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The Mental Health Care Bill : 
Dark Clouds ! 
Ajit Avasthi 
Sudhir Mahajan 
Department of Psychiatry 
PGIMER, Chandigarh
Salient Features of Mental Health Care Bill 
2013 
Objectives: 
1. To provide for mental health care and services for 
per...
Chapter I: Definitions 
New Names 
 “Person with mental illness” for “mentally ill” – 
less stigmatizing, separating the ...
Chapter I: Definitions 
Mental health establishment 
 General hospital psychiatric units run by Govt. or 
private sector ...
Chapter II: Capacity to make mental 
health care & treatment decisions 
 Mental health professional includes professional...
Chapter II: Capacity to make mental 
health care & treatment decisions 
Recommendation of Rajya Sabha Standing Committee: ...
Chapter III: Advance Directive 
 Advance directive to be signed by medical 
practitioner and not necessarily a psychiatri...
Chapter III: Advance Directive 
 Power Rajya to Sabha review, Standing alter, modify Committee: or cancel makes advance 
...
Chapter III: Advance Directive 
Evidence base for Advance Directive 
Impact on Psychiatric Service delivery 
• Some resear...
Chapter IV: Nominated Representative 
 Appointment of Nominated Representative by 
Director, Dept. of Social Welfare in c...
Chapter V: Rights of persons with mental 
illness 
Provisions: 
 Right to access mental health care 
• All these are good...
Chapter V: Rights of persons with mental 
illness 
Provisions: 
Right to confidentiality: 
 There are few exceptions to t...
Chapter V: Rights of persons with mental 
illness 
Provisions: 
Right to legal aid: 
 Clause 27 (2) imposes duty only on ...
Chapter VI: Duties of appropriate 
Government 
Provisions: 
 Promotion of mental health and preventive 
programmes 
 Cre...
Chapter VII & VIII: Central and State 
Mental Health Authority 
 Psychiatrists should have adequate representation 
in th...
Chapter IX: Finance, Accounts and Audit 
 Grants by Central Government to Central Mental 
Health Authority – Central Ment...
Chapter X: Mental Health Establishments 
 Procedure for establishing and maintaining Mental 
Health Establishments is cum...
Chapter XI: Mental Health Review 
Commission 
Rajya Sabha Standing Committee 
 For its implementation, “District Mental H...
Chapter XI: Mental Health Review 
Commission 
 As “Mental Health” is a “state subject”, how could 
district boards which ...
Chapter XII: Admission, Treatment and 
Discharge 
 As per the bill, patient can challenge the 
involuntary admission (sup...
Chapter XII: Admission, Treatment and 
Discharge 
Prohibited procedures 
Unmodified ECT 
• Beneficial and safe procedure e...
Conclusions 
 The bill has imported ideas from the West without 
due consideration of the ‘cultural & ground 
realities’ ...
Thank You
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Mental health care bill kochi 2014

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Mental health care bill kochi 2014

  1. 1. The Mental Health Care Bill : Dark Clouds ! Ajit Avasthi Sudhir Mahajan Department of Psychiatry PGIMER, Chandigarh
  2. 2. Salient Features of Mental Health Care Bill 2013 Objectives: 1. To provide for mental health care and services for persons with mental illness 2. To protect, promote and fulfill the rights of such persons during delivery of these services Much emphasis have been given on the rights of persons with mental illness to the extent that it hinders the service delivery to them
  3. 3. Chapter I: Definitions New Names  “Person with mental illness” for “mentally ill” – less stigmatizing, separating the person from the illness  It defines mental illness which also includes mental This will sort out the prevailing confusion about conditions associated with the abuse of alcohol and character of services catering to these conditions drugs  The definition of mental illness is over-inclusive – will hurt a large no. of victims of even minor mental illnesses- Stigmatize
  4. 4. Chapter I: Definitions Mental health establishment  General hospital psychiatric units run by Govt. or private sector will also come under the Act  This will increase the stigma associated with psychiatry • Kill general hospital psychiatry!! • Corporate sector will not provide care!!  To establish a psychiatric unit in general hospital one has to go through the cumbersome procedure  Rehabilitation facilities will also come under its purview • So anyone who wants to start a rehabilitation facility will have to go through the same cumbersome procedure • Will eventually hinder delivery of these services
  5. 5. Chapter II: Capacity to make mental health care & treatment decisions  Mental health professional includes professional with MD (Ayurveda) in “Mano Vigyan Avum Manas Roga” or MD (Homeopathy) in psychiatry  So And these mental specialists illness are to be expected determined to follow in accordance allopathic with latest edition of ICD system of classification!! So who will issue the fitness certificate: Psychiatrist  Decision of whether a person is of unsound mind to be taken by “competent” or Court?? court & not psychiatrist  People with mental illness have been granted legal capacity to take decisions about their health care and treatment • No other law in the country dealing with disability - mental or other – grants such a right • What if patient refuses treatment but is likely to improve with treatment?? What about the rights of caregivers who might have to suffer because of person’s illness??
  6. 6. Chapter II: Capacity to make mental health care & treatment decisions Recommendation of Rajya Sabha Standing Committee: Clause 4 (1): Capacity to make mental health care & treatment decisions  There shall be a presumption in favour of persons with mental illness  Every person, including a person with mental illness shall be deemed to have capacity to make decisions regarding his mental health care or treatment unless proved otherwise • Ministry has accepted this suggestion saying that it upholds the constitutional norm of equality & accordingly suggested the change in Section 4 (1)
  7. 7. Chapter III: Advance Directive  Advance directive to be signed by medical practitioner and not necessarily a psychiatrist  That means a medical practitioner will assess the capacity to make advance directive!!!  It might contain refusal of all future medical What to do, in such a case??....not mentioned !!! treatment for mental illness  One can change previously written advance directive as many no. of times as one wants & every time Board have to certify the validity of it after hearing – increases the work load - enough manpower??  Maintenance of online register of all advance Is online register valid?? What if hacked?? directives
  8. 8. Chapter III: Advance Directive  Power Rajya to Sabha review, Standing alter, modify Committee: or cancel makes advance it directive They will first have to write to Board & wait till the mandatory by mental to write health to the professional, Board if one relative desires or care-giver decision. How long?? not to follow it  For minor, legal guardian shall have the right to Contravenes rights of minors!! make advance directive  It has been said that the provision of an advance directive will give people more control over their treatment and give them an opportunity to exercise choices even when they are incapacitated by mental health problems But what is the evidence??
  9. 9. Chapter III: Advance Directive Evidence base for Advance Directive Impact on Psychiatric Service delivery • Some researchers have reviewed the practical issues of advance directives in mental health settings & pointed that advance directives have not worked as intended even in the West; also states it to have no scientific evidence to back it • Advance directives are seen by both the service providers and the carers as yet another wedge being pushed between family and the patients in the name of transplanting individual rights as understood It is undesirable in the to West have too many controls on the (Sarin, 2012; Sarin et al, 2012) • The great professional premium functioning put on individual • Cochrane Review: concluded of psychiatrists autonomy in “Currently, it is not the Western societies is at wide variance with the possible to recommend advance treatment concept of familial interdependence in our country, directives for people with severe mental illness due where collective goals and rights of family are to the lack of supporting data” culturally considered at par with individual rights (Campbell et al, 2009) (Kala, 2013)
  10. 10. Chapter IV: Nominated Representative  Appointment of Nominated Representative by Director, Dept. of Social Welfare in case no person Are they willing to undertake this task?? is available  The representative of the organization working for • persons Too What many with authority duties mental for the illness, Board! may temporarily be mental health professional has • engaged Will Board by have the the mental capacity health professional to over NGO? to deal with so many discharge demands? the duties of a nominated representative • pending Board is appointment replacing professional of a nominated – Psychiatrist! representative by the concerned Board • What if nominated representative does not discharge his duties?? • Nominated representative not a family member: will have access to family or home based rehabilitation services– conflict with family!  Too many responsibilities put on nominated representative
  11. 11. Chapter V: Rights of persons with mental illness Provisions:  Right to access mental health care • All these are good provisions & if implemented may led to betterment of services • Many provisions sound like poverty alleviation program! • But how much implementable these are, given the resources we have??  Right to community living  Right to protection from cruel, inhuman and degrading treatment  Right to equality and nondiscrimination  Right to information  Right to confidentiality It does not seem to be in accordance with the policy measure of District Mental Health Program which plans to cover all the districts in a graded fashion and this bill is an ambitious blue print of a network of mental health services free of cost to those who cannot afford it (Kala, 2013)  Restriction on release of information in respect of mental illness  Right to legal aid
  12. 12. Chapter V: Rights of persons with mental illness Provisions: Right to confidentiality:  There are few exceptions to this right – some modifications recommended by Rajya Sabha Standing Committee pointing that the clause (23:2) is very vague, leaves scope for ambiguity & confusion Right to access medical records: controversial Rajya Sabha Standing Committee recommends that there is a scope of misuse of medical records which may be relooked & suitably addressed before finalizing the Bill Right to personal contacts and communication: Responsibility of Psychiatrists, but how to block e-mails?
  13. 13. Chapter V: Rights of persons with mental illness Provisions: Right to legal aid:  Clause 27 (2) imposes duty only on the medical officer or psychiatrist in charge of a mental health establishment to inform the person with mental illness that he is entitled to free legal services  Rajya Sabha Standing Committee: Recommends that it shall be the duty of the magistrate, the police officer, person in charge of a custodial institution in addition to doctors Good Provision: Due to the ignorance, people with mental illness are not deprived of legal remedies and rights guaranteed to them through various provisions of the Bill
  14. 14. Chapter VI: Duties of appropriate Government Provisions:  Promotion of mental health and preventive programmes  Creating awareness about mental health and illness and reducing stigma associated with mental illness  Appropriate Government to take measures as regard to human resource development and training, etc  Co-ordination within appropriate Government Good provisions But how much implementable?
  15. 15. Chapter VII & VIII: Central and State Mental Health Authority  Psychiatrists should have adequate representation in these bodies. Because they are the only group, among professionals Psychiatrists in marginalized this field, who by other by their stake-training holders. and experience, have the required expertise in managing mental health establishments  It would be better to have a person with judicial background as chairman of State Mental Health Authority, rather than having the Health Secretary of the state Government – can take up the important task of protecting human rights of inmates of all Mental Health Establishments (Antony, 2014) Bureaucrats rule the roost!!
  16. 16. Chapter IX: Finance, Accounts and Audit  Grants by Central Government to Central Mental Health Authority – Central Mental Health Authority Fund • The But the bill bill has has been not written indicated in anywhere, the fashion about of the an “manner announcement” in which by the the Government government would & not mobilize like an the “Act” huge resources that would be needed to render • If care the for objective such a large is just no. to of improve mentally the ill persons plight of the • Strangely, mentally ill, in it could the Financial be achieved Memorandum, more effectively it by is stated having that a well “there thought is no of easy “National way to Mental estimating Health the Program” full financial with burden the required likely to budgetary be incurred” support • If It also the Govt. reminds of India that “Health creates is a a funding “State Subject” agency for as per mental the health Constitution care in – the thereby whole implying country, that in the entire form of responsibility University Grants for implementation Commission, State of various Govt. commitments could build all in kinds the bill of institutions would be on and State services Govt. for & the not welfare Central of Govt. mentally ill (Antony, 2014)  Grants by State Government to State Mental Health Authority- State Mental Health Authority Fund It’s a good provision that the bill proposes to constitute two separate funds for delivery of committed services
  17. 17. Chapter X: Mental Health Establishments  Procedure for establishing and maintaining Mental Health Establishments is cumbersome - might hinder service delivery  All other kinds of institution, like GHPUs, or even designated areas in a mental hospital where a patient has a constant presence and support of a relative or friend, need not be treated as a “mental health establishment” for the purpose of the Law Rajya Sabha Standing Committee  As per Clause 65 (4), Central Authority is empowered to make regulations for regulating mental health establishment Recommended that the State Authorities will be in best position to understand the requirements & practical difficulties in their own state & regulations made by them will be more suited to administration
  18. 18. Chapter XI: Mental Health Review Commission Rajya Sabha Standing Committee  For its implementation, “District Mental Health Review Boards” for each revenue district are made Recommended that the Mental Health Review Board proposed under Clause 81 (C) should be a Psychiatrist & not “any other mental health professional” as being a specialist Psychiatrist is better equipped to protect the interests of patient  “District Review Boards” are vested with powers to regulate the professional conduct of psychiatrist  And the Board consists of only one psychiatrist!!  Further as per section 86, all proceedings before the “Commission” and the “Board” shall be deemed as judicial proceedings, as laid down in IPC  There is a serious danger that the functioning of district boards would go against the federal nature of governance in the country
  19. 19. Chapter XI: Mental Health Review Commission  As “Mental Health” is a “state subject”, how could district boards which are created by the Centre & controlled directly by a central body, be legally acceptable?? (Antony, 2014)  And how could these “Boards” control mental health professionals, over the heads of the administrative machinery, Medical Councils and even the Judicial System, of concerned states??  In Section 90, it is laid down that the Commission will appoint an expert committee, who would prepare “guidance document” to tell psychiatrist regarding assessment and treatment decisions!! • All required skills and wisdom are to be “prescribed” by “guidance” documents issued by the Commission!!
  20. 20. Chapter XII: Admission, Treatment and Discharge  As per the bill, patient can challenge the involuntary admission (supported admission)  A panel of Mental Health Review Commission will then take a call and patient may be allowed to go home • Similarly, In our country expertise families of bear Psychiatrist the total in burden making of decisions mental illness, about and involuntary constitute by admission far the largest have manpower been challenged resource in treating mental illness • But Psychiatrists instead and of using patients them, have they also been have put been on the marginalized opposite side of legal fence
  21. 21. Chapter XII: Admission, Treatment and Discharge Prohibited procedures Unmodified ECT • Beneficial and safe procedure especially if there are Recommendation of Rajya Sabha Standing Committee: The Committee is of the opinion that Clause 104 prohibiting certain treatments, such as unmodified ECT and sterilization and restrain on chaining are highly desirable pro human right provisions • Reservations on ECT for minors: The committee suggests the provision of prohibiting the use of ECT on minors below a certain age based on the concept of maturity of minors - However no such cut off for age suggested!! no facilities for anesthesia ECT for minors • The bill stipulates that ECT to minors will be given only after permission from the Review Commission on a case-to-case basis • ECT cannot be given in emergency: what to do with youngsters having catatonic features - run around for permissions!!! • Where is evidence that ECT has more side effects in minors than in older adults? Why such a prohibition?
  22. 22. Conclusions  The bill has imported ideas from the West without due consideration of the ‘cultural & ground realities’ of our country  Rather than using family as an important resource they have been marginalized  Role & position of Psychiatrists diluted  Too much legal hassles for delivery of mental health care. Too cumbersome procedures  Future of GHPU’s at stake- will stigmatize psychiatry more  Commitment made in the bill for provision of various mental health services seems non-implementable for the Government
  23. 23. Thank You
  • VenkateshRaju17

    Oct. 20, 2017
  • amrtavarshini

    Apr. 8, 2017
  • sandipkamal

    May. 28, 2015

This was a presentation ANCIAPP 2014

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