This was a presentation ANCIAPP 2014

1. The Mental Health Care Bill :
Dark Clouds !
Ajit Avasthi
Sudhir Mahajan
Department of Psychiatry
PGIMER, Chandigarh

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Thank You