Mental health bill

Sir,
I wish the following suggestions in regard Mental Health Care Bill 2013 be incorporated.
I wish to be given chance of oral evidence in favour of my suggestions. Kindly give me appropriate time for oral evidence in this regard.
The suggestions are as follows:
1.The Mental Health Care bill 2013(hereinafter is mentioned as THE BILL)
2. The Bill  is modern in terminology and its approach is progressive.
3.The provisions under CHAPTER V , RIGHTS OF PERSONS WITH MENTAL ILLNESS are laudable. To quote :
Section 18 subsection(3) The appropriate Government shall make sufficient provision as may be necessary, for a range of services required by persons with mental illness. And subsection (4) Without prejudice to the generality of range of services under sub-section (3), such services shall include––(a) provision of acute mental health care services such as outpatient and inpatient services.
Also the provisions in same section 18 subsection(5) (a) integrate mental health services into general health care services at all levels of health care including primary, secondary and tertiary health care and in all health programmes run by the appropriate Government.
The above provisions are welcome by me as Psychiatrist and member of my organization. I fully support the Ministry of Health, GOI, on these provisions in the bill.
4 .The provision regarding exemption from prosecution to those who attempt suicide is much needed and most welcome.  I compliment the ministry on this and hopes that it could include all those who attempt suicide since insurmountable mental distress is undeniably present in all those who attempt suicide, even if there is no diagnosable mental illness.
5. The very aim of making mental health care available to all seems to be defeated when we examine admission procedures as described in sections 96 to 99 of chapter XII which deals with Admission , Treatment  And  Discharge of  person with mental illness.

6. Section 96 has provision for admission of person with mental illness below the age 18 (MINOR) which need formal application by nominated representative and to be examined by two psychiatrists (one Psychiatrist and one Mental health professional) individually. The admission of single day even when the relatives are also staying with the minor has to be reported to concerned board. The admission if extends to 30 days then again the Psychiatrist in-charge of establishment has to inform the concerned board and compulsory review by the board is required. This system of reporting to concerned board and compulsory review is to be repeated every thirty days.

7. In W.H.O. Expert Committee on Mental Health (1955) “the Court review prior to compulsory hospitalization was severely criticized as stigmatizing the patient. Non-judicial forms of hospitalization with power to appeal afterwards were believed to be much more desirable. The Expert Committee endorsed the principle of ready access to treatment with opportunity for easy appeal by patient at any time against his involuntary admission. The relatives of minor who are in well capacity make treatment decisions and discharge there to, while staying with the minor all the time in open ward, hardly any issue of human right protection arise”.

8. This is barren fact that there are many Districts in India where no Psychiatrist or Mental Health Professional is available and many more with a single Psychiatrist is available. The number of Districts with many Psychiatrists is few. The admission having rider of being examined by two Psychiatrists individually, is not feasible in majority of places in India.  So how laudable concept of providing mental health to all is pronounced in the BILL, the ground realities are different. The bill is contradictory and self defeating in this sense.

9. I therefore request through this memoranda to retain the position held by Mental health Act 1987 of allowing minor admission as independent (volunteer) admission were done on the request of relatives. The relatives staying during admission can make a request for treatment and make decision of discharge of their wards. I would also pray to remove the requirement of examination by two mental health professional individually from the respective section   and subsection of the Act.

10. Section 98 has provision to admit person with mental illness who
(i) has recently threatened or attempted or is threatening or attempting to cause bodily harm to himself; or
(ii) has recently behaved or is behaving violently towards another person
or has caused or is causing another person to fear bodily harm from him; or
(iii) has recently shown or is showing an inability to care for himself to a degree that places the individual at risk of harm to himself;

In the bill Such person with mental illness are to be admitted on formal application by the nominated representative and again as in the case of minor need to be examined by two mental health professionals individually. The admission need to be informed to the concerned board and if this continues more than 30 days then Establishment in charge has to inform concerned board and mandatory review by concerned board is required.
11. I humbly want to submit that such patients in medical terminology are acutely psychotic and they are usually treated in open wards of hospital where the relatives as a rule stay all the time with them and approach is multidisciplinary. For first few weeks this is not possible to assess and diagnose to be suffering purely from mental illness thus at least for six weeks the formalities to report to board are unwarranted.
12. Similarly examination of person with mental illness by two Mental Health Professionals is not feasible seeing acute shortage of such professionals in the country.
13. Section 99 is provided for admission section 98 exceeds 30 days which requires mandatory review by board to be repeated every 30 days of admission.
14. Having to seek approval for each admission under Section 96 and 98,and for all subsequent renewals in sections 96 and 99 will lead to harassment of patients ,the families and the psychiatrists alike. It appears totally un-necessary for approval of review commission to be mandatory for each such admission, when  the family members think that admission is necessary and patient is not challenging this. Mere information being sent to the concerned board should be sufficient.
15. Considering that vast tracts of central India and northern hills have no mental health facilities for hundreds of kilometers, the time period for Emergency treatment (Section 103) should be at least 96 hrs.
16. Having to send report of each involuntary (described in Bill as those require High Level of support) admission to Mental Health review board will lead to un-necessary paper work. The mental Health review board  may intervene only those involuntary admissions, which are challenged by patients, serves the purpose. The post-admission review of such person with mental illness having any complaint serves the purpose. Also, if an approval is delayed by the commission panel, beyond prescribed limits, the patients in the interim should continue to be admitted, to prevent harassment to him and the families. For any delay, patients should be compensated by the commission.
17. Blanket prohibition of ECT for patients below 18 years is based on sentiments rather than on science. There is no evidence whatsoever that ECT is unsafe below age 18 years. There are plenty of case reports and case series of the use of ECT in children and adolescents. These document the efficacy of the treatment in patients who were treatment-refractory, catatonic, or suicidal. The only caveat is that seizure threshold, for physiological reasons, is lower in youth; so, all that the clinician needs to do is to adjust the dose that is administered.
18. The commonest psychotic illness Schizophrenia typically starts between 15-20 years of age and many times starts acutely as catatonia with the person in a severely excited or stuporose condition refusing food and medication. These patients respond extremely well to ECT. It would be negligence to deprive a critically ill adolescent of a possibly life-saving treatment. Checks and balances, however, would be welcome to ensure that the treatment is not abused.
19.Similarly, the prohibition of Unmodified ECT seems to be based on issues more related to popular perception rather than scientific evidence. Such a ban would stop the ECT from being administered at small and remote locations which are the rule rather than exception in our country where anaesthetic support is not available even for routine surgery. Many of the district hospitals do not have an anaesthetist.
20. In fact, the whole idea of prescribing or prohibiting any particular form of treatment, in a mental health legislation, is anachronistic. The right of Professionals to do the best for patients which is based on scientific evidence has to be regarded. Also the scientific evidence for or against a particular treatment keeps changing and it would be presently unwise to freeze such recommendations for two or three decades in a mental health act. However safe-guards for particular treatments can be prescribed. This is also the way it is done in most other countries.
21 .Advance Directives: (Chapter III section 5 of the bill)
While the advance directive, theoretically, is a highly desirable clinical tool for collaborative decision making between the person with mental illness and the treatment provider, at this time, more needs to be done before legal enforcement is considered in India. Most of the countries where it has been used have had mixed results. In India, where mental health services are scarce and community mental health services almost non-existent, families bear most of burden of mental illness and its treatment. Introducing a brand new concept which positions the family and the patient as adversaries is fraught with consequences which may do more harm to patients’ interests than good.
22.Two psychiatrists, one from public sector and one from private sector should be members of the Mental Health Review commission(MHRC). One of these two should be nominated by Indian Psychiatric Society. Same pattern should be followed in State panels of MHRC.
23. The chapter I of the bill where it defines Mental Health Establishment says, “but does not include a family residential place where a person with mental illness resides with his relatives or friends” is confusing and needs further clarification. Open wards admission with many family members around is perfectly the residential family situation. I plead the the limited time admission anywhere in such situation where family members are staying with patient with mental illness shall be exempt from the bill.

With regards, I am.

Dr    Rajeev Jain                                      HIG-2 Gour Nagar , Makroniya SAGAR

Email: Jrajeev @yahoo.com

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