan it stands for people aged 65 or above. In India, state-funded aid for mental healthcare isn’t available, though there are multiple mental healthcare rehabilitation helplines, while countries like Japan offer government and insurance funded mental healthcare schemes for the elderly. Since India is a larger country, both in terms of geographical area and population than both the countries used in this analysis- it is necessary to spread out mental health care facilities even more. Setting up community mental healthcare centers in every district like Malaysia did would not only make healthcare facilities accessible even in the most remote areas, but also increase social awareness about geriatric mental health problems. There is also a need for more financial aid or reduced fees for the elderly for availing mental healthcare services. It could also be provided by their healthcare insurance schemes.

India could also set up a national technical committee to look after the functioning of community mental healthcare centers, similar to what Malaysia has implemented. The directors appointed in the committee can be from healthcare, welfare, legal, labor and housing backgrounds and they would have to look into the efficiency of community healthcare centers in different states. They would also be responsible for organizing and conducting awareness drives, workshops, and setting up training facilities. The community healthcare centers would ensure an increase in job opportunities for specialized caretakers, psychiatrists, and other healthcare workers, thereby increasing employment as well.  A separate state budget can be allocated for mental healthcare too.

The youth population across the world is on a steady decline, with the population of the aged increasing at an alarming rate, from 12 percent in 2015 to 22 percent by 2050. With such a growing population of the older generation, the physical challenges faced by them need to be properly addressed and recognized, and appropriate care needs to be provided for their rehabilitation. Most importantly, the issue of mental health needs to be openly discussed, as it is still stigmatized in our society and is often overlooked and unidentified by healthcare professionals as well as the elders themselves. This would help in eliminating the reluctancy that the elderly face to seek relief. Massive demographic changes, a growing vulnerable population of female older adult population, rapid changes in the family structure and lack of adequate social benefits are some of the big challenges faced by the Indian society.

Problems in the geriatric psychiatry such as lack of training opportunity, inadequate chronic care disease models, lack of geriatric care awareness and insufficient distribution of medical resources continue to remain prevalent. Although social security schemes of the government are in place, they lack the coverage that was aimed while formulating them. Such plans and schemes are required to be reformed and reframed, so that they not only cover the people in need but also ensure that the benefits are suitably enjoyed. A mental healthcare ecosystem that focuses on bolstering training and research, raising awareness among the professionals as well as the public, and developing a program based on community rehabilitation are the need of the hour. Innovation and changes in health, economic and social programs are the paths that will help in building an effectual and successful healthcare ecosystem in India.

With COVID-19 affecting the entire world, India needs to take steps to strengthen its healthcare system, by studying the positive measures followed in countries such as Japan and Malaysia, as discussed above. The health regulatory laws in India, although widely enforced, lack the force in their execution. The extensive laws on mental health in the two discussed countries, can serve as an inspiration for Indian legislators to

adopt the provisions that best serve the interests of our population, while framing the laws.

India still has a long way to go, in terms of building a robust healthcare system, that equally emphasizes on both physical and mental healthcare issues. A shift in the mood of the public is being observed, as there has been an increase in the acceptance, sensitization, and acknowledgement of mental illnesses.