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Mental Health Care Bill

Presenter : Dr. Udayan MajumderResident in Psychiatry, RIMS

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What is a Mental Health Act/ Care bill ?

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Mental Health Act It is a short title used for all kinds

legislation  relating to mental health laws.

Developed to protect the basic fundamental right of people “Right to live ” that comes under article 21 of constitution.

IPC 309

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The Mental Health Care Bill sets out:• What is Mental Health?

• When and how people can be treated if they have a mental disorder

• When people can be treated or taken into hospital against their will?

• What people's rights are, and the safeguards which ensure that these rights are protected

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Mental Health Acts In India?

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MENTAL HEALTH ACTS IN INDIA

PRE-INDEPENDENCE

1858:Indian Lunatic assylum act of 1858

1912:Indian Lunancy act of 1912

POST-INDEPENDENCE

1947:Indian Psychiatric association established.

1987:Mental Health act of 1987(indian

psychiatric society)

Mental Health Care Bill proposed in 2013

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1858:Indian Lunatic Assylum act of 1858

The main stress was on preventing the society from dangerousness of mentally ills and taking care that no sane person is admitted in these asylums

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1912:Indian Lunacy act of 1912

The 1912 Act guided the destiny of Psychiatry in India

regulated and supervised by a central authority.

Procedure of admission and certification in this respect was clearly defined.

The provision of voluntary admission was introduced.

Psychiatrists were appointed as full time officers in these hospitals.

Still, the main stress was on preventing the society from dangerousness of mentally ills and taking care that no sane person is admitted in these asylums.

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Why 1912 Act needed to be changed

Offensive terminologies used in Indian Lunacy act of 1912: Lunatic person Criminal Lunatic

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MHA Act 1987

Came into effect in April 1993

To ensure availability and accessibility of minimum mental health care for all.

10 chapters and 98 Sections

Main Aim to establish governing bodies at central and state level for licensing and supervision of psychiatric hospitals and nursing home.

Protection of human rights of mentally ill.

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MHA 1987

To promote community participation in mental health service development and to stimulate self-help in the community

Provisions of voluntary admission and admission on the reception orders were retained.

Role of Police and Magistrate to deal with cases of wandering mentally ill.

Guardianship and Management of properties of mentally ill.

Provisions of penalties in case of breach of provisions of the Act.

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Why MHA 1987 needed Amendment

Concerned with legal proceedings and guardianships. MHA 1987 has not been able to adequately protect the rights of person with mental illness and promote access to the mental health care in the Country.

Human right issues and mental health care delivery are not properly addressed in this Act

Human right activists have questioned the constitutional validity of the MHA, 1987 because it involves curtailment of personal liberty without the provision of proper review by any judicial body.

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Need of the new bill:

It is provided that research on mentally ill can be carried out by consent of guardian. This provision violates human rights.

Once a person is admitted to mental hospital he is termed insane or mad by the society. There should be provisions in the act to educate the society against these misconceptions in which this act lacks.

Rights-based protection of mentally-ill person’s .This was not focused in focus of the Mental Health Act 1987 .

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The Mental Health Care Bill, 2013

Comes under Ministry Of Health and Family Welfare.

Introduced in the Rajya Sabha on August 19, 2013.  The Bill repeals the Mental Health Act, 1987.

The union cabinet has approved the amendments on Jan 30, 2014.

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Mental Health Care Bill , 2013

The new Bill is much longer than the existing MHA having 16 Chapters and 137 clauses.

The Draft Mental Healthcare bill, tries to fix both the issues of taboo and Abuse related to mental illness.

MHA 1987 was medical model of disability, while the 2013 Bill understands mental illness from a Social model, giving a broad and inclusive definition as to what may constitute mental illness. A entire chapter covers the criteria for determination of mental illness.

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The proposed on MHCB, 2013 came after ratifying the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) which came into force in 2008. MHCB, 2013 aims

To provide access services for persons with mental illness and To protect, promote and fulfill the rights of person with

mental illness during the delivery of mental health care and services and for matters concerned therewith. 

Enactment of this bill will replace the Mental Health Act (MHA) 1987 and the new Act may be called the Mental Health Care Act (MHCA), 2013

Contd.

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Comes under Ministry Of Health and Family Welfare

Passed in the Rajya Sabha on August 8th , 2016. 

If passed in Lok Sabha, then it repeals the Mental Health

Act, 1987.

The premeable clearly depicts protect, promote and fulfill

rights of persons with mental illnesses.

Consists of 16 chapters and 126 clauses.

Mental Health Care Bill 2016

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CHAPTER I: PRELIMINARY:CLAUSES

CHAPTER II: MENTAL ILLNESS AND CAPACITY TO MAKE MENTAL HEALTH CARE AND TREATMENT DECISIONS

CHAPTER III: ADVANCE DIRECTIVE

CHAPTER IV: NOMINATED REPRESENTATIVE

CHAPTER V: RIGHTS OF PERSON WITH MENTAL ILLNESS

Chapters and Clauses

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CHAPTER VI:DUTIES OF APPROPRIATE GOVERNMENT

CHAPTER VII: CENTRAL MENTAL HEALTH

CHAPTER VIII: STATE MENTAL HEALTH

CHAPTER IX :FINANCE,ACCOUNTS AND AUDIT

CHAPTER X :MENTAL HEALTH ESTABLISHMENTS

CHAPTER XI: MENTAL HEALTH REVIEW COMMISSION

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CHAPTER XII: ADMISSION, TREATMENT AND DISCHARGE

CHAPTER XIII :RESPONSIBILITIES OF OTHER AGENCIES

CHAPTER XIV: RESTRICTION TO DISCHARGE FUNCTIONS BY PROFESSIONALS NOT COVERED BY PROFESSION

CHAPTER XV: OFFENCES AND PENALTIES

CHAPTER XVI: MISCELLANEOUS

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‘Mental illness’ is a “a disorder of mood, thought, perception, orientation and memory which causes significant distress to a person or impairs a person’s behavior, judgment and ability to recognize reality or impairs that person’s ability to meet the demands of daily life and includes mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation”.

Definition of Mental Illness

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Features of the New Bill

1. Mental health Professionals

2. Mental Health Establishments

3. Legal Capacity

4. Informed Consent for treatment and researches

5. Rights of persons with mental illness

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6. Administrative Bodies

7. New rules on admission, leave and discharges

8. Duties of the Government

9. Special Measure for Minors

10. Decriminalizes attempted suicides

Contd.

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11. Medical insurance to cover mental health treatment

12. Ban on ECT without anaesthesia, psychosurgery and

chaining

13. Nominated representatives

14. Emergency treatment

15. Granting Divorce

Contd.

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Appreciation of the MCHB 2016

Decriminalization of attempted suicide

Rights of person with mental illness

Provision for medical insurance for treatment for mental illness

Duties of appropriate government

Admission, Treatment and Discharge INDEPENDENT ADMISSION

Any person who considers himself to have mental illness and desires admission, who is not a minor.

Admitted if the Medical officer or Psychiatrist is satisfied that

A. Mental illness of severity requiring admission

B. Patient should benefit from admission and treatment

C. Request made is under free will and not under undue influence and has capacity to make mental health care decision

D. Informed consent

E. Bound to rules and regulations of the establishment.

Discharge procedures An independent patient may get

himself discharged from the mental health establishment without the consent of the medicalofficer or mental health professional in charge of the MHE.

Minor : If the nominated representative no longer supports admission or requests discharge of the minor, from the mental health establishment, the minor shall be discharged thereof

Contd. Power with the mental health professional to

prevent discharge of person for a period of 24 hrs to allow assessment if necessary ?

Recent suicide attempt/threatening

Violence towards others

Inability to care for oneself

Admission and Treatment up to 30 days

When and how? Upon application by Nominated Representative 2 mental health professionals, including a Psychiatrist,

after independent examination

Feels that the person has a mental illness of such severity that the person

a) Recently threatened or attempted to cause bodily harm

b) Recently behaving violently towards another person, or causing another person to fear bodily harm

Contd.

c) Recently shown inability to care oneself to a degree that places at risk of harm to oneself

Limited to a period of 30 days.

To be informed to MHRC within 7 days (10 days for Northeast) of admission

Admission and treatment exceeding 30 days

Continue admission in the establishment

Same procedures as the previous clause, where a re-examination will be done, but 2 psychiatrists examine the patient

Consistent inability to take care of oneself

To be informed to MHRC, to be approved within 21 days (30 days for Northeast)

Limited to 90 days. Renewal to 120-180 days.

Admission of Minors

2 Psychiatrists 1 Psychiatrist & 1 mental health professional

1 Psychiatrist & 1 medical practitioner

Minor

Contd.

Nominated Representative to be with the minor for the entire duration of admission

Treatment for the minor with informed consent of Nominated Representative.

Leave of absence Granted by - Medical officer or Psychiatrist

After securing consent of Nominated Representative

Power with the practitioner to terminate when appropriate to do so

If the patient does not return, contact the patient on leave, or nominated Representative or both

Absence without leave

Without discharge, absents one-self

Taken into protection by Police Officer at the request of the Psychiatrist in charge and brought back.

Emergency Treatment Who can treat ?

Any Registered Medical Practitioner, subject to informed consent from the Nominated Representative.

When ?

When its necessary to prevent :

a) Death or irreversible harm to health of the person, or,

b) Person inflicting serious harm to himself/others

c) Person causing damage to property

Contd. ECT is NOT permitted as an emergency procedure

Emergency treatment limited to 72 hrs (96 hrs for Northeast) or till the person is assessed at a mental health establishment.

Disasters/emergencies, it may extend to 7 days.

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Criticism/suggestions of Mental Health Bill 2016

1. Mental Health Establishment2. Capacity to make mental health care and treatment 3. Advance directives4. Nominated representatives5. Mental health review boards6. Right to confidentiality7. Discharge planning8. Role of family members9. Treatment guidelines10. Lack of resources

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Mental Health Establishments

NMHP mandates integration of mental healthcare into primary healthcare

MHCB mandates all the establishments to take license to treat patients

In MHA‑1987, “any general hospital or generalnursing home established or maintained by the government and which provides also for psychiatric services” were excluded from the ambit of definition “psychiatric hospital/ psychiatric nursing home”

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Contd. Refusal of private hospitals and nursing homes

Hostels, prisons, jails, juvenile homes, temples, churches, dargahs keeping patients with mental illness will be at stake

Anticipated “License Raj” of harassing MHC providers

Supposed to inflict greatest damage to the system of mental health care delivery

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Capacity to make MHC and treatment

Inadequate & can have dangerous consequences

Clause by default says everyone has capacity and right and so the contrary has to be proved before involuntary admission

Psychotic patients with absent insights usually refuse admission ultimately troubling the family

Permission be sought from the mental health board

Proposed admission by informed consent of family

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Advance directives To be followed by mental health profesionals during

treatment Becomes difficult in Indian scenerio when :1. Treatment proposed in a costly/far to reach

hospital2. Treatment choice may be 2nd or 3rd choice some

situations3. Cochrane review studies doesn’t support advance

directives in mental illness Can put family to heavy burden and difficulties

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Nominated representatives Selection by patient (with colored thought and

perception) may be affected by the illness

Nominated representative may break the Indian family system who ultimately care for the patient after all odds

Costly treatment selection by the nominated representative can affect the whole family

Ultimately at some point the family may disown the patient

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Mental health review boards Quasi judicial boards May introduce hurdles in smooth treatment

procedures Limited boards to visit individual patient is

questionable and delay in addressing the issue is anticipated (e.g. festive seasons in India)

Tedious, prolonged and costly judicious procedures Time limit for doctors while no time limit for

boards

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Right to confidentiality The MHCB provides unlimited access to all the

documents of the patient by nominated representative

“Breach of confidentiality” by Mental health professionals as per Medical council ethics, 2002

Impinges on fundamental rights “right to privacy”

Proposed disclosure of family members only in verbal form and written form only on written request

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Discharge planning Ultimate decision of continuation of treatment or not lies

on patient/ nominated representative

“Continuity of care” is at stake due to lack of role of family members and most of all the treating psychiatrist/physician

Bill is silent about much needed community care

Finally pressure over the family members even if they want treatment in proper way

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Role of family members Not only protects right of the patient but also

promotes family participation in active treatment process

MHCB undermines the role of family members in providing care

Bill needs to modified that in case of involuntary treatment, presence of at least one family member should be present

Management of property of person with severe mental illness is absent

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Treatment guidelines Treatment should be as per national professional

guidelines ECT has been established as a modality of choice in

many major psychiatric illnesses The bill banns ECT during emergency management as

well as in minors Withholding the same just for the permission of

mental health board is “delay in justified treatment” Hands of treating Psychiatrist this way is curtailed to

a large extent

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Lack of resources Bills overloaded with right based ideology not fully

acceptable in Indian family structure Logistic problems like poor infrastructure, inadequate

mental health workforce, low budget allocation for MHC, siphoning fund of MHC to general health care

Bill needs to focus on smooth running of the MHC rather than over exaggeration on compensation

Urgent need to introduce basic psychiatry at UG level (MBBS) for learning of treatment of basic psychiatric diseases

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Neglected role of statutory body MHA‑1987 was conceived, piloted and drafted by the Indian

Psychiatry Society (IPS) Though invited to the consultation process at different

stages, IPS was not assigned any role in drafting of the current Bill

IPS expressed apprehensions about a number of provisions in the Bill as not considered to be in the interest of persons with mental illness

MOHFW, for unknown reasons, entrusted the job of drafting the current Bill and conducting the initial consultation process to a private psychiatrist, who is not even an ordinary member of the IPS

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CONCLUSION

1. The MHCB, 2016 comes out to be a praiseworthy effort for addressing the long standing problems encountered by patients and practitioners in the sector of mental health care.

2. The bill can bring a radical change in the field of mental health care and service in our country.

3. Even though some sections of this bill are being criticized but still this bill seems more humane and appropriate in the current situation.

4. With further amendments in necessary areas this bill can prove a blessing to the Mental health care system

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References Rao GP, Math SB, Raju M, Saha G, Jagiwala M, Sagar R, et al. Mental

Health Care Bill, 2016: A boon or bane?. Indian J Psychiatry 2016;58:244-9.

Narayan CL, Shikha D, Narayan M. The Mental Health Care Bill 2013: A step leading to exclusion of psychiatry from the mainstream medicine? Indian J Psychiatry 2014;56:321-4.

Antony JT. The mental health care bill 2013: A disaster in the offing?. Indian J Psychiatry 2014;56:3-7.

Kala A. Time to face new realities; mental health care bill-2013. Indian J Psychiatry 2013;55: 216-9.

Mental Health Care Bill. Available from http://www.prsindia.orguploads/media/Mental%20Health/Mental%20health%20care%20as%20 passed%20by%20RS.pdf. [Last accessed on 2016 Aug 15].

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Contd. Math SB, Srinivasaraju R. Indian psychiatric epidemiological studies:

Learning from the past. Indian J Psychiatry 2010;52 Suppl 1:S95-103. Ranjan R, Kumar S, Pattanayak RD, Dhawan A, Sagar R. (De-)

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Pattanayak RD, Sagar R. Health insurance for mental health in India:A welcome step toward parity and universal coverage. J Ment Health Hum Behav 2016;21:1-3

Math SB, Murthy P, Chandrashekar CR. Mental health act (1987): Needvfor a paradigm shift from custodial to community care. Indian J Med Res 2011;133:246-9

Seventy-Fourth Report on the Mental Health Care Bill-2013, Rajya Sabha Secretariat, November; 2013. Available from: http://www. 164.100.47.5/ webcom/MainPage.aspx. [Last accessed on 2016 Jan 19]

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Thank you