The Mental Health Care Bill 2013: A step leading to exclusion of psychiatry from the mainstream medicine?

After India signed and ratified the United Nations’ Convention on Rights of Persons with Disability, 2006 (UNCRPD), Ministry of Health and Family Welfare (MOHFW) initiated the exercise of revising the Mental Health Act – 1987 (MHA-1987) to bring it in harmony with the UNCRPD in 2010. After about 3½ years long drafting and consultation process, the proposed legislation named Mental Health Care Bill, 2013 (MHCB) was introduced in the Rajya Sabha in August 2013. The Parliamentary Standing Committee on Health Related Matters submitted its report with suggestions of some minor changes in November 2013.[1] Though invited to the consultation process at different stages, Indian Psychiatry Society (IPS) was not assigned any role in drafting of the current Bill. IPS and other professional bodies of psychiatrists have expressed apprehensions about a number of provisions in the Bill, which are not considered to be in the interest of persons with mental illness (PMI). IPS has submitted its representations at various stages expressing these concerns. Antony (2014) said that the Bill has an over-inclusive definition for mental illness, which will hurt a huge number of victims of even minor mental illnesses and their families, because of the wide prevalence of stigma.[2] Though there are provisions of emergency admission on any bed anywhere in the country for a maximum period of 72 h (96 h in NE states), all the hospitals or nursing homes who admit PMI have been brought under the purview of the Bill and are required to be registered as mental health establishments (MHEs). All involuntary admissions in MHE even for a day may be subject to review by Mental Health Review Board to be established throughout the country by the Mental Health Review Commission. Kala (2013) said that the provision is undoubtedly progressive, but expressed his doubt that whether we as a society, are ready for this large scale countrywide post-admission review in almost all cases of involuntary admissions.[3] Unmodified electroconvulsive therapy (ECT) has been totally banned, and ECT to minors can be given only after approval from the board. Many other provisions like those of nominated representative, advance directive etc., are supposed to create an obstacle in the treatment of PMI.

The Bill has many positive features as well which, if properly and genuinely implemented, are set to revolutionize mental health care services in our country. The Bill ensures the right of every person to access affordable and good quality mental health services funded by the government. All PMI have the right to equality of treatment, protection from inhuman and degrading treatment, free legal services, right to access their medical records, and right to complain regarding deficiencies in provisions of mental health care.[4] Special emphasis has been given to human rights of PMI, and there is a separate chapter in the Bill for this purpose. The government is mandated to establish good quality mental health services at all levels so as to ensure everyone to have access to mental health care services. Decriminalizing suicide is another welcome feature of the Bill.

The single provision, which is supposed to inflict greatest damage to the system of mental health care delivery, is that of bringing all the general hospital psychiatry unit (GHPU) within the ambit of definition of MHE. It will result in moving the clock backwards, so far as the development of psychiatry and mental health care in our country is concerned. In Indian Lunacy Act, 1912, there was no mention of the GHPU. 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”. Thus, the GHPU established or maintained by the government were exempted from obtaining a “license” for running psychiatric inpatient services. A welcome step would have been to broaden the ambit of this exemption to all the GHPUs including those established or maintained by private agencies. However, the Bill has scrapped even this exemption clause and all the GHPUs including those established or maintained by the government are now required to get registered as MHE.

In India, psychiatry is a relatively a new branch of medicine and is in a developing stage. It has made tremendous progress in past few decades, and now we can see Departments of Psychiatry established in almost all the medical colleges across the nation. Initially, very few medical graduates opted for psychiatry as a career. But of late, it has become one of the popular choices among the medical graduates. The GHPUs have made a fair share of contribution in the progress achieved by Indian Psychiatry in the post-independence period. Murthy states that the growth and development of GHPUs in India, is an important milestone in the development of Indian Psychiatry.[5] Wig refers to it as slow and silent change, but in many ways a major revolution in the whole approach to psychiatric treatment in our life time.[6] GHPUs have contributed significantly to psychiatric research in India, in last 25 years.[7] Establishment of GHPUs has provided the psychiatry, a great opportunity to come out from the shackle of the mental asylum and make a welcome entry into the mainstream of the medical system. Our National Mental Health Program 1982 calls for integration of mental health services with the general health services. World Health Organization (WHO) also stressed the need of this integration and the slogan for World Health Day for 2001 was “Mental Health: Stop Exclusion - Dare to Care.”[8] Availability of psychiatric services in the mainstream medical system has resulted in its greater acceptance by the community and greatly reducing the stigma attached to it. GHPUs are situated right in the community, and they are more accessible and easily approachable.[9] It is necessary to augment the momentum of development of GHPUs by taking steps to encourage establishment of more and more GHPUs in all general hospitals including those in the corporate sectors. If at this crucial step, all GHPUs are brought under the purview of the MHCB, it will prove to be a retrogressive step and will move the clock backwards so far as the development of Indian Psychiatry is concerned. This step will lead to separation of psychiatry from the mainstream of medical science. Points in favor of exempting GHPUs from the purview of the definition of MHE can be summarized as below:

• Psychiatric disorders are widely prevalent in the society. The WHO has estimated that neuropsychiatric disorders and suicide account for 12.7% burden of the global burden of disease.[10] According to another WHO report, one person out of four will develop one or more mental or behavioral disorders during their lifetime and these disorders are present at any point in time in about 10% of the adult population worldwide (WHO, 2004).[11] Most of the psychiatric patients are nonpsychotic and suffering from a minor ailment. It will be a great disservice to the society, if such a large chunk of patients are denied treatment in mainstream medical system. They will feel further stigmatized, if they are told to go to an MHE situated at a remote and segregated place

• There is a great paucity of services for persons living with mental illness, be they services for care and treatment, leisure and recreation, habilitation and rehabilitation. The rigorous registration requirements further discourage people from setting up services. The question of abuse comes into play, only if services are in existence. A legal procedure, which discourages people from entering the mental health arena and thereby further disadvantages persons living with mental illness requires reconsideration[12]

• In health care services in India, private sector especially corporate hospitals are going to play an important role in coming days. Psychiatry inpatient units are not in the priority list of corporate hospitals, as they do not generate much revenue. Corporate hospitals will be further discouraged to establish psychiatric services, if the requirement of registration as MHE and its stiff norms are imposed. As a result, mental health care services will not be a part of the general health care services. This will be a great disservice to the PMI, who constitute a large chunk of the population. If persons suffering from even minor psychiatric ailment are required to go to seek help at a remote and secluded place, it will be highly inconvenient for them. Such persons may not go there at all, because of widely prevalent feeling of stigma attached to psychiatric illnesses

• Clinical Establishment Act has been enacted to regulate and ensure the minimum standard of services of all private hospitals/nursing homes, and it is on its way becoming applicable all over the country. It will also be applicable to the MHE. Multiple agencies to prescribe and enforce the minimum standard of services will prove to be a further deterrent in establishment of mental health care services

• Legislation in mental health care is required for two purposes, which are ensuring the minimum standard of services and providing for review of involuntary admissions. To take care of the first, we already have the Clinical Establishment Act. To take care of the second, it can be stipulated that GHPU not registered as MHE would have only open ward, and would not be entitled to make any involuntary admission except under the emergency treatment provision of the MHCB. In other words, GHPU not registered as MHE will be allowed to make only voluntary admissions. Hospitals, who are willing to provide for involuntary admission too by establishing closed wards, may be given the option to get registered as MHE under the MHCB

• Availability of a wide range of GHPU is of immense help in reducing stigma attached to psychiatric disorders. Large numbers of patients, who are suffering from nonpsychotic minor psychiatric ailments, take benefit of these GHPU without having any adverse stigmatic feeling. If the services are not available in their vicinity but at a remote and secluded place, the stigma attached even to minor psychiatric illnesses would get accentuated. Moreover, persons suffering from these minor illnesses retain their insight into the illness, and the question of involuntary admission and violation of their human rights after such admission does not arise for them

• Psychiatry is essentially a branch of Medicine, and it must function as such. If GHPUs are not encouraged, psychiatry will not properly function as a branch of medicine and will be cut off from the mainstream medical system. Psychiatric disorders many a times co-exist with other medical disorders, and not so infrequently the primary presentation of these disorders appears to be like that of a physical disorder. Many of the physical illnesses have superadded psychiatric manifestations. In such situations, it is highly desirable that psychiatric services are integrated into the general health services

• Medical Council of India norms stipulate that all medical colleges, who have undergraduate or postgraduate education, must have specified number of beds in psychiatry. After the MHCB comes into force, it will be a statutory requirement for all the medical colleges to get registered as MHE. It will prove to be cumbersome to the medical colleges with fewer resources. Moreover, medical colleges would be obliged to establish the psychiatry units at a different and secluded place in their set-up, which would have a stigmatizing effect

• GHPUs are small and open units, and meant for short stay patients. These are open to scrutiny by anyone including the family members of the patient. The question of violation of basic human rights is not likely to arise in such units. Establishment of GHPU should be encouraged by all possible means so far. Therefore, small GHPU (say limited to 30 beds) with open wards only and meant for short stay patients (say for <30 days) must be exempted from the requirement of registration as MHE

• GHPU provides a great opportunity of getting family involved in the management of psychiatric illness. In India, unlike in western countries, family is a great asset, and we must utilize it. Various epidemiological studies have stated that the prognosis of schizophrenia and other psychotic disorder is better in our country in comparison to that in the western countries. One of the main reasons behind it is that familial and social support system is much better in our country. We must tap this useful resource in the management of psychiatric illnesses and for this purpose, the GHPUs would prove to be of great help.

Recognition of the global importance of mental disorders has put psychiatry firmly on the international health agenda.[13] However, it is still to happen in our country due to various reasons. IPS, the largest professional organization of psychiatrists in India with more than 90% of Indian Psychiatrists in its fold, is a vibrant and active organization that is run in a very professional and democratic way. It has been consistently fighting for the rights of PMI and for the betterment of their conditions right since its inception in 1948. It was closely associated with enactment process of MHA-1987. In fact, the MHA-1987 was conceived, piloted and drafted by the IPS.[3] However, the 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. IPS and other major psychiatric professional organizations, like Indian Association of Social Psychiatry and Indian Association of Private Psychiatry are consistently opposing some of the provisions in MHCB, which are supposed to be detrimental to the interest of the PMI as well as to that of the society. Compulsory requirement of registration as MHE for all the psychiatric indoor units is one of the most significant of them. Exemption of small GHPUs with only open ward is a necessary step in the public interest, and the government must take this point into its consideration.

Human rights activists group and nongovernmental organizations (NGO) working in the field of mental illness are at the forefront in the fight for rights of PMIs. They are significant stakeholders in the current enactment process. But the legislations for PMI are meant for the PMI and not for mental health professionals or for the activist groups. The primary concern of all the stakeholders should be to see how the interest of PMI is served the best, their human rights are protected and stigma attached to seeking psychiatric help is reduced.[14] Ensuring easy availability of mental health care services in mainstream medical system, where it can be availed without any feeling of stigma is definitely in interest of the PMI as well as the society. Keeping this in mind, the activists and NGO groups must support the exemption of the GHPUs from the ambit of MHCB. After all, the activists groups and NGOs are working for the betterment of conditions of PMI and protection of their rights. Widespread availability of GHPUs in the mainstream of the medical system is definitely in the interest of PMI and their families. There will be no harm in exemption of GHPUs from the ambit of MHCB, as these will be small open units meant for short stay patients only, with least likelihood of violation of basic human rights.

Exemption of GHPUs, with open ward only, from registration as MHE, together with the right for everyone to access good quality mental health services funded by the government will usher a new era in Indian Psychiatry and will open immense growth opportunity for the specialty and the mental health services in India. It will serve a large section of society suffering from all sorts of psychiatric disorders for the decades to come.