Major deficiencies in the Mental Health Care Bill (MHCB) 2016

To, The PM,     We, the psychiatrists of this country represented by the Indian Psychiatric Society (IPS)(the largest Professional Association of Indian psychiatrists) request your intervention in the above mentioned Bill passed by Rajya Sabha on 8 th August 2016, that seeks to improve the mental health care of the mentally ill in the country, and repeal the existing Mental Health Act 1987.
Sir, the Bill in the current form is flawed on many counts and not in harmony neither with the vision of the guiding document (UN General Assembly Resolution No A/RES/46/119) nor with the socio cultural ethos or realities of the country. It is based on several concepts borrowed from the West which are totally alien to the Indian system. Instead of improving mental health care, this Bill will make treatment to the mentally ill more stigmatizing, difficult, delayed and deprived.
1. The Preamble or the opening lines of the Bill state “ A Bill to provide for mental health care and services for persons with mental illness and to protect, promote and fulfill the rights of such persons during delivery of mental health care and services ……”. We wish to emphasize that the rights of the mentally ill need protection in all circumstances and throughout life. Why the protection or rights should be limited only to “ during treatment” ? The UN Gen Assembly Resolution, on which this Bill is said to be based, is called as “ The Protection of Persons with Mental Illness and Improvement in Mental Health Care”. We need to retain the same focus on protection of the persons with mental illness and improvement in mental health care. The focus should be on “delivery of mental health care” rather than only on “protection of rights during delivery of mental health care”.

Thus, the Preamble itself is grossly deficient and misplaced, and needs to be changed making it more inclusive and comprehensive. A Bill whose vision is wrong cannot be right.

 

2. The bill marginalizes the families who in India bear the major burden of care of the mentally ill. The MHCB is not suitable for our culture as it has borrowed Western concepts never heard and practiced by mental professionals and family members in this country. The MHCB totally ignores the parents and the families and for the first time proposes that the patient can nominate any person as his nominated representative who will take all the major decisions regarding his care and property. Since many mentally ill patients lack insight during acute phase of illness, they can be easily cheated by so called Nominated Representatives and parents will be helpless. Further, it is presumptuous that others will act in patient’s best interest, and shifting the burden of care on “ other persons” who are not emotionally involved with the patients are unlikely to show compassion needed for such patients.

 

3. The bill seeks to segregate the treatment of the mentally ill from the mainstream medical establishments and will therefore increase stigma. We on one hand want to destigmatize mental illness and on the other hand restricting the provision of mental health care in general hospitals and primary care facilities. Mental illness, except those which are severe or in need of longer term treatment in a high dependency unit, should be treated at par with medical/ surgical illnesses treatment for which should be freely available.

 

4. Major decisions relating to treatment of mental illnesses are proposed to be taken by judiciary or non mental health professionals i.e. Mental Health Review Commission. Can or should the courts direct the type and duration of treatment of mental disorders? It will delay treatment, make it costly and complicated.

The parents will not be able to seek indoor treatment for many of their family members including children without the permission of Mental Health Review Commission.

 

5. During the acute phase of major mental illness patients may lack insight and thus may not be willing for treatment from which they recover quickly and regain insight. The family members use gentle pursuation, or seek the help for relatives and friends to bring such patients for treatment. The MHCB proposes that patients suffering from major mental illness cannot be treated without their consent. This not only will increase disruption in the family, but will cause the severely mentally ill patients to cause disruption in society by aimless roaming, violence, or may even end up in prisons due to untreated mental disorders.

 

6. Concept of advance directive is alien to our system and detrimental to the interests of the severely ill patients. Many patients in acute mania or in severe stage of illness will not be treated if such a patient has given advance directive.

 

7. The landmark development in India was starting of the psychiatry units in general hospitals and medical colleges. This development brought mental illness on a similar platform as medical illness. There was reduction in stigma as families were comfortable in seeking treatment in general hospitals. However, these facilities are now proposed to be brought under the term “Mental Health care Establishments” in the Bill and will be legally regulated. It will make the treatment very cumbersome and stigmatising . This will also affect the postgraduate training as they will be denied the opportunity to see variety of cases as all the beds will soon get filled with chronic cases and there will be no bed for psychiatry emergencies.

 

8. The biggest challenge in the treatment of mental illness is the rehabilitation, but MHCB is totally silent about the care and rehabilitation of patients after discharge from long stay facilities . These patients will require constant care and support while staying in the community and MHCB must address this issue like rest of the world has done.

 

9. We understand that the Govt of India is under obligation to amend the existing acts governing the disability in order to bring these in conformity with the UNCRPD. But , it is important to recognise that majority of common mental disorders do not have associated disability and it is just the more severe ( which are only a small proportion ) form of mental disorders which can lead to disability. Thus , there is no justification to bring all the provisions of UNCRPD in the MHCB.

 

10. The role of psychiatrists and other mental health professional has been totally marginalized and replaced by non professionals which again does not serve the interests of patients. Psychiatrists are the specialists doctors who specialize in the science and art of treating mental illness and should be the major expert groups involved in decisions about the care of the mentally ill.

 

 

Sir, care of the mentally ill is a serious and sensitive matter and cannot be handled in a piecemeal hurried manner. The psychiatrists of this country requests your kind personal intervention in the matter. The MHCB 2013 in its present form will cause more harm to the interests of the mentally ill and their families. It is a Bill whose preamble and objective is wrong, and therefore, can not be right. Moreover the current Bill is passed with 134 amendments. It would be better if it is rewritten.

 

IPS has submitted its reservations and observations several times in the past, none of which have been taken into consideration. IPS does not endorse it in its present form.

 

11. It is prayed that that the Bill is withdrawn and opened for wider discussion and scrutiny and concerns of the IPS as the major stakeholder are heard.
Psychiatrists are the specialists doctors who specialize in the science and art of treating mental illness and should be the major expert groups involved in decisions about the care of the mentally ill.

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