Legislations On Mental Health in India

The mental health legislation in India has undergone a number of reforms since its inception. The Lunatic Removal Act 1851 was the first law in relation to mental illness in British India. This law dealt with the transfer of mentally ill British patients back to England. Following the departure of the British, the Indian administration introduced a number of laws with the aim of caring for people with mental illness (Firdosi & Ahmad, 2016)-

• The Indian Lunatic Asylum Act 1858

• The Military Lunatic Act 1877

Under the provisions provided within these laws, people with mental illness were detained for indefinite periods of time in inhumane conditions with minimal chance of discharge. To rectify these issues, The Indian Lunacy Act 1912 was introduced but this law did not lead to any improvement in the state of people with mental illness.

A marked change in approach and understanding came forth with the Mental Health Act (MHA) 1987. This act was progressive in that it focused on improving the living conditions and ensuring treatment for individuals with mental illness. Though this act was a marked improvement on previous legislations, there were still many areas that needed to be modified. Some of the objectives of the MHA 1987 were-

• To safeguard the rights of individuals with mental illness

• To change offensive terminologies

• To set up licensing authorities (central and state)

• To set up psychiatric hospitals

It was believed that the MHA 1987 did not adequately address the needs of individuals with mental illness and neither did the act tackle the problem of rehabilitation post discharge. Such criticisms and more led to an amendment of the act which finally culminated in the Mental Health Care Act (MHA) 2017. Major changes include (Kumar, 2018; Mishra & Galhotra, 2018)-

• A significant shift in language has occurred, with words such as ‘detained’ being dropped and words such as ‘consent’ being emphasized

• Introduction of advanced directive

• Introduction of proxy decision making options

• Strict monitoring of restraints and seclusions

• Decriminalizing suicide

• Defining the role of patient safety

This is not to say that the MHA 2017 is anywhere close to perfect. Though there are some positive aspects, major limitations have been identified which are seen to be in contradiction to the principles of the act. Some of these drawbacks are-

• The act now requires that the medical officer be satisfied that the person has a mental illness, of a severity requiring admission and that the person will benefit from the treatment. Unlike when dealing with a physical health condition, the mental health professional (MHP) will have to make a diagnosis prior to admission. Often, patients are admitted so as to make a diagnosis or to make a choice regarding the treatment, even when the symptoms may not be severe. In bringing voluntary admissions under a regulatory mechanism, the act has not only infringed on the principle of equality, it is also discriminatory in nature.

• Patients can now appoint nominated representatives (NRs) who will act as ‘proxy decision makers.’ Without an application from the NR, an involuntary admission cannot be made. Though on paper it appears that the act has made provisions for empowering the family members, what it essentially does is increase the responsibility on them while also increasing the likelihood of the patient experiencing hostility and resentment towards family members.

• What happens to those patients living alone without family members? In case their capacity is limited, they cannot be admitted without a NR. The only option then is for the medical officer to request the district review board to appoint an NR which takes approximately 7 days. What happens to the patient in those 7 days?

• The MHP status is given to psychologists, social workers and nurses. Professionals in such roles often have to make decisions regarding the patient’s illness, diagnosis, and treatment and this requires extensive training. Nurses are not trained to deliver such services. The act seems to have compromised with a competent workforce, focusing on quantity instead of quality.

The MHA 2017 is a huge improvement on previous legislations and it has tried to work with the interests of the patient in mind which is praise worthy. However, there are many contradictions present within the act itself that will hopefully be rectified. For a country that is only gradually coming to terms with the reality of mental illness, a strong and resilient legislation can go a long way in prioritizing mental health.

Parvathy Nair, Clinical Psychologist. – Nagaland Post