MENTAL HEALTH NURSING

UNIT XIVLEGAL ISSUES IN MENTAL HEALTH

NURSING
TOPIC : MENTAL HEALTH CARE BILL AND RIGHTS OF MENTALLY ILL CLIENTS

Prepared By: Mrs Bemina JA

Assistant Professor
ESIC College of Nursing
Kalaburagi
REASONS TO THE BILL
 The new Bill was introduced as the existing Act does not adequately protect the
rights of persons with mental illness nor promotes their access to mental
healthcare.
THE KEY FEATURES
 Every person shall have the right to access mental health care and treatment

from services run or funded by govt.

 A mentally ill person shall have the right to make an advance directive that

states how he wants to be treated for illness.

 Every mental health establishment has to be registered with the relevant Central

or State Mental Health Authority, These authorities are in addition responsible

for supervising and maintaining a register of all mental health establishment.
 A person who attempts suicide shall be presumed to be suffering from mental

illness at that time and will not be punished under the Indian Penal Code.
 Electro-convulsive therapy is allowed only with the use of muscle relaxants and

anesthesia. The therapy is prohibited for minors.

The Mental Health Care Bill sets out:
 • What is Mental Health?
 • When and how people can be treated if they have a

mental disorder
 • When people can be treated or taken into hospital

against their will?

 • What people's rights are, and the safeguards which

ensure that these rights are protected

Features of the New Bill
 1. Mental health Professionals
 2. Mental Health Establishments
 3. Legal Capacity

 4. Informed Consent for treatment and researches

 5. Rights of persons with mental illness
 6. Administrative Bodies
 7. New rules on admission, leave and discharges
 8. Duties of the Government

 9. Special Measure for Minors

 10. Decriminalizes attempted suicides
 11. Medical insurance to cover mental health treatment
 12. Ban on ECT without anesthesia , psychosurgery and chaining
 13. Nominated representatives
 14. Emergency treatment

 15. Granting Divorce

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 Person With Mental Illness
 Chapter VI: Duties Of Appropriate Government
 Chapter VII: Central Mental Health
 Chapter VIII: State Mental Health
 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
Appreciation of the MCHB 2016
 Decriminalization of attempted suicide
 Rights of person with mental illness
 Provision for medical insurance for treatment for

mental illness
 Duties of appropriate government
Admission , Treatment and Discharge
 INDEPENDENT ADMISSION
 Any person who considers himself to have mental illness and

desires admission, who is not a minor.

 Admitted if the Medical officer or Psychiatrist is satisfied that
 A. Mental illness of severity requiring admission
 B. Patient should benefit from admission and treatment
 C. Request made is under free will and not under undue

influence and has capacity to make mental health care

decision
 D. Informed consent
 E. Bound to rules and regulations of the establishment.
Discharge procedures
 An independent patient may get himself discharged from the
mental health establishment without the consent of the medical
officer or mental health professional in charge of the MHE.
 Minor : If the nominated representative no longer supports
admission or requests discharge of the minor, from the mental
health establishment, the minor shall be discharged thereof
 Power with the mental health professional to prevent
discharge of person for a period of 24 hrs to allow assessment
if necessary ?
Recent suicide attempt/threatening
Violence towards others
Inability to care for oneself
Admission and Treatment up to 30 days
 When and how?
 Upon application by Nominated Representative
 2 mental health professionals, including a Psychiatrist, after independent
examination
 Feels that the person has a mental illness of such severity that the person
a) Recently threatened or attempted to cause bodily harm
b) Recently behaving violently towards another person, or causing
another person to fear bodily harm
c) Recently shown inability to care oneself to a degree that places at risk
of harm to oneself
Limited to a period of 30 days.
To be informed to MHRC within 7 days (10 days for Northeast) of
admission
Admission and treatment exceeding 30
days
 Continue admission in the establishment
 Same procedures as the previous clause, where a re-

examination will be done, but 2 psychiatrists examine

the patient
 Consistent inability to take care of oneself
 To be informed to MHRC, to be approved within 21

days (30 days for Northeast)

 Limited to 90 days.
 Renewal to 120-180 days.
Admission of Minors
 2 Psychiatrists
 1 Psychiatrist &
 1 mental health professional
 1 Psychiatrist & 1 medical practitioner Minor
 Nominated Representative to be with the minor for the

entire duration of admission

 Treatment for the minor with informed consent of

Nominated Representative.
Leave of absence
 Granted by - Medical officer or Psychiatrist
 After securing consent of Nominated Representative
 Power with the practitioner to terminate when

appropriate to do so
 If the patient does not return, contact the patient on

leave, or nominated Representative or both

 Absence without leave
 Without discharge, absents one-self
 Taken into protection by Police Officer at the request

of the Psychiatrist in charge and brought back.

Emergency Treatment
 Who can treat ? Any Registered Medical Practitioner, subject
to informed consent from the Nominated Representative.
 When ? When its necessary to prevent :

a) Death or irreversible harm to health of the person, or,

b) Person inflicting serious harm to himself/others
c) Person causing damage to property
 ECT is NOT permitted as an emergency procedure
 Emergency treatment limited to 72 hrs (96 hrs for Northeast)

or till the person is assessed at a mental health establishment.

 Disasters/emergencies, it may extend to 7 days.
Criticism/suggestions of Mental Health
Bill 2016
 1. Mental Health Establishment
 2. Capacity to make mental health care and treatment
 3. Advance directives
 4. Nominated representatives
 5. Mental health review boards
 6. Right to confidentiality
 7. Discharge planning
 8. Role of family members
 9. Treatment guidelines
 10. Lack of resources
Mental Health Establishments
  NMHP mandates integration of mental healthcare
into primary healthcare
  MHCB mandates all the establishments to take

license to treat patients

  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”
 Refusal of private hospitals and nursing homes
 Hostels, prisons, jails, juvenile homes, temples, churches,
dargahs keeping patients with mental illness will be at stake
 Anticipated “License Raj” of harassing MHC providers
 Supposed to inflict greatest damage to the system of mental
health care delivery
 Capacity to make MHC and treatment
Inadequate & can have dangerous consequences
Clause by default says everyone has capacity and right and so the
contrary has to be proved before involuntary admission
Psychotic patients with absent insights usually refuse admission
ultimately troubling the family
Permission be sought from the mental health board
Proposed admission by informed consent of family
 Advance directives
 To be followed by mental health professionals during treatment
 Becomes difficult in Indian scenario when :
1. Treatment proposed in a costly/far to reach hospital
2. Treatment choice may be 2nd or 3rd choice some situations
3. Cochrane review studies doesn’t support advance directives in mental
illness
Can put family to heavy burden and difficulties
 Nominated representatives
Selection by patient (with colored thought and perception) may be
affected by the illness
Nominated representative may break the Indian family system who
ultimately care for the patient after all odds
Costly treatment selection by the nominated representative can affect the
whole family
Ultimately at some point the family may disown the patient
Mental health review boards
 Quasi judicial boards
 May introduce hurdles in smooth treatment procedures
 Limited boards to visit individual patient is questionable and delay in
addressing the issue is anticipated (e.g. festive seasons in India)
 Tedious, prolonged and costly judicious procedures
 Time limit for doctors while no time limit for boards 44
 Right to confidentiality
 The MHCB provides unlimited access to all the documents of the patient
by nominated representative
 “Breach of confidentiality” by Mental health professionals as per Medical
council ethics, 2002
 Impinges on fundamental rights “right to privacy”
 Proposed disclosure of family members only in verbal form and written
form only on written request
Discharge planning
   Ultimate decision of continuation of treatment or not
lies on patient/ nominated representative
 “Continuity of care” is at stake due to lack of role of

family members and most of all the treating

psychiatrist/physician
 Bill is silent about much needed community care
 Finally pressure over the family members even if they

want treatment in proper way

Role of family members
   Not only protects right of the patient but also
promotes family participation in active treatment
process
 MHCB undermines the role of family members in

providing care
 Bill needs to modified that in case of involuntary

treatment, presence of at least one family member

should be present
 Management of property of person with severe mental

illness is absent
Treatment guidelines
 Treatment should be as per national professional
guidelines
 ECT has been established as a modality of choice in

many major psychiatric illnesses

 The bill banns ECT during emergency management as

well as in minors
 Withholding the same just for the permission of mental

health board is “delay in justified treatment”

 Hands of treating Psychiatrist this way is curtailed to a

large extent
Lack of resources
 Bills overloaded with right based ideology not fully
acceptable in Indian family structure
 Logistic problems like poor infrastructure, inadequate

mental health workforce, low budget allocation for

MHC, siphoning fund of MHC to general health care
 Bill needs to focus on smooth running of the MHC

rather than over exaggeration on compensation

 Urgent need to introduce basic psychiatry at UG level

(MBBS) for learning of treatment of basic psychiatric

diseases
Neglected role of statutory body
 MHA-1987 was conceived, piloted and drafted by the Indian
Psychiatry Society (IPS)
 Though invited to the consultation process at different stages,

IPS was not assigned any role in drafting of the current Bill
 IPS expressed apprehensions about a number of provisions in

the Bill as not considered to be in the interest of persons with

mental illness
 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
CONCLUSION
 1. The MHCB, 2016 comes out to be a praiseworthy effort
for addressing the long standing problems encountered by
patients and practitioners in the sector of mental health
care.
 2. The bill can bring a radical change in the field of mental
health care and service in our country.
 3. Even though some sections of this bill are being
criticized but still this bill seems more humane and
appropriate in the current situation.
 4. With further amendments in necessary areas this bill can
prove a blessing to the Mental health care system
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 Thank you