P R E S E N T E R - D R . M AY U R I M O H A N T Y , R E S I D E N T- 3 R D Y E A R ,

B H A R AT I H O S P I TA L .

MENTAL HEALTH ACT

CONTENTS• History

• Indian lunacy act,1912

• Mental health act,1987 Chapters

Prerequisites for psychiatric hospitals

Admission & detention in psychiatric hospitals

Reception order

• Mental health bill,2013 Definition

Chapters

Amendments proposed

Advanced directive

Nominated representative

Admission & discharge

Mental health establishment

Mental health review commission

HISTORY

• Mental health care acts in india was covered in two phases- pre-independence and post independence.

• Pre-independence- 1858- Indian Lunatic asylum act of 1858

1912- Indian Lunacy act of 1912• Post Independence

1947- Indian Psychiatric Society established1987-Mental health Act of 1987• Mental health care bill (Proposed) ,2013

INDIAN LUNACY ACT

• Act 4 of 1912• Replaced Lunatic Asylums Act , Act 36 of 1858• Enacted to govern reception, detention and care of lunatics and

their property, and to consolidate and amend the laws relating to lunacy.• 8 chapters consisting of 100 sections• Provided punishment if two or more “lunatics” are illegally

detained for gain in any place other than asylum.

MENTAL HEALTH ACT , 1987

• It is an “act to consolidate and amend law relating to mentally ill persons, to make better provision with regard to property and affairs and for matters connected therewith & connected thereto”.• Act is divided into 10 chapters consisting of 98 sections.

CHAPTERS

• Chapter I – Definition• Chapter II – Mental Health authorities• Chapter III – Psychiatric Hospitals & Psychiatric nursing

homes• Chapter IV – Admission & detention in psychiatric hospitals

or psychiatric nursing homes• Chapter V- Inspection , discharge, Leave of absence and

removal of mentally ill persons

• Chapter VI – Judicial inquisition regarding mentally ill person

possessing & managing his property

• Chapter VII – liability to meet cost of maintenance of mentally ill

persons detained in psychiatric hospitals

• Chapter VIII – Protection of human rights of mentally ill persons

• Chapter IX – penalties & procedures

• Chapter X - Miscellaneous

• Reception Order Order for admission and detention of a mentally ill person by a psychiatric hospital.

• Psychiatric Hospital- Hospital established or maintained by government or any other person for treatment & care of mentally ill persons & includes a convalesent home established & maintained by govt or private party . It doesn’t include general hospitals with psychiatry wards.

It gave definition to ‘Mentally ill persons’ replacing ‘lunatics’ & ‘psychiatric hospital’ replacing ‘asylum’.

OUTDATED TERMS

NEW TERMS

Nursing Home/Asylum

Psychiatric Hospital

Lunatic Mentally ill person

Criminal Lunatic Mentally ill prisoner

PREREQUISITES FOR PSYCHIATRIC HOSPITALS(ESTABLISHMENT OR MAINTENANCE)

• A valid license granted under the act by licensing authority if :

1. Receipt of application for license.2. On enquiry, such establishment or maintenance is

necessary. 3. Minimum facilities for admission, treatment & care of

mentally ill persons.4. Incharge is a medical officer who is a psychiatrist5. License is not transferable or heritable.6. Valid license for 5 years following which needs renewal.

• License can be revoked if licensing authority feels that :1. Psychiatric hospital not maintained by licensee in accordance of

the act.2. Maintenance is carried out in a detrimental to moral, mental or

physical well-being of patients.

ADMISSION & DETENTION IN PSYCHIATRIC HOSPITALS

Admission in one of the following ways :1. Voluntary2. Special circumstances (not more than 90 days)3. Reception order on application4. Reception order on production of mentally ill person before

magistrate5. Inpatient after inquisition6. Mentally ill prisoner

RECEPTION ORDER

• A reception order for admission can be obtained from magistrate by:

a. A petition or application which contains particulars of case and is presented by husband or wife of alleged mentally ill person.

b. Supported by two medical certificate , one of which shall be from a medical practitioner in the service of Government.

• Reception order without petition can be issued by a Magistrate, if an officer in-charge of a police station arrests a: Wandering mentally ill person, who is believed to be incapable of taking care of himself, or Dangerous or Ill treated or neglected mentally ill person

MENTAL HEALTH CARE BILL 2013

• “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 and for matters connected therewith or incidental thereto “

• 16 chapters and 137 clauses.

DEFINITION OF MENTAL ILLNESS

“Disorder of mood, thought, perception,orientation and memory which causes significant distress to a person or impairs that person’s ability to meet the demands of daily life and includes mental conditions associated with the abuse of alcohol and other drugs, but does not include mental retardation”

STATEMENT OF OBJECTS AND REASONS

• The United Nations Convention on the Rights of Persons with Disabilities, which was signed by the Government of India in October, 2007, made it obligatory on the Government to align the policies and laws of the country with the Convention.

• Bill was introduced by then health minister - Ghulam Nabi Azad on 7th august in Rajya sabha.

• The need for amendments to the Mental Health Act, 1987 was felt by the fact that the related law, i.e., the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 was also in the process of amendment.

CHAPTERS

• Chapter I – PRELIMINARY• Chapter II – MENTAL ILLNESS AND CAPACITY TO

MAKE MENTAL HEALTH CARE AND TREATMENT DECISIONS • Chapter III – ADVANCE DIRECTIVE • Chapter IV – NOMINATED REPRESENTATIVE • Chapter V- RIGHTS OF PERSONS WITH MENTAL

ILLNESS

• Chapter VI – DUTIES OF APPROPRIATE GOVERNMENT • Chapter VII – CENTRAL MENTAL HEALTH AUTHORITY • Chapter VIII – STATE MENTAL HEALTH AUTHORITY • Chapter IX – FINANCE, ACCOUNTS AND AUDIT • Chapter X - MENTAL HEALTH ESTABLISHMENTS • CHAPTER XI -

MENTAL HEALTH REVIEW COMMISSION

• CHAPTER XII- ADMISSION, TREATMENT AND DISCHARGE • CHAPTER XIII- RESPONSIBILITIES OF OTHER AGENCIES • CHAPTER XIV - RESTRICTION TO DISCHARGE

FUNCTIONS BY PROFESSIONALS NOT COVERED BY PROFESSION • CHAPTER XV- OFFENCES AND PENALTIES • CHAPTER XVI - MISCELLANEOUS

AMENDMENTS PROPOSED

• Definition of mental illness • Advance directive • Nominated representative• Admission procedures like independent admissions, supported

admissions• Treatment procedures like emergency • Insurance for mental illnesses• Shelter homes , supported accomodation, community based

rehabilitations • rights for person with mental illness to seek information about

illness , treatment plan & procedures

• New governing bodies like mental health review commission (MHRC) and state wise mental health review boards( MHRB).• ECT without anaesthesia is banned & psychosurgery is

restricted.• Medical research on person with mental illness can be done

with their free and informed consent.• Decriminalizes suicide

ADVANCED DIRECTIVE

• Right to make an Advanced directive –right to decide how a patient should or should not be cared and treated for a mental illness in the future.• Every person who is not a minor has the right to make an

advance directive specifying any of the followinga) the way a person wishes to be cared for and treated for a mental illnessb)the way he wishes not to be so cared for and treated for a mental illnessc)nominated representative.

NOMINATED REPRESENTATIVE1. Right to appoint a nominated representative.

2. The nomination shall be made in writing on plain paper with the person’s signature or thumb impression of the person referred to.

3. Nominated representative shall not be a minor, be competent to discharge the duties or perform the functions assigned to him under this Act, and give his consent in writing to the mental health professional

4. In case no nominated representative was chosen, following people will be chosen for the purpose of this act:–– (a) the individual appointed as the nominated representative in the advance directive or (b) a relative, (c) a care-giver(d) a suitable person appointed as such by the concerned Board; or (e) if no such person is available, the Board shall appoint the Director, Department of Social Welfare, or his designated representative, as the nominated representative of the person with mental illness

5. The representative of the organization, referred to in the proviso to sub-section (4), may make a written application to the medical officer in charge of the mental health establishment or the psychiatrist in charge , as the case may be, to accept him as the temporary nominated representative.

6. A person who has appointed any person as his nominated representative under this section may revoke or alter such appointment at any time.

7. The Board may revoke an appointment made by it under this section, and appoint a different representative under this section.

RIGHTS & DUTIES OF NOMINATED REPRESENTATIVE

• Duty to support PMI in making treatment decision.• Information on diagnosis & treatment.• Right for discharge planning.• Consent for treatment modalities.• Appoint a suitable attendee.

ADMISSION

• Independent Admission• Admission of a minor• Supported Admission upto 30 days• Supported Admission beyond 30 days

Admission

Independent admission Admission of Minor

Supported admission under 30 days

Supported admission beyond 30 days

• Not a minor • Self requests for

Admission

• Severity of illness needs Admission

• PMI benefits from Admission

• Not under influence

• Doesn’t need Support for decisions

• Capable to take decisions

Application by nominated representative of minor

• Severity of illness requires admission

• To ensure his or her health, well-being or safety,

• Community based alternatives to admission have been shown to have failed

Application by nominated representative

• Bodily harm to himself; or

• Behaving violently towards another person or is causing another person to fear bodily harm from him; or

• Inability to care for himself to a degree that places the individual at risk of harm to himself

Application by nominated representative beyond thirty days or readmission within 7 days of such discharge

• Bodily harm to himself; or

• Behaving violently towards another person or is causing another person to fear bodily harm from him; or

• Inability to care for himself to a degree that places the individual at risk of harm to himself

Discharge

Independent admission

• On request• Minor becoming

major under inpatient care & can decide as independent patient.

• Psychiatrist in charge

Admission of Minor

• nominated representative• On becoming an adult • Psychiatrist in charge

Supported admission under 30 days

• At end of 30 days no longer meets criteria for admission

• Nominated representative

• Psychiatrist in charge

Supported admission beyond 30 days

• Nominated representative

• Mental health review board

• Psychiatrist in charge

LEAVE OF ABSENCE

• Granted by medical officer/ Psychiatrist after consent from nominated representative• Power to terminate with Psychiatrist• If person doesn’t return, contact the person on leave or

nominated representative• If patient on leave requires patient care and nominated

representative feels so, police officer can be sought out to get back PMI.

ABSENCE WITHOUT LEAVE

• Taken into protection by police officer at the request of psychiatrist in charge and brought back to establishment

EMERGENCY TREATMENT

• By any registered medical practitioner , subject to informed consent by nominated representative• To prevent:a) Irrevesible harm to health of PMI or deathb) Person inflicting harm to self or othersc) Person causing damage to property• Emergency treatment limited to 72 hours• In disasters extended to 7 days• Ect is not emergency procedure

PROHIBITED PROCEDURES

• Ect without anaesthesia• Ect for minor• Sterilisation of men/women as treatment for mental illness• Chained in any manner

• ECT with consent of nominated representative & permission of board• Psychosurgery with consent of PMI & board.

MENTAL HEALTH ESTABLISHMENTS

• “Mental health establishment” means any health establishment, including Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy establishment, by whatever name called, either wholly or partly, meant for the care of persons with mental illness, established, owned, controlled or maintained by the appropriate Government, local authority, trust, whether private or public, corporation, co-operative society, organisation or any other entity or person, where persons with mental illness are admitted and reside at, or kept in, for care, treatment, convalescence and rehabilitation, either temporarily or otherwise; and includes any general hospital or general nursing home established or maintained by the appropriate Government, local authority, trust, whether private or public, corporation, co-operative society, organisation or any other entity or person; but does not include a family residential place where a person with mental illness resides with his relatives or friends;

REGISTRATION OF MENTAL HEALTH ESTABLISHMENT

(1) No person or organisation shall establish or run a mental health establishment unless it has been registered with the Authority under the provisions of this Act.

“Authority” meaning— (a) Hospitals under Central Government, the Central Authority; (b) Hospitals not included in (a) , the State Authority.

(2) Every person or organisation who proposes to establish or run a mental health establishment shall register the said establishment with the Authority under the provisions of this Act.

(3) The Authority shall, on receipt of application , on being satisfied that such mental health establishment fulfills the standards specified by the Authority, issue a certificate of registration in such form as may be prescribed:

(4) Every mental health establishment shall, for the purpose of registration and continuation of registration, fulfill–– (a) the minimum standards of facilities and services; (b) the minimum qualifications for the personnel (c) provisions for maintenance of records and reporting (d) any other conditions as may be specified by regulations made by the Central Authority.

(5) The Authority may––(a) classify mental health establishments into such different categories, as may be specified by regulations made by the Central Authority; (b) specify different standards for different categories of mental health establishments; (c) while specifying the minimum standards for mental health establishments, have regard to local conditions.

(6) the Authority shall, within a period of eighteen months from the commencement of this Act, by notification, specify the minimum standards for different categories of mental health establishments.

Submit an application

provisional certificate by concerned Authority - valid for a period of twelve months

Authority publish in print and in digital form within a period of forty-five days

period of six months from date of notifying such standards, apply and obtain permanent registration

Authority within a period of thirty days grant permanent certificate of registration

Every mental health establishment has to display the certificate

PROCEDURE FOR REGISTRATION OF MENTAL HEALTH ESTABLISHMENTS

CENTRAL MENTAL HEALTH AUTHORITY

• The Central Government shall, within a period of nine months from the date on which this Act receives the assent of the President, by notification, establish, for the purposes of this Act, an Authority to be known as the Central Mental Health Authority.• Composition of Central Authority :

1. Secretary or Additional Secretary in the Department of Health and Family Welfare –chairperson

2. Joint Secretary in the Department of Health and Family Welfare - members

3. Joint Secretary in the Department of Ayurveda, Yoga and

Naturopathy, Unani, Siddha and Homeopathy— member ex officio;

4. Director General of Health Services––member ex officio;

5. Joint Secretary in the Department of Disability Affairs of the

Ministry of Social Justice and Empowerment–– member ex officio;

6. Joint Secretary in the Ministry of Women and Child

Development–– member ex officio;

7. Directors of the Central Institutions for Mental Health ––

members ex officio;

8. one mental health professional as defined as having at least fifteen years experience in the field, to be nominated by the Central Government—member;

9. one psychiatric social worker having at least fifteen years experience in the field, to be nominated by the Central Government––member;

10. one clinical psychologist having at least fifteen years experience in the field, to be nominated by the Central Government––member;

11. one mental health nurse having at least fifteen years experience in the field of mental health, to be nominated by the Central Government––member;

12. two persons representing persons who have or have had mental illness, to be nominated by the Central Government––members;

13. two persons representing care-givers of persons with mental illness or organisations representing care-givers, to be nominated by the Central Government—members;

14. two persons representing non-governmental organisations which provide 25 services to persons with mental illness, to be nominated by the Central Government––members.

• The members of the Central Authority referred to in clauses (h) to (n) of sub- 30 section (1) of section 34 shall hold office as such for a term of three years from the date of nomination and shall be eligible for re-appointment:

STATE MENTAL HEALTH AUTHORITY

• Every State Government shall, within a period of nine months from the date on

which this Act receives the assent of the President, by notification, establish, for

the purposes of this Act, an Authority to be known as the State Mental Health

Authority.

• The State Authority shall consist of the following chairperson and members:—

(a) Secretary or Principal Secretary in the Department of Health of State

Government–– chairperson ex officio;

(b) Joint Secretary in the Department of Health of the State Government, in charge

of mental health–– member ex officio;

(c) Director of Health Services or Medical Education––member ex officio;

(d) Joint Secretary in the Department of Social Welfare of the State Government— member ex officio; (e) Superintendent of any of the Mental Hospitals in the State or Head of Department of Psychiatry at any Government Medical College, to be nominated bythe State Government–– member; (f) one eminent psychiatrist from the State not in Government service to be nominated by the State Government–– member; (g) one mental health professional as defined as having of least fifteen years experience in the field, to be nominated by the State Government—member;

(h) one psychiatric social worker having at least fifteen years experience in the field, to be nominated by the State Government––member; (i) one clinical psychologist having at least fifteen years experience in the field, to be nominated by the State Government––member; (j) one mental health nurse having at least fifteen years experience in the field of mental health, to be nominated by the State Government––member; (k) two persons representing persons who have or have had mental illness, to be nominated by the State Government––member; (l) two persons representing care-givers of persons with mental illness or organisations representing care-givers, to be nominated by the State 20 Government ––members; (m) two persons representing non-governmental organisations which provide services to persons with mental illness, to be nominated by the State Government — members.

MENTAL HEALTH REVIEW BOARD

Each Board shall consist of–– (a) a District Judge, or an officer of the State judicial services who is

qualified to be appointed as District Judge or a retired District Judge who shall be chairperson of the Board;

(b) (b) representative of the District Collector or District Magistrate or Deputy Commissioner of the districts in which the Board is to be constituted;

(c) two members who shall be mental health professionals of whom at least one shall be a psychiatrist;

(d) two members who shall be persons with mental illness or care-givers or persons representing organisations of persons with mental illness or care-givers or non-governmental organisations working in the field of mental health.

POWERS AND FUNCTIONS OF BOARD.

a) to register, review, alter, modify or cancel an advance directive; (b) to appoint a nominated representative; (c) to receive and decide application from a person with mental illness or his nominated representative or any other interested person against the decision of medical officer or psychiatrists in charge of mental health establishment or mental health establishment under section 96 or section 98 or section 99; (d) to receive and decide applications in respect non-disclosure of information specified under sub-section (3) of section 25; (e) to adjudicate complaints regarding deficiencies in care and services specified under section 28; (f) to visit and inspect prison or jails and seek clarifications from the medical officer in charge of health services in such prison or jail.

MENTAL HEALTH REVIEW COMMISSION

(1) The Central Government shall, within nine months from the date on which this Act, constitute the Mental Health Review Commission to exercise the powers conferred upon and to perform the functions assigned to it under this Act.

(2) The head office of the Commission shall be at Mumbai.(3) Composition of Commission :• The Commission shall consist of a president and four members. • The president and members of the Commission shall be appointed by the

President of India• Provided that in case a serving Chief Justice of a High Court or a Judge of

the High Court with five years experience is appointed as the president of the Commission, he shall be appointed in consultation with the Chief Justice of India.

4. Out of the four members referred to in section 74, one each shall be chosen from amongst— (a) psychiatrists having at least fifteen years experience in the field; (b) persons with mental illness or representatives of persons with mental illness; (c) representatives of families and care-givers to person with mental illness or of non-Governmental organisations working in the field of mental health; (d) persons having at least fifteen years of experience in public administration.

Mental health act Mental health bill

Patients Mentally ill persons Person with mental illness(PMI)

Psychiatric hospitals • Doesn’t include general hospitals with psychiatry ward.

• Called Mental Health establishment

• Includes general hospitals with psychiatry ward

Admission 1. Voluntary2. Special circumstances

(not more than 90 days)3. Reception order on

application4. Reception order on

production of mentally ill person before magistrate

5. Inpatient after inquisition

6. Mentally ill prisoner

1. Independent Admission2. Supported Admission

upto 30 days3. Admission of a minor4. Supported Admission

beyond 30 days

Emphasis Regulation of Psychiatric hospitals & treatment of mentally ill person

Right of person with mental illness

Advance directive absent present

Nominated representative absent present

Governing bodies • Central Authority• State Authority

• Central mental health authority

• State mental health authority

• Mental health review commission

AGAINST MENTAL HEALTH BILL,2013

CRITICAL APPRAISAL

• over-inclusive definition for mental illness likely to increase stigma. Also suggests that we need to have a precise definition.

• huge resource-mobilization• Urges all psychiatrists to come together because bill threatens

future of psychiatry• No words on how it would persuade victims of "mental

illnesses," mild and severe, to avail services from the right kind of institutions, overcoming their stigma-based inhibitions.

• Punishment for private individuals or companies, who while running institutions, fail to comply with prescribed regulations .• No regulations about government functionaries that may fail the

promises they offer.• No elaboration of methods of prevention of exploitation of mentally

ill persons in "non-mental-health institutions," as is happening now.• No definite budget for the bill.• matter of state government & not central.

• A 'mentally ill person' stating that a person who is determined on the basis of a due process, as needing compulsory treatment in a mental health establishment, because of either serious mental disease, or profound mental retardation.”• He also suggested that mental health establishments wouldn’t

have relatives during admission period.• General hospitals not to be treated as mental health establishment.• Advance directive only for PMI is unfair, should be applied in

other fields as well.

• Psychiatrists to be projected in bad light • It’s a measure to control this branch of physicians.• Guidance document to guide diagnosis & treatment. As well as ban

on ECT without anaesthesia.

CRITICAL APPRAISAL

• resource burden• increase burden on caregiver and mental health professionals • Restriction on treatment modality• No details on budgets and promises made• mental health act has still not been fully applied

FOR MENTAL HEALTH BILL,2013

THANK YOU