Mental Health Care Bill consised in ppt form with latest data from editorials from IJP

1. Mental Health Care Bill
Presenter : Dr. Udayan Majumder
Resident in Psychiatry, RIMS
1

2. What is a Mental Health Act/ Care bill ?
2

3. 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
3

4. 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
4

5. Mental Health Acts In India?
5

6. 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
6

7. 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
7

8. 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.
8

9. Why 1912 Act needed to be changed
Offensive terminologies used in Indian Lunacy act of 1912:
 Lunatic person
 Criminal Lunatic
9

10. 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.
10

11. 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.
11

12. 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.
12

13. 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 .
13

14. 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.
14

15. 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.
15

16.  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
16
Contd.

17.  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.
 17
Mental Health Care Bill 2016

18. 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
18
Chapters and Clauses

19. 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
19

20. 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
20

21. ‘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”.
21
Definition of Mental Illness

22. 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
22

23. 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
23
Contd.

24. 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
24
Contd.

25. 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
25

26. 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.

27. Discharge procedures
 An independent patient may get
himself discharged from the mental health
establishment without the consent of the medical
officer 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

28. 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

29. 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

30. 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

31. 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.

32. Admission of Minors
2 Psychiatrists 1 Psychiatrist & 1 mental
health professional
1 Psychiatrist & 1
medical practitioner
Minor

33. Contd.
 Nominated Representative to
be with the minor for the
entire duration of admission
 Treatment for the minor with
informed consent of
Nominated Representative.

34. 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

35. 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.

36. 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

37. 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.

38. Criticism/suggestions of
Mental Health Bill 2016
1. Mental Health Establishment
2. Capacity to make mental health care and treatment
3. Advance directives
4. Nominated representatives
5. Mental health review boards
6. Right to confidentiality
7. Discharge planning
8. Role of family members
9. Treatment guidelines
10. Lack of resources
38

39. 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 general
nursing 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” 39

40. 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
40

41. 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
41

42. 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 hospital
2. Treatment choice may be 2nd or 3rd choice some
situations
3. Cochrane review studies doesn’t support advance
directives in mental illness
 Can put family to heavy burden and difficulties
42

43. 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 43

44. 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
44

45. 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
45

46. 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 46

47. 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
47

48. 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
48

49. 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
49

50. 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 50

51. 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
51

52. 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].
52

53. 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-)
criminalization of attempted suicide in India: A review. Ind Psychiatry J
2014;23:4-9.
 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]
53

54. Thank you 54