Doctors divided on India’s new mental health bill
While some say the proposed law would make it harder to treat those with severe mental illnesses such as schizophrenia, others say it would prevent exploitation of the mentally illmumbai Updated: Apr 08, 2017 01:04 IST
The recently introduced Mental Health Bill 2016, which seeks to empower and protect patients by giving them and their nominated representatives more say in their treatment, has created a sharp divide among psychiatrists and other mental health professionals.
The new bill specifies two types of people will mental illness – independent patients, who don’t need support to take decisions, and supported patients, who are highly dependent and suffer from severe mental ailments that affect their judgment.
“The bill categorically places more emphasis on independent patients and has a long set of procedures to admit supported patients,” said a senior psychiatrist at a government-run hospital.
According to the bill, a supporting patient can be admitted only after one psychiatrist and one mental health professional or medical practitioner independently confirm that the patient may cause bodily harm to himself or others, has a tendency to behave violently with himself or others, or is unable to care for himself to the extent of putting himself or others in harm’s way.
The consent of a relative is also required to treat such a patient. If no relative is available, the patient may be admitted, but for only 30 days.
After this, their condition must be reviewed and communicated to the medical board, which will decide whether the person needs institutionalised care.
This board, mental health professionals say, includes only one psychiatrist and none of its other members have medical backgrounds.
Some mental health professionals have criticised the move, saying those who suffer from serious psychological disorders such as schizophrenia and bipolar disorder often lack the ability to make sound decisions and don’t always have a relative to speak on their behalf.
Dr Sagar Mundada, who has an MD in psychiatry, told HT about one such case, in which the police found a man in a gutter in Mazgaon and took him to JJ Hospital. There, doctors learnt that he was an engineer who suffered from schizophrenia. He was treated and soon returned to his hometown of Kolkata.
Dr Yusuf Matcheswalla, head of psychiatry at Masina Hospital and GT Hospital, who has admitted and treated patients at GT and JJ hospitals on his own accord, said that the new bill, if enacted will complicate the process of admitting a patient.
“While the bill gives lot of power to the authorities when it comes to admitting and treating schizophrenics and those with bipolar disorder, it will increase the amount of time it takes to admit such patients. These problems are due to the fact that no leading practitioners, who are aware of the ground realities of admitting and treating mental health patients, were consulted on the bill,” said Matcheswalla.
He said that since doctors will wait for the bill to become law and then see how they can work under its ambit.
“Every bill is meant to be in the best interests of the people. If it affects the quality of treatment provided, there will certainly be amendments that will make it workable,” he added.
Dr Harish Shetty, a prominent psychiatrist, said, “There are no such regulations for neurologists, gynecologists or experts in any other medical field. Why the government is doing this in our field is beyond my knowledge. The bill has to achieve a balance. Too many filters while admitting or treating a patient will delay the process and will have negative consequences for the patient.”
He added that while there ought be to rules governing voluntarily admissions by doctors, the ultimate goal of providing treatment to patients shouldn’t be affected.
The new bill also introduces some new concepts, which doctors fear may end up increasing red tape and taking away doctors’ decision-making powers. The most controversial of these is the concept of ‘advanced directive’.
Advanced directive gives patients more power to decide aspects of their treatment – how they do and don’t wish to be treated for a mental ailment. It also gives patients the power to nominate a representative to take decisions on their behalf.
Dr Mundada said the concept of advanced directive was blindly picked up from the West without consideration for local factors such as existing mental health resources and lack of awareness about mental illness in India.
“In Western countries, where the concept originated, mental ailments are not considered taboo. Here, apart from the fact that the field is largely limited to the public sector, there is an acute shortage of resources. In such a situation, doctors are in the best position to take decisions because patients or their nominated representatives have limited knowledge on mental health and mental illness,” said Dr Mundada.
On the flip side
However, others have welcomed the proposed new rules, saying they will combat the exploitation of patients, an all-too-common occurrence given the superstition, lack of understanding and social stigma associated with mental illness in India.
Dr Rajesh Nagpal, neuro-psychiatrist from Delhi who worked on the bill, said it was an attempt to bring India’s mental health laws up to date.
“The bill is fantastic. There are some loopholes in it but it will regularise the field of psychiatric, which is necessary. The guidelines have been set according to global standards and if we want to have international-standard services, we have to have laws that match international standards as well. There will be a lot of funds required after the bill becomes law but all of it will be in the best interests of patients,” said Dr Nagpal.
Dr Vishal Sawant, director of Juno Clinic, which provides mental health advice online, said concepts such as advanced directive will combat unscrupulous rehabilitation centres that exploit patients.
“There are some bad practices in the field, which were restricted by the Mental Health Act, 1987, but continued because the law wasn’t implemented. The new bill is the government’s attempt to bring institutions that exploit mentally ill patients under the ambit of the law. Yes, there is a little additional paperwork and doctors may have to change certain practices, but in the long run, it will be in the best interest of patients,” said Dr Sawant.
Will set up more centres to help those in need: Dr Vijay Satbir Singh, additional chief secretary, health
From using yoga to setting up centres in rural areas, the state has various plans to create awareness about mental ailments, said Dr Vijay Satbir Singh, additional chief secretary, health. Excerpts from an interview:
Taking the prevalence of mental ailments and limited resources into account, is there a need to allocate more funds for mental health?
There is a need to create awareness about mental ailments. We plan to spend a large part of the budget on developing various communication channels for it. We will also review the existing Information, Education and Communication scheme of the Centre and train our staff to reach out to the rural population
How will the state tackle manpower shortage?
We are training the Accredited Social Health Activist (ASHA) workers. They will visit households with a simple questionnaire which can help detect signs of depression. The patient can then be referred to psychiatrists. We are also training our helpline staff to address the issue of depression across professions and classes, so they can get counselling.
Many district or sub-district level hospitals don’t have sufficient number of psychiatrists. Is there a plan to increase the number?
We are planning discussions with psychiatrists to understand the issue and come up with a solution. Psychiatrists will be hired on a contractual or honorary basis and the ones working for us will undergo additional post-graduate degree programmes. We will also get experts from different fields such as Aayurveda, Siddhha and other alternate medicine degree-holders to join our scheme. Paramedical staff and social workers will be trained to fill the void.
What will be the role of district and sub-district hospitals in creating awareness?
We have a large network of small and large medical establishments across the state, which will house a wellness and counseling centre each. Yoga and meditation will be promoted as an effective tool. A well-connected chain of 2,000 diagnostic centres, to be set up at a cost of Rs150crore, will come into action in the next two months.
How will you spread the reach?
Telemedicine will be used effectively. Conference centres will be built in the most tribal and distant areas, so experts can connect with people through video-conferencing. Many pilot projects are underway.
The network will gradually grow.