Mumtaz Sanghamita speaks on The Mental Healthcare Bill, 2016

FULL TRANSCRIPT

We are discussing such an important Bill at a time where on April 7 will be celebrating the World Health Organisation Day and this year’s theme is ‘Depression – Let’s Talk’. It is showing the global importance about the psychological situation. And we are the pioneer, we can say, about dealing with mental health issues this year. This Bill is a revolutionary approach to mental healthcare and it is unique. It seems to be idealistic but not totally realistic. And it is not foolproof.

The Act of 1987 provided only general protection of people with mental illness (PMI) against indignant and cruel treatment. The Bill of 2016 talks about mental care in the broader sense or aspects, mostly dealing with human rights aspect and focusing on admissible patients. According to WHO’s international code of diseases, PMI is defined as a disorder of thinking, mood perception, orientation, memory, excluding mental retardation and including drug abuse. And in the Bill we corporate that. This is good.

Taking this in account, this Bill when it appears as an Act, will be help to change the general public attitude towards PMI persons and it will prevent public to call them lunatics and abuse them, hesitate to be associated with them and it would remove this stigma of avoiding the medical health. Instead of mental asylum – in Bengali we used to call it ‘pagla garod’ that means it is a jail for pagals; It is a very bad thing – now I suppose it will have a new dignified name. It is highly appreciable that the Bill guarantees certain human and social rights to PMI persons. Most of these concepts are of western, developed countries and they may not be feasible or suitable for implementation in our country because of budgetary constraints as well as social lifestyles.  

Directive has been given in the Bill of the right to access affordable, good quality, easily accessible, minimum mental care up to district level. This right is already given in our constitution, for any patient to have access of healthcare facilities; it’s a fundamental right. I don’t know what the necessity is for emphasising this in this Bill.

NHM has already got programmes for PMIs and the proposal for the establishment of special units for them up to at least the level of districts. In West Bengal, we already have 61 such centres including in seven medical colleges and in many district hospitals, some of which are being upgraded to medical colleges. The irony is that the budgetary allocation for health would be quite insufficient for these new health programmes ventured into by the Central Government.

The most bold and acceptable issue in the Bill is the decriminalisation of suicide. Unless otherwise proven, such victims should be considered as cases of PMI. Well, it is a very bold attitude, but the Bill does not give any directives about, when the person has recovered from the effect of attempting suicide, what would be the next steps – how we would counsel them, etc.  Another very good thing is about the insurance coverage. It is an appreciable gesture and it is a very important issue in such people’s lives. The problem, however, is that there are no proper guidelines about the coverage of this insurance. In the case of all other diseases, we take the amount of insurance coverage to include the sum of the cost of operation, hospitalisation, medical facilities, etc. But here proper guidelines are not there. Also, the basic thing in such cases may be counselling, something not taken into account as well.

The Executive Body of the Indian Psychological Association, the largest psychological organisation, which is present in States all over India, has some reservations and resentment regarding this Bill, though they also are quite appreciative of some parts of the Bill.  They have already expressed their feelings and given representation to the honourable Minister. My opinions regarding those lacunae are more or less similar.

As it has been said by many people, five to seven per cent of Indians are mentally imbalanced, comprising of millions of people, and consisting 12 per cent of the global burden. This figure is likely to increase.  Five to seven per cent among them are suffering from a severe nature of mental illness, who need admission to hospital or special care, that is, indoor care. The rest 95 per cent are looked after in OPDs or at homes and otherwise through the consultative business. The care of those majority have not been addressed in this Bill properly.

Proper guidance regarding running of the general hospital, and the indoor beds in medical colleges and district hospitals which is very niger amount usually can be used only for the emergency admissions. Why can’t we think about increasing those and taking special care because, when we are trying to streamlining these mental illnesses along with the other illnesses, why should we give a special name and special category?

There is a clause about ECT (electrocardio shock). This is concerned with the modified ECT with muscle relaxants and anesthesia. In our set up, it is only possible in tertiary care centers in the medical colleges and clinics with a special facility in most cases, and it also needs at least half-day admission. Moreover, it may be good in aesthetic sense, but, scientifically, it is neither mandatory or, is it not evidence-based to prove to be better than conventional ECT without muscle relaxants and anesthetics. Moreover, it requires an extra cost, manpower and set up. Neither it is contra-indicated in adolescent also, ie persons over nine years of age, to less than 19 years of age.

Most of the sections are dealing with the establishment of the central and state level boards. This Bill gives right to the patient about persons’ own consent regarding admission, place and type of treatment and Advanced Directive to choose a representative.Who is going to decide a person is in solid mental condition to give consent for that directive is not given in this Bill. That is a real fallacy. And the board has been given the power to decide, register or prove the authority of the directive and in need can appoint patient’s representative. Funny enough, when the disease itself defines alteration of mood, loss of power of decision making etc, the Bill doesn’t mention about who is going to certify the mental status of the person in that moment. It is sad that the person has to apprehended before hand that they may go through this.

I don’t know what is the need of a special board where most are executives from the government and officials. Highly professional people are not there. Moreover, there is a dearth of psychologists and mental health nurses in the country.

This Bill isolates the institutions and the psychologists from the other general medical practitioners and frustrates the idea of streamlining psychiatrist treatment along with the others. It should deal with the medical education, which is badly lacking in psychiatrist education. It also needs research of the psychological situation for rapists and other criminals in jail.

The Bill doesn’t address the issue of property management of the PMI persons if and when he or she is not in position to do it he or herself. It doesn’t give any direction regarding property custody of those patients.

This is the Bill which invited 124 amendments in Rajya Sabha. This implies that it should be reconsidered later on, and with a special facility for child psychologists and women.

Thank you very much.

 

 

 

Idris Ali speaks on The Mental Healthcare Bill, 2016

FULL TRANSCRIPT

While participating in the discussion on The Mental Healthcare Bill, 2016, passed by the Rajya Sabha, and now been amended as The Mental Healthcare Bill, 2017, I would like to say that though public health is a State subject, with the financial constraints, it is next to impossible for the States of the country to implement the provisions of this Bill.

India is the worst-affected country in the world with regard to depression, having more than 6 crore sufferers. The data of the UN agency shows that the number of people living with depression across the world has increased by 18.4 per cent between 2005 and 2015. In India, depression and mental anxiety disorders prevail in over 5 per cent women and in over 4 per cent men.

Apart from that, about 4 crore people in India suffered from anxiety disorders in 2015, with a prevalence rate of 3 per cent. It is a fact that 78 per cent of global suicides occurred due to mental instability and 1 per cent commits suicide every 40 seconds.

The most alarming thing is that a study indicated an average of 20.5 per cent mental health morbidity in older adults with 17.3 per cent in urban areas and 23.6 per cent in rural areas. Accordingly, it is found that, at present, 18 million older adults, consisting of a population of 83.58 million, are suffering from mental health problems in India.

In 1982, the Government launched the National Mental Health Programme (NMHP) and in 2014, the Health Ministry came up with a revised National Mental Health Policy to treat the elderly, affected by Alzheimer’s and other dementias, Parkinson’s disease, depression and psychogeriatric disorders.

The population of older adults in India is growing: in 1951 it was 5.3 per cent, in 1981 it was 6 per cent, in 1991 it was 6.8 per cent, in 2001 it was 7.4 per cent and in 2006 it was 7.5 per cent. Thus it has been steadily rising and is projected to become 12.5 per cent in 2026; thus it is likely to become a challenge in the near future.

Surveys have found that depression still ranks as the most prevalent psychiatric illness of the aged. One out of every six older persons living in urban areas in India is not obtaining proper nutrition, one out of every three older persons does not obtain sufficient healthcare and medicines, and one out of every two older persons does not receive due respect or good conduct from family members or people in general.

The Indian Council of Medical Research (ICMR), using sound methodology, has revealed that 17.3 per cent of urban and 23.6 per cent of rural older adults, that is, those aged 60 years and above, are suffering from syndromal mental health problems and 4.2 per cent of urban and 2.5 per cent of rural older adults are suffering from subsyndromal mental health problems. According to the Global Burden of Disease Study (GBD), although the world proportion of people of 60 years and above is smaller now, by 2030 the absolute number of older adults is likely to be the highest in India, with enormous mental health morbidity in older adults.

So, the Mental Healthcare Bill, 2017 is not just a health Bill but one which deals with a mixture of health and social care issues, and hence, we have to think differently to protect and promote speedy procedures of treatment and the rights of persons with mental illnesses.

Keeping in view making fruitful the objects of the Bill, we immediately require community-based mental healthcare by using the public health infrastructure and other resources of the primary health centres in the administrative structure to develop and monitor the progress of the programme in a centralised manner. To make it a successful project, we have to immediately set up psychiatry and psycho-orientation departments at all levels of health centres and hospitals in the country.

I therefore request the Central Government to ensure funds to State Governments for due implementation of this Bill and this Bill may kindly be included with the schemes of the Department of Health and Family Welfare which are under 100 per cent Central Government funding, before the situation gets out of the hand of the Government.

Ratna De Nag speaks on The Mental Healthcare Bill, 2016

FULL TRANSCRIPT

Thank you Sir for giving me the opportunity to speak on The Mental Healthcare Bill, 2016. The Bill seeks to promote and improve the rights of the patient in need of the mental healthcare.

National Human Right Commission conducted a detailed study of the patients in mental institutions and condition they live in. They found numerous instances of cruel treatment – people being beaten, people being chained and being denied dignity of any kind.

Sir, at present we have about 300 district mental health programmes. But the effectiveness of the programmes varies across the States because of the restricted funding, lack of trained human mental health care providers and low motivation among the health providers at the all stages.

The access to mental health programmes is going to be a big concern in India. Up to 40% of the patients do not get access to the mental health programme because they have to travel more than 10 km.

Depression is the leading cause of death in the world and it is the second leading cause of death among 15-29 years old. According to World Health Organisation, about 350 million people suffer from depression worldwide. As per the National Crime Records Bureau, 1.31 lakh people committed suicide in India in 2014. Lack of funding, lack of human resources, and social stigma associated with mental illness – along with lack of access – are the main reasons for the failure of effectiveness of these programmes.

Lack of funding, lack of human resources, and social stigma associated with mental illness – along with lack of access – are the main reasons for the failure of effectiveness of these programmes. There are about four thousand psychiatrists in India. Most of them are in the private practice, so there is a massive shortage of psychiatrists in the public sector. This will lead to large number of people, requiring treatment, remaining undiagnosed.

But Sir, there are some good provisions in the Bill also. For example, Advanced Directive, stating how he or she wishes to be treated for a future mental illness also how he does not wish to be treated. Such an Advanced Directive can also be challenged by families, professionals.

Decriminalisation of suicide is a much needed reform. A person attempting suicide shall be considered to be under serious stress and will not be liable to be prosecuted under Section 309 of IPC. The Government shall provide care, treatment and rehabilitation to all such persons.

Another good provision, Sir, is that the Bill provides protection to patients from cruel, inhuman and degrading treatment. Some treatments currently being used will be prohibited, most importantly, electroconvulsive therapy given without anesthesia and the practise of chaining the patients to their bed.

But, there are some points Sir, I would like to raise. The Provision of appointing a nominee and then subsequent decisions being taken by them may lead to damage to the bonding and goodwill between the families.

Furthermore, a mental patient can only be admitted in a mental institution after review by the Mental Health Review Commission.This may lead to undue delay in the treatment and make the entire process more complicated. Furthermore, this reason may discourage the families from playing a proactive role.

The Mental Health Review Commission has six members, out of which one is a psychiatrist and another a mental healthcare personnel. This means that it will lead to crucial decisions being taken in the field of mental health by a non-expert.

The Bill speaks about ECT, that is, electroconvulsive therapy in the case of some mental illnesses for minors. But, Sir, the Board advises it with the consent of the parents with prior permission of a psychiatrist. Sir, due to serious hazards of electroconvulsive therapy on minors, it is a controversial implementation in the case of mental health issues of a minor, and so a blanket ban on electroconvulsive therapy for the treatment of mental illnesses of minors should be implemented, as advised by the World Health Organisation.

The Bill states that medical records can be assessed by the patient unless it causes a “serious mental harm”. But there is no definition as to what would constitute a “serious mental harm”, and it is linked to the psychiatrist’s decision. This may lead to unscrupulous people taking advantage of these patients for their own benefits. Sir, the Bill must provide for a stringent punishment in cases of falsifying medical records.

The Bill states that there shall be one district board for eight north-eastern States covering at about 262.230 sq km. This would make it inaccessible to large number of people, due to difficulties in connectivity and terrain.

Sir, the Bill states about the community-based rehabilitation establishment and health services. But is not defined. A clear-cut definition is required.

Sir, I would request the Hon. Minister to:

  • include Dementia under Mental Healthcare Bill,
  • incorporate a neurologist in the Board,
  • ensure that the admission and discharge of a mental patient in a mental health institution should be under the jurisdiction of the physician,
  • organise regular mental health awareness camps. They can be organised by government and non-government organisations,
  • review and assess the programme by an expert, and finally,
  • assess and analyse the benefit of the programme and response of the people.

 

I would request the Hon. Minister to look into these issues so that the country gets a good Bill and we are able to eradicate the social stigma associated with mental illness.

Thank you, Sir.