[Polity] Rights of Persons with Mental illness and [Public Health] Mental Healthcare Bill: Features, Criticism

1. Two issues with Mental illness
2. #1: Taboo
3. #2 Abuse
4. What is Mental Illness?
5. Examples of Mental Illness
6. Rights given to Mentally ill patients
7. Right to Non-discrimination
8. Right to live with dignity
9. Confidentiality
10. Free treatment
11. Right to Humane Treatment without cruelty
12. Right to Personal Contacts & communication
13. Right to Information
14. Right to make Complaints
15. No punishment for Suicide Attempt
16. Right to Legal Aid
17. Duties of Government
    1. Authority #1: Mental Health Review Commission
    2. Authority#2: State Panels of the Mental Health Review Commission
    3. Authority#3: State Mental Health Authority
    4. Duties of Police Officers
    5. Duties of Prison Authorities
18. Diagnosis and treatment
19. Independent patients: Advanced Directives
20. Incapable patient
21. Minor Patient
22. Compulsory registration of Mental Health Establishments
23. Medical Research on Patient

Two issues with Mental illness

#1: Taboo

• Mental illness is curable just like a physical disease. Although there are some diseases where 100% cure is not available but still with the use of drugs and therapy, a patient can serve as a productive member of the society.
• Yet there exists lot of stigma and misunderstanding in the society.
• By and large, society believes that if a person was mentally ill, he will remain mentally ill forever. Therefore such person has hard time finding a job/bride/getting accepted by the society.

#2 Abuse

• Sometimes the relatives of mentally ill persons, are interested in lodging him into the asylum forever- to grab his property.
• Sometimes family members donot send the mentally ill person to the asylum fearing that his brothers and sisters won’t find suitable marriage partners. Then such person is forcibly confined at home, sometimes even chained and ill-treated.
• There are many bogus mental health care institutes, where patients are ill-treated, sometimes even sexually abused.

The Draft Mental Healthcare bill, tries to fix both this issues.

What is Mental Illness?

• a disorder of mood, thought, perception, orientation and/or memory.
• Includes mental conditions associated with the abuse of alcohol and drugs, but excludes mental retardation (e.g.Down’s syndrome).

Examples of Mental Illness

Name	Symptoms
Paranoia	Patient has deep conviction that everyone, including his or her closest family members, wants to injure or destroy him.
Heavy Depression	Patient feels that life is so dreary and unhappy that it is better to commit suicide.
Anorexia	person has an intense fear of gaining weight. He severely restricts food intake and usually becomes extremely thin.
Phobia	intense and persistent fear of a specific object for example telephone, spiders etc.
Obsessive-Compulsive Disorder(OCD)	Common obsessions include fears of contamination from germs, doubts about whether doors are locked or appliances are turned off, hoarding vast amounts of useless materials, and repeating words or prayers internally. Such persons keeps repeating same activity over and over again.
Schizophrenia	A person with schizophrenia has difficulty telling the difference between real and unreal experiences, logical and illogical thoughts, or appropriate and inappropriate behavior. He avoids social contacts, hears voices inside his that command him to act in strange or unpredictable ways.
Dementia/Alzheimer’s Disease	In the early stages, patient experience some memory loss  then to a decrease in thinking ability such as decision making. Later such patient cannot perform daily activities or recognize his loved ones, because of damage in brain cells.

Rights given to Mentally ill patients

The draft Mental healthcare bill gives following Rights
Right to Non-discrimination

• Public and private insurance providers cannot deny medical insurance to a person because he has (or had) medical illness.
• Mentally ill patient is entitled to the use of ambulance services in the same manner and quality as provided to persons with physical illness.

Right to live with dignity

1. All persons with mental illness have a right to live in, be part of and not be segregated from society.

2. A person cannot be labeled as mentally ill merely because

• He took past treatment or hospitalization  in mental health establishment
• His behavior is in non-conformity with moral, social, cultural, work or political values or religious beliefs prevailing in a person’s community

3. proof of a person’s current or past treatment for mental illness shall not by itself be ground for granting divorce
4. No person with mental illness shall continue to remain in an asylum, merely because he does not have a family or is not accepted by his family or is homeless. It’ll be responsibility of the Government  to provide them shelter/community homes.
5. Mentally ill person cannot be locked up in police custody or in jail.

Right to Confidentiality

• No person or authority shall classify that a person has (or had) a mental illness, except for purposes directly relating to the treatment of mental illness. For example, a newspaper cannot write a report like “Thieves robbed Mr.X but he unable to recall their faces because of dementia.”
• A person with mental illness has a right to confidentiality in the context of his mental health, mental health care and physical health care.
• Protection of privacy, in particular for women – during and after treatment.
• Right to confidentiality also applies to all information stored in electronic format / website / in public or private sector.

Right to Free treatment
Government shall provide budgetary allocations so that

1. No person with mental shall have to travel long distances to access mental health services.
2. Free treatment to Mentally ill person who are poor (with or without BPL card) or destitute or homeless.
3. As a minimum, essential medicines shall be available free of cost to all persons with mental illness at all times at health establishments.

Right to Humane Treatment without cruelty

1. No patient shall be subjected to any cruel, inhuman or degrading treatment in a mental health establishment
2. Not to be forced to undertake work in a mental health establishment
3. to not be subject to compulsory tonsuring (shaving of head hair).
4. not be forced to wear uniforms provided by the hospital.
5. To be protected from all forms of physical, verbal, emotional and sexual abuse.
6. No Electro-convulsive therapy or shock therapy for minors
7. For adult patient- ECT/Shock therapy only with use of anesthesia.
8. No Sterilization of men or women
9. No chaining of the patients
10. provision for food, space, and articles of personal hygiene during the stay in hospital.
11. have facilities for leisure, recreation, education and religious practices.

Right to Personal Contacts & communication

1. A patient in mental asylum has the right to refuse or receive visitors.
2. He shall be allowed to make a reasonable number of telephone/mobile phone calls at reasonable times of the day.
3. He shall be allowed send and receive mail and email.

Right to Information

1. A person with mental illness and his Nominated Representative shall have the right to know the nature mental illness and the proposed treatment plan including the side effects of drugs.
2. If the patient is unable to understand such information because of his illness, still his nominated representative can ask for the information.
3. When the treatment is complete, the ex-patient can ask for all the details regarding the treatment and medicines given to him.

Right to make Complaints

• A mentally ill person or his nominated representative can complaint for Deficiencies or poor quality of treatment given in the hospital to the State Mental Health Authority
• and if not satisfied with the response he can approach State Panel of the Mental Health Review Commission

No punishment for Suicide Attempt

• Any person who has attempted to commit suicide shall be examined by a psychiatrist.
• If the psychiatrist certifies that the person has a mental illness, then such person cannot be prosecuted for attempted suicide under Indian Penal Code (Section 309).

Criticism

• This can only be described as a stop-gap arrangement.
• The section 309 of Indian Penal Code should be deleted. No person should be tried for attempting suicide, irrespective of what psychiatrist says about his mental condition.
• The only countries in which attempt to suicide is punishable are India, Pakistan, Bangladesh and Malaysia. The penalty had its roots in the religion that considered life and death as godly acts over which man should not have any control, notwithstanding the legality of capital punishment.
• But Scientific studies have proved that a person attempting suicide is a victim of circumstances and deserves sympathy and psychiatric treatment, rather than punishment.

Right to Legal Aid

• Person with mental illness shall be entitled to receive free legal services to exercise any of the rights given to him.

Duties of Government

• Through television, radio, print and online media, display ads to create awareness and reduce stigma associated with mental illness.
• Government  shall setup following authorities for securing the rights of Mentally ill patients.

Authority #1: Mental Health Review Commission

• HQ: Mumbai

Composition

1. President =serving/ retired Chief Justice of a High Court
2. Psychiatrist with at least 15 years experience
3. a person with mental illness or representative of persons with mental illness and,
4. representative of families and care-givers to persons with mental illness or NGO in the field of mental health, and
5. One member with a background in public health administration.

Functions

• Appoint and remove members of the State Panels
• Give guidance to the State Panel
• Advise the Central Government on matters relating to the promotion and protection of rights of persons with mental illness

Authority#2: State Panels of the Mental Health Review Commission

Composition

1. Chairman: Serving / retired District Judge
2. Representative of the District Collectors
3. healthcare professionals
4. Persons with past mental illness/ care givers/ NGOs

Functions

• It’ll entertain the complaints from mentally ill persons / their nominated representatives.
• In exceptional circumstances, the State Panel shall accept an application made verbally over telephone from a person admitted to a mental health establishment.
• It’ll have judicial powers to call for evidences, witnesses.
• It can impose punishment ranging from six months to two years and/or fine from Rs 10,000 to Rs five lakh
• Visit jails to make sure no mentally ill person is forcibly lodged in it.
• Registration, renewal and modification of advanced directives (and maintain electronic database) and give that database to concerned psychiatrist. (explained in bottom part of this article)

Authority#3: State Mental Health Authority

• This will be made up of Secretary, Department of Health, State Government and other Government officials.

Functions of State Mental Health authority

1. Inspect and register all mental health establishments in the state.
2. maintain and publish (including online on the internet) a register of such establishments.
3. supervise all mental health establishments in the State and receive complaints about deficiencies in provision of services.
4. make rules and regulations for the registration of clinical psychologists, mental health nurses and psychiatric social workers in the State.
5. Train judicial officers, police officers, mental health professionals etc. about the provisions and implementation of this Act.
6. Advise the State Government on all matters relating to mental health care and services.

Duties of Police Officers

Wandering people

• If the police officer believes that xyz person wandering around his area, and has mental illness -then he shall to take him to the nearest public health establishment. Two situations can happen

Situation 1:

• If the psychiatrist certifies that xyz person has mental illness, then
• Police officer shall lodge an FIR of missing person, try to find the relatives/family members of that patient.
• he’ll produce the patient in front of magistrate, and magistrate will send him to a mental asylum for treatment.

Situation 2:

• If the psychiatrist certifies that xyz person doesn’t have mental illness, then
• Such person will be sent to either his home or to Government establishment for homeless people.

• In either situation, a homeless/wandering person cannot be locked up in police custody.

Cruel family members

• If the police officer believes that xyz person living (not wandering) in his area, has some mental illness but he is forcibly confined in his home or neglected or mistreated by his family members. (just like Anupam Kher in the movie “Betaa”)
• Then the police officer shall bring this matter before a Magistrate, who shall decide the future course of action.

Duties of Prison Authorities

• The Medical officer of every jail shall send quarterly reports to the State Panel that there are no prisoners with mental illness in my jail.

All sounds well and good until now. But still the experts are criticizing this bill heavily, why?

Let’s examine those provisions of the bill.

Diagnosis and treatment

There are two types of patient:

Independent patients: Advanced Directives

1. Those in a early stage / mild disease. They are aware of what they’re doing and they’re capable of making decisions e.g. “yes I feel I’ve xyz disease and I need to get treated”
2. These people can write an application called “advanced directives” this is similar to property will. It lists the directives like where do you want to get treatment, who is your nominated representatives to decide treatments or legal actions on your behalf etc.
3. State Panels of the Mental Health Review Commission will keep this database and provide it to the concerned hospital or psychiatrist.

Incapable patient

1. Those who are suffering from some severe mental disease/emergency situation
2. They’re completely dependent on family and relatives for every decision.
3. Such person can be admitted to a mental care institute on the written consent by his guardian/nominated representative. But he cannot be kept in the institute for more than 30 days. After every 30 day, the psychiatrists will have to give certificate whether he is treated or required further medical care.
4. State Panels of the Mental Health Review Commission will keep an eye on such cases.

Criticism

• The State Panels will be usually under-staffed, they cannot physically visit and check every patient. And this give ample opportunity to abuse the law for example
• A private mental institute has profit motive to keep writing reports that person still needs treatment after every 30 days.
• If the family members/relatives of the patient want to grab his property, they’ll also not raise objection to above practice. In fact they might encourage the private institute to keep the patient lodged in forever.
• Thus this bill deprives liberty of disabled persons and favours medical professionals and psychiatrists.
• the role of the judiciary has been taken off and a psychiatrist can decide whether a person can be put in mental asylum or not.

Minor Patient

• A person less than 18 years shallnot be admitted to mental care institute except in exceptional circumstances.
• He cannot be given Electro Convulsive Therapy (ECT) or shock therapy.

Criticism

Banning of Electro Convulsive Therapy (ECT) or shock therapy altogether in minors can be a problem because many a time it is an emergency life-saving procedure. Say a 16-year-old with severe depression is wheeled into the OPD with indications of suicidal ideation; do we not give him ECT? The legal provisions should not affect the medical aspects of care.” (Dr Roy Abraham Kallivayalil, national president of Indian Psychiatry Society)

Compulsory registration of Mental Health Establishments

• Bill says No person or organization shall run a mental health establishment unless it has been registered with the State Mental Health Authority. You’ve to apply, they visit and inspect your premises and give you the license.

Criticism

1. Will lead to license-inspector-bribery raj.
2. The penalty provisions are not deterrent enough, as there is only a fine of Rs 50,000 proposed on the first offence
3. There is no scope for general hospital care of psychiatry. Mentally ill persons have to be treated in separate registered institutions.
4. We have only 4,000 psychiatrists in government and private sector together. Compulsory registration would lead to many private hospitals shutting shop. This would add to the existing shortage of specialists.

Medical Research on Patient

• Medical professionals can conduct research, on patients with mental illness – including testing of drugs, but only after taking written consent of patient or his nominated representative/ guardian.

Criticism

• Private hospitals have profit motive in allowing pharma companies to conduct research. And if such companies offer money to nominated representative/relatives, then imaging the plight of a patient- they will be turned into Guinea pigs.
• Bill needs more stringent provisions and oversight over medical research on mentally ill patients.