Development of mental health law in Iran: work in progress

Abstract

A brief account of the three stages of development of a new mental health law in Iran is given. At each stage, the expert opinions of mental health professionals and lawyers interested in the rights of psychiatric patients were obtained. The final draft of the law consists of six sections and 50 articles. It has been submitted for ratification by Parliament.

At present, Iran has no laws that specifically address mental health. However, the civil law, the Islamic penal code, a jurisdiction act, a set of safeguarding measures from 1960, family protection law and a law permitting payment of wages to psychiatric patients do help to protect different aspects of the rights of psychiatric patients (Hojjati-Ashrafi, 1990; Jafarzadeh, 1996; Asgharzadeh-Amin & Shahmohammadi, 2004). Also, under the existing laws, the care of patients who are considered to have a mental health disability, as with people who have a physical disability, is the responsibility of the state’s Welfare Organisation. In these laws, terms such as ‘insanity’, ‘idiot’, ‘insane’ and ‘senile’ are used. These terms do not have clear scientific definitions and there is no agreement among authorities in the field regarding their precise use (Tofighi, 1996).

Currently, there are some 7500 psychiatric beds scattered throughout the country. There are about 1300 psychiatrists and 5000 psychologists in Iran. There are in addition social workers, psychiatric nurses and related specialists. Due to the absence of a mental health law, the rights of psychiatric patients have been disregarded. Violation of their rights becomes more evident at the time of involuntary hospitalisation. Fortunately, the expansion of mental health services has raised public and official awareness of patients’ rights and the need to develop mental health law.

Drafting the mental health law

In 2003, based on a suggestion from the Ministry of Health, a special committee of university professors was formed to draft the mental health law at Tehran Psychiatric Institute (the authors prefer ‘Tehran, Institute of Psychiatry’, but this has been much less used internationally).

The committee first reviewed the literature regarding mental health laws in both Western and Islamic countries (Segal, 1989; Mane & Gandevia, 1993; Wall et al, 1999; World Health Organization, 2006a,b, 2008). Then, based on the cultural considerations and existing legislation, and taking into account the recommendations of the World Health Organization (2003a,b) regarding the development of mental health legislation, a draft law was prepared. In order to obtain expert and stakeholder opinion, the draft was sent to 35 organisations, research centres, scientific associations, psychiatric and clinical psychology departments, private hospitals in the city of Tehran, and one nongovernmental organisation (the Iranian Society for Supporting Patients with Schizophrenia), and their suggestions were received.

In the following three stages, the draft was modified and the final document was prepared.

Stage I: national workshop

The initial draft, along with the comments and suggestions of the experts and stakeholders, was presented in a 2-day workshop, which was attended by more than 50 professionals, including psychiatrists, clinical psychologists, psychosocial workers, authorities in the field, university professors, and officials from the Ministry of Health. At the end of the second day, after extensive review, the final draft was prepared.

Stage II: review by a joint committee

In the second stage, the next draft was given to a joint committee of three representatives of the initial committee and three lawyers familiar with mental health issues in order to rewrite it as a legislative document, so that it could be presented to Parliament. The committee rewrote the draft as a legal Act. This demanding work took 47 sessions of 4 hours each.

The document was then sent to a number of lawyers, mental health professionals, judicial and legal officials. Afterwards, the comments and suggestions were reviewed at another national workshop attended by lawyers, mental health experts and a number of relevant authorities, and modifications were made if they were endorsed by the majority.

This version of the draft Act comprised 10 sections and 112 articles. It was sent to the Ministry of Health.

Stage III: Ministry of Health review

The Ministry authorities indicated that the draft should be condensed in order to facilitate its ratification by Parliament. This was done in several sessions with representatives of the law office of the Ministry and a number of the members of the joint committee. However, the original content of the draft was preserved.

This final draft of the Act comprises one introductory article and six sections with a further 49 articles in total.

Content of the law

Section 1. Definitions

In this section, all of the terms and phrases used in the Mental Health Act are defined. This chapter contains one article and 18 clauses. As an example, the definition of ‘severe mental disorder’ is:

A state which is manifested by a transient or persistent severe destruction of most mental functions of the individual with at least one of the following symptoms or signs being present: delusions, hallucinations, severe formal thought disorder, severe mood disorder, severe cognitive disorder and behaviours which signify any of the above symptoms.

Section 2. Compulsory hospitalisation and treatment

In this section, the conditions and criteria for mandatory hospitalisation and treatment are addressed. For compulsory hospitalisation of an individual with severe mental illness, the presence of serious risks of harm to self or others together with signs of persistent and severe mental illness is required. For compulsory hospitalisation, the consensus of two psychiatrists is necessary. If compulsory hospitalisation is indicated, a forensic physician has to evaluate the patient within 1 week of hospitalisation and approve the continuation of compulsory hospitalisation for a maximum of 2 months. In Iran, forensic physicians are medical officers who specialise in the forensic aspects of medicine, and they are not responsible for the treatment of patients. The extension of subsequent 2-month periods of involuntary hospitalisation requires the same steps.

This section consists of 11 articles.

Section 3. Specific treatment techniques

In this section, compulsory community-based treatment, compulsory electroconvulsive therapy (ECT), physical restraint and physical isolation are addressed and the conditions and procedures for their implementation are described.

In order to protect the rights of patients, stringent restrictions have been imposed on such actions. For example, for administering involuntary ECT, recommendation by the treating psychiatrist, endorsement of another psychiatrist and confirmation by the psychiatric commission of the hospital is mandatory. That body comprises two psychiatrists appointed by the hospital superintendent and a forensic physician.

Physical restraint and seclusion can be done only with the approval of the treating psychiatrist and by specially trained and authorised staff. The maximum duration of seclusion for individuals under the age of 15 is 2 hours and for others is 4 hours. Such procedures can be repeated only once during each period of hospitalisation.

These measures are to be used strictly to prevent patients from harming themselves or others, interfering with a treatment programme or damaging property. Use of these procedures as a means of punishing the individual or because of staff shortage or insufficient resources is prohibited.

This section consists of seven articles.

Section 4. Prisoners (accused or convicted) with a mental disorder

This section concerns prisoners who have a history of any psychiatric illness or who develop a psychiatric illness during trial or while serving their sentences, or who on observation show bizarre behaviour indicating possible psychiatric illness.

The judicial officer has the responsibility of referring the individual to a forensic psychiatrist for evaluation. The forensic psychiatrist must then declare an expert opinion regarding the presence of current or previous mental disorder, the person’s criminal responsibility, the relation between the individual’s psychiatric problem and the crime, the person’s competency to stand trial, the possibility of deterioration of the individual’s condition as a result of enforcement of the judgement, and the availability of psychiatric treatment and regular follow-up.

This section consists of six articles.

Section 5. Special groups

This section relates to children and adolescents, elderly people and those who are not capable of making decisions regarding their affairs. It has four articles.

Section 6. Other rules

In this section, the responsibilities of both the judiciary and the executive (including the Ministry of Health, the Welfare Organisation and insurance companies) to psychiatric patients are addressed. This section comprises 20 articles.

Discussion

The new draft Mental Health Act in Iran has been prepared in collaboration with the departments of psychiatry and clinical psychology of most medical schools in the country and the Iranian Psychiatric Association. Due to the practical nature of the law, one expects many of the current problems facing patients, carers and members of staff to be resolved after the Act is ratified.

The Bill is presently at the Ministry of Health, but is due to be submitted to Parliament. The next stage will be to educate and prepare guidelines for patients and carers. We hope we achieve our objectives in the near future.