|VIEWPOINT/PERSPECTIVES (THEMESECTION: MENTAL HEALTH CAREBILL, 2013)
|Year : 2015 | Volume
| Issue : 2 | Page : 134-140
Leave and Discharge: Legalising Science of Psychiatry and the Art of Caregiving!!
Savita Malhotra, Ruchita Shah
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||6-Jan-2016|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
The central theme and guiding principles of Mental Health Care Bill (MHCB), 2013 are “individual autonomy and protection of rights” of persons with mental illness. It has endeavored to address the rights of persons with mental illness. Pertaining to “leave and discharge,” the Bill provides for legal mechanisms and mandates for discharge of independent patients and their detention beyond 30 days; discharge of patients under supported admissions; leave of absence; discharge planning; role of Mental Health Review Boards (MHRB); nominated representatives; psychiatrists, medical officer, and other mental health professionals; and police. MHCB seems to be inspired by and modeled on Western laws borrowing several concepts and provisions such as that of MHRB and nominated representative. In this context, there are four major areas where the provisions of MHCB are either unenforceable without severe negative repercussions or nonviable. Close clause by clause analysis reveals that MHCB emphasises on individual autonomy and right to freedom at the cost of compromising other important fundamental rights such as to health and dignity. First, the Bill completely neglects the role of the most important resource, Indian family system; creating more hurdles for patient and family; even putting them on opposite sides of the legal fence. Second, though MHRB is meant for protection of rights, unlike the Western laws from where the concept is drawn, it has gross under-representation of psychiatrists, leaving medical decisions to the judiciary, and other nonmedical professionals. This seems to be a retrogressive step. Third, the periods for which detention is allowed under each section is clinically ill-informed and seems arbitrary (not even similar to Western laws!). Finally, several of the provisions including that of discharge planning cannot be implemented in practice unless, through its mental health policies and programs, the government creates community-based resources, and services of substantial quality.
Keywords: Discharge, family, leave, Mental Health Care Bill, rights
|How to cite this article:|
Malhotra S, Shah R. Leave and Discharge: Legalising Science of Psychiatry and the Art of Caregiving!!. Indian J Soc Psychiatry 2015;31:134-40
|How to cite this URL:|
Malhotra S, Shah R. Leave and Discharge: Legalising Science of Psychiatry and the Art of Caregiving!!. Indian J Soc Psychiatry [serial online] 2015 [cited 2020 Jun 2];31:134-40. Available from: http://www.indjsp.org/text.asp?2015/31/2/134/173292
| Preamble|| |
The Mental Health Care Bill, 2013 (MHCB) is all set to replace the Mental Health Act (MHA), 1987, in an attempt to harmonize the existing laws of India with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), 2006. After several drafts and consultations with various stakeholders, and minor changes by the Standing Parliamentary Committee on Health, the present form of the MHCB has now been placed before the Rajya Sabha. The central theme and guiding principles of MHCB, 2013 are “individual autonomy and protection of rights” of persons with mental illness, and it has endeavored to address the rights of persons with mental illness.
| Leave and Discharge|| |
The MHCB covers the provisions for leave and discharge of persons with mental illness from mental health establishments under Chapter XII admission, treatment, and discharge under various sections. These are sections 95. Independent admission and treatment, 96. Admission of minor, 97. Discharge of independent patients, 98. admission and treatment of persons with mental illness, with high support needs, in mental health establishment, up to 30 days (supported admission), 99. Admission and treatment of persons with mental illness, with high support needs, in mental health establishment, beyond 30 days (supported admission beyond 30 days), 100. Leave of absence, 101. Absence without leave or discharge, and 107. Discharge planning. While reviewing this part of the MHCB, 2013, we have tried to ask and if possible, answer a few questions; Are the provisions in keeping with UNCRPD? Do the provisions respect autonomy and dignity, and protect basic human rights of persons with mental illness and their families? Do these provisions foster “clinical” beneficence? How do these stand when compared to mental health laws of other signatory member nations? Shall these provisions help in de-stigmatizing mental illness? Will these support best practices in the treatment of and recovery from mental illness?
A brief note on process of admission under MHCB: Admissions are broadly divided intothose where the person has “capacity” to make mental health care and treatment decisions without support or with minimal support versus those who do not. The admission, in the former case, is as an “independent patient.” For the latter patients, provision of “supported admission” (sections 98 and 99) can be invoked, and it requires certification by a psychiatrist and a mental health professional or a medical practitioner. A minor can be admitted with consent of a nominated representative under section 96.
All patients seeking and requiring treatment for mental disorders, and all mental health facilities have been brought under the legal ambit of the new Bill. No distinction has been made between patients being admitted with their families and those admitted alone, or those requiring short ward stay (around 6–8 weeks) vis-à-vis those needing long stay. Again, no distinction is made between General Hospital Psychiatry Units on one hand, which have open wards, require family to stay and are in close liaison with other disciplines of medicine; and Mental Hospitals on the other. In reality, however, a majority of patients with minor and major mental disorders are treated in open wards of General Hospital Psychiatry Units, mainly housed in medical college hospitals for relatively shorter durations. These patients are accompanied by their families during their admission and family plays an integral part in all decisions. Also, admission of the independent patient should not be put under legal ambit, but it should be rather at par with treatment for medical illnesses. To legalize treatment services for these patients shall create more obstacles for the patient and his family be stigmatizing and overall be detrimental to their cause. These concerns have been raised time and again by the psychiatric fraternity, including experienced and eminent psychiatrists for over last 3½ years.,,, It has been suggested, and rightly so, that the Act should cover only patients requiring long stay admission to mental hospitals without families  who are vulnerable to abuse.
Further, certification for supported admission requires an additional mental health professional or a medical practitioner, besides the psychiatrist. Mental health professionals include clinical psychologists, mental health nurses, and psychiatric social workers. In reality, firstly, there is a severe dearth of trained nonpsychiatrist mental health professionals in the country. India has a meagre 0.16 nurses, 0.04 psychologists, and 0.03 social workers per 100,000 population working in the mental health sector, which is just 6–8% of average numbers or 12–15-fold less than the world over. Secondly, the role of a psychiatrist for important matters of admission and discharge cannot be entrusted upon nonpsychiatrist mental health professionals, who are not knowledgeable about the medical nuances of treatment. These provisions of MHCB seem to be borrowed from mental health laws ,, of better-resourced developed nations, where a cadre of professionals have been clearly defined based on their qualifications, with special training for the purposes of the act and roles and duties. Consider this example from day-to-day clinical practice, a patient with acute psychosis (or mania) needs urgent treatment in inpatient setting. The process under MHCB will be delayed, as well as cumbersome. Instead, a psychiatrist's advice and family's consent should suffice as is being practiced currently. To summarize, MHCB in its current form will make the process of health care delivery not only difficult and inaccessible by requiring one more professional other than the psychiatrist for important decisions, but also compromised by leaving clinical decisions partly or wholly to nonpsychiatrists.
The provisions for discharge are, of course, in accordance with the provisions for admission of MHCB.
Discharge of Independent and Minor Patients
An independent patient may get himself discharged without the consent of the medical officer, except when the latter invokes the provisions contained in section 97, subsection 3. A mental health professional may prevent discharge of such a person for 24 h so as to allow assessment necessary for supported admission. Within 24 h, the person shall be either admitted as a supported patient under section 98 or discharged.
An independent patient can get himself discharged without the consent of the doctor. This is in accordance with the general principles (Article 3) of the UNCRPD  which state respect for inherent dignity, individual autonomy including the freedom to make one's own choices, and independence of persons as the first principle. It presupposes patient's capacity to decide rationally in his own interest and in the interest of the society; which may not be so in cases of psychotic conditions, delirium, dementia, drug intoxication, etc., So, it is equally important to safeguard the individual's rights to life and health; which can be jeopardized if the person's condition is such that it warrants continued admission. Thus, it is imperative that a legal mechanism is in place to protect the individual under such circumstances. Section 97, subsection 3 provides such a mechanism. However, concern has been raised by a mental health advocate  that retaining an independent patient for a period of 24 h for assessment under provision of section 97; subsection 3, is against the spirit of UNCRPD. It should here be emphasized that a fine balance between right to autonomy versus beneficence and nonmaleficence is essential. This justifies that if in opinion of a qualified psychiatrist, discharge might cause more harm than good to the person himself or others or most likely, both, a minimum period of assessment is required before a sound clinical decision can be taken. A similar stand, recognizing the need for assessment in certain cases, has been taken by the Ministry. However, whether an upper legal limit of 24 h for purposes of assessment is clinically justified, is debatable. Psychiatric evaluation often takes longer, may need observation over a period of time or may need investigations. Therefore, the length of time should be reasonable taking into account these factors. In fact, the MHA, 2007 of the United Kingdom (UK) gives doctors the ability to detain someone in the hospital who is already an inpatient for a period of “up to 72 h,” to assess and decide if further detention is necessary under the Act. After assessment during this period, the MHA of UK further provides for detention up to 1 month for the purpose of assessment. Also, as pointed out previously, nonpsychiatrist mental health professionals have been given the responsibility to take important clinical decisions; in this case about detaining a voluntary patient who is demanding discharge. This may seem to be a practical arrangement under certain circumstances. Say, for example, a patient is requesting discharge, and the psychiatrist is not available at that time. The social worker thinks that the patient is “not fit” to be discharged, and retains him back for 24 h. This sounds similar to the provision of MHA of the UK where a nurse under similar circumstances can withhold the patient, but only for 6 h. However, the nurse is “of a prescribed class,” in other words trained for the purposes of the Act. On the other hand, in our case will the nonpsychiatrist mental health professionals be trained enough to take such a decision? In case of lack of training, the rights of the patient may be seriously impinged upon; but at the same time, if the paraprofessional is adequately trained, this provision will safeguard the patient's rights to health and safety. Thus, training of other mental health professionals is imperative for the success of MHCB. However, so far, it does not seem that this has been considered at all. Moreover, is the government committed and equipped enough to fulfill such a prerequisite for the effective implementation of MHCB?
In case a minor attains the age of 18 years, he shall be classified as an independent patient under section 95, and can thus, request discharge. If the nominated representative of the minor no longer supports admission or requests discharge, the minor shall be discharged.
In case the nominated representative, who is the legal guardian of a minor requests discharge, he or she shall be discharged. This appears to be a blanket diktat, not considering real clinical scenarios, where the nominated representative might have some ulterior motives. Consider this: A minor boy, aged 16 years living in a sheltered home suffering from a psychotic illness has been admitted under section 96. As the boy's condition is improving, the legal guardian fears that since the child is coherent, he might reveal history of physical (and even sexual) abuse to the doctor, and that it might be taken seriously. So, he “requests” discharge and the doctor has to comply as per MHCB. In such not-so-rare cases, the present form of MHCB fails not only to protect the right to health, but also the right to safety of the minor. Thus, there must be a provision for retaining the minor in the mental health establishment for some reasonable length of time until the psychiatrist in charge is able to re-evaluate the need for continued admission. Moreover, if the psychiatrist suspects ill intentions of the guardian, he should be given adequate time to alert the Board. An abrupt discharge, thus, may do more harm than good to the minor, and a provision for a quick review by the psychiatrist is required. Another option that can be considered is the appointment of a psychiatric social worker as the nominated representative for such minors in order to protect their interests. However, such appointment would also rest with the Board, making the process almost impossible. A well-thought of provision that empowers the doctor or a team of professionals to appoint a nominated representative on an emergency basis, to be reviewed by the Board within the shortest possible time is needed. Although sections on supported admission do mention about reporting admission of minor to the Board, it is unclear if minors can be admitted under those sections!
Discharge of Person from Supported Admission (Up to 30 Days)
Supported admission under section 98 can be for a maximum of 30 days. At the end of this period, patient may continue as an independent patient with a right to get himself discharged at any time. In case he still needs supported admission, he can be admitted in accordance with section 99.
Most acute therapeutic treatments other than electroconvulsive therapy such as antidepressant and antipsychotic trials take 4–8 weeks for significant clinical improvement. Further, more than one drug trial may be required in acutely ill patients when one drug trial fails. Moreover, certain pharmacological treatments (such as use of clozapine) may warrant admission which practically would take longer than 1 month. Thus, a 1-month cut-off for termination of admission under this section seems clinically ill-informed and impractical. Under the circumstances, most patients admitted under this provision shall be needed to be detained under section 99. Instead, a period of maximum of 3 months or 90 days or even longer should be provided for the first phase of “supported admission” for example, in the UK, MHA  provides for a detention period of up to 6 months for treatment, which can be extended if required.
A person admitted under this section or his representative may apply to the concerned Board for Review of the decision of the medical officer or psychiatrist pertaining to his admission. The concerned Board shall review and give a decision that shall be binding on all the concerned parties.
Provision of request for review of decision regarding admission and an identified body for the purpose is commendable as it ensures protection of basic human rights and individual autonomy and is in keeping with the right to liberty as stated in Article 14 of the UNCRPD. In MCHB, the Board has been given the complete power to make a decision regarding continuance of admission and can direct the “clinician” to discharge the patient. The Board ironically is not a clinical body with knowledge and expertise of a branch of medical science called “psychiatry.” The Board has only one psychiatrist and one other mental health professional among a total of six members. The remaining members are taken from judiciary, bureaucracy, and others, i.e. nonmental health professionals. Decisions of the Board are by consensus, or by voting, and in case of equality of voting, the decision of the chairperson a judge shall be final. How can clinical decisions be left to voting by people who are not experts in medicine, leave alone psychiatry? Consider this: A person with paranoid schizophrenia harboring dangerous delusions, who is not overtly suicidal or violent, “appears alright,” has applied to the Board for review of his admission. The Board takes a decision to discharge a patient; as after all, the decision might be vote based. He is thus, discharged prematurely with inadequate doses of medications or a viable postdischarge plan. His mental condition would most likely deteriorate, become noncompliant to treatment, run away from the house in a disheveled state, called a “madman” by passers-by or commit a crime under the influence of his delusions. Shall we not be denying the person his basic rights to health and to live with dignity? In such cases, what happens to continued care in the community and who shall own up the responsibility if the person proves to be a threat to himself or others immediately after discharge! Is the doctor expected to further contest the decision to safeguard his own interests?
Broadly, the Board as described in the MHCB resembles mental health tribunals constituted under similar laws in other nations , in terms of functions. However, the constitution of mental health tribunals elsewhere is more balanced and requires each member to be present for the hearing. Take for instance; in the UK there is a two-tier tribunal system. The first-tier tribunal (mental health) is the primary mechanism for appeal against the use of the MHA's powers of detention, guardianship or supervised community treatment. It is constituted of three members a legal member, a specialist member, and a medical member. The medical member is invariably a consultant psychiatrist of several years' standing while the specialist judges are senior experienced practitioners or therapists with a vast amount of experience within the mental health profession. The medical member has a dual role to perform; that of examining the patient and forming a medical opinion and that of being a judge during the hearing along with the other members. The three judges (legal, specialist, and medical) are appointed from a panel of members for a particular hearing. Moreover, there is provision in the Australian law, of a chief psychiatrist with substantial powers, who oversees functioning of psychiatrists, and decisions are not left to nonspecialists. Thus, the presence of a psychiatrist for each hearing has been mandated by these laws and rightly so. Drawing from this, it is highly desirable that the constitution of the Mental Health Review Boards (MHRB) under MHCB should be revisited. One way would be that a panel of psychiatrists be appointed for a particular region from whom depending on the availability; a particular psychiatrist sits for a particular hearing. The other way can be to have more psychiatrists on the Board or constitute an expert panel of psychiatrists of high standing from time to time to resolve such matters.
Discharge of Person from Supported Admission (More Than 30 Days)
The Board shall review all admissions under section 99. It can permit such admission or order discharge of such person. Also, a person shall not be permitted to remain admitted merely on grounds of nonexistence of community-based services. A person no longer requiring supported admission, may be discharged or may continue as an independent patient. Similar to provisions under section 98, a person with mental illness or his representative, may apply to the concerned Board for review of decision of doctor regarding admission. The decision of the Board shall be binding on all parties.
Each admission or readmission under this section shall be reviewed by the Board for “need for admission” which seems both unnecessary and clinically jeopardizing. As most supported admissions are likely to cross 1 month period, all these admissions shall be reviewed for their “correctness.” This seems unnecessary and shall only increase the workload of the Board, turning such reviews into mere formalities; thus, defeating the whole purpose. There are just 0.3 psychiatrists per 1,00,000 population, and still fewer other mental health professionals  and the judiciary is already overburdened with crores of pending cases across the country. With inadequate human resources, both judicial and medical, is such a proposition of reviewing all cases, viable or prudent? It does not seem so. Again, for each such admission, the decision of the Board with only one psychiatrist; who may or may not be present in a meeting shall be final. Only three members are needed to conduct a meeting of the Board with no mandate for the presence of a psychiatrist. Also, the Board's decision cannot be challenged merely due to any vacancy, which can very well be that of a psychiatrist. Such an approach seems anarchical and retrogressive; as it seems that it has been assumed that mental illness is not a medical condition; and management decisions including need for admission and discharge can be taken authoritatively by nonpsychiatrists. This can lead to more harm and harassment of persons with mental illness and their families. The family might stand to lose an opportunity for treatment of their loved one, especially when there are no specialized psychiatry services available in the community, which may still be the case more often than not in the foreseeable future. On the other hand, review by the Board in case of disputed admissions is necessary and welcome. Needless to say, the constitution of the Board begs for a rethink, at least for core clinical purposes.
Further, in India, the family forms the main resource for not only the treatment, but also rehabilitation and reintegration in the community of persons with mental illness. The family provides emotional, as well as logistic support during all the phases of treatment. More often than not, it is the family that brings the patient for treatment, suffers various hardships to get their near ones treated (to the point of losing their own livelihoods), takes the brunt of stigma and relentlessly accompanies the patient for follow-up, ensures he is taking medications, and tolerantly tries to occupy him productively in farming or household chores. Majority of our patients, as high as 98.3% are living with their families in the community, unlike “state provided shelters and rehabilitation centers” as seen in the West, where only 50% of patients live with families., It is then, to our utter disbelief and surprise, that the MHCRB completely undermines the role of the family and legalizes and outsources the entire caregiving process. In India, it is the family again that plays an important role in “persuading” the patient for the need of treatment and provides healthy and encouraging environment. Cynics might call this coercion. Though always a subject of great debate, even clinicians from the “West” opine that laying too much emphasis on individual autonomy would do more harm and impinge on basic rights to live with dignity and health. This will put our patients and their families, not always, but still substantially, on opposite sides of the legal fence.,,,
It is commendable to propose that patients would not be kept admitted merely on the grounds of nonavailability of services at community level. However, in reality, quality and specialized mental health services are nonexistent at the community level. So, to make such a proviso viable, the Government has to make enormous, dedicated, and sustained efforts to make mental health services accessible at the community level. Even with such efforts, it would take a long time for the scene to change.
Leave of absence
The medical officer or psychiatrist may grant leave to any person admitted under sections 96 or 98 or 99, after obtaining consent of nominated representative. If the patient does not return, the medical officer shall first contact the patient and his nominated representative. According to subsection 6, if the patient and his representative do not feel the need for continued admission, then the doctor is legally bound to discharge such person. In case, the medical officer or psychiatrist believes that ongoing admission is required, and if the nominated representative agrees, then the medical officer shall report to the police. If the person is not conveyed by the police in 1 month time, he is deemed to be discharged.
If a patient absents himself beyond the period of leave, and the psychiatrist is in favor of continued admission, but the nominated representative is not, the psychiatrist is duty bound to discharge the patient. However, the nominated representative might have some vested interest in keeping the person with mental illness away from treatment, and the said provision does not safeguard against such scenarios. Moreover, in such cases, the treatment in the community might be compromised or nonexistent; further detrimental to the well-being of the person with mental illness.
Absence without leave or discharge
If a person with mental illness admitted to a mental health establishment under this Act absents without leave or without discharge from the mental health establishment, he shall be taken into protection by the police at request of the medical officer or psychiatrist and taken back to the mental health establishment immediately.
This provision ensures that efforts are made to bring the patient back to treatment services; and protects his rights to health and safety. However, there is complete reliance on the police for bringing the patient back to the hospital. On the other hand, practically, family plays a major role in tracing the whereabouts and bringing the patient back. Even the police would need assistance from the family in tracing the patient. Surprisingly, there is no mention of the family's role and involvement. Suppose the patient absents himself, and the family traces him to a certain place, convince him to return, and bring him to the hospital. In that case, is there need to involve the police for bringing him back? It might actually overburden the police when the family can take charge of the situation. In cases where the family is unable to bring him back, the local police can take over. Also, should all cases be reported immediately? Many a times, the family brings back the patient in a couple of hours. One way to deal with such situations is to report to the police after a stipulated period of time in cases where the family is available (as in general hospital psychiatric units and family units). In other cases, reporting should be immediate along with mobilization of family resources. Also, police and family should coordinate their efforts. All said, it is imperative to develop a system of liaison with the police defining the time after which request should be sent, to whom and how it should be sent, and the role of police and the family.
Section 107 provides that whenever a person is to be discharged into the community or there is a change of psychiatrist or transfer, the treating psychiatrist shall discuss with the patient, his representative, family member, or caregiver as to what treatment or services would be appropriate for the person. The discharge planning under this section applies to all discharges from a mental health establishment. Moreover, the Board can demand a “discharge plan” from the treating doctor in case of supported admissions.
Explicit mention of discharge planning is in keeping with the right to live independently and in community and right to health as stated in the UNCRPD and is commendable. Ideally, sound clinical practice calls for drawing an after discharge plan for ongoing care and rehabilitation of individuals. This process should involve the patient and his family, other professionals and include medical, as well as psychosocial needs. Also, it should take into consideration the available treatment options and their accessibility and affordability. There is great variability of psychiatric care across India; discharge plans and discharge planning will not be present at all places. Hence, the requirement of a proper detailed discharge plan with appropriate documentation in MHCB is welcome. This concept also is reflected in the aftercare planning mandated by the MHA of the UK (2007). In the UK, aftercare is planned with the patient, their family and carers, as well as professionals, looking at both health and social care needs. Importantly, discharge plans are implemented through multidisciplinary care planning and managed by a care coordinator. In that case, would discharge planning in itself ensure ideal aftercare? Would not adequate resources be required in the community? As emphasized in earlier sections, what is needed, therefore, is that through its mental health policies and programs, the government creates quality resources in the community. Only then, can there be any change in the ground situation.
| Final Remarks|| |
To conclude, MHCB emphasizes much on individual autonomy and protection of the right to freedom of persons with mental illness. The provision of independent or voluntary admission with freedom to get oneself discharged at any time, taking into account the person's wishes and consent, and capacity to consent at every stage in a supported admission and provision to request for a review and discharge to the Board, all reflect the same spirit. However, a close clause by clause analysis reveals that the Bill emphasizes on individual autonomy and right to freedom at the cost of compromising other important fundamental rights such as right to health and right to dignity. The MHCB seems to be “inspired” by and “modeled” on autonomy-driven Western laws such as those of UK  and Australia., It emphasizes on concepts such as “nominated representative” which are completely alien to the Indian family system, culture, and ethos; and are either unenforceable without severe negative repercussions or nonviable. Paradoxically, it has been pointed out in the developed, autonomy-driven nations, that current capacity-based legislation and practice overvalues autonomy to the detriment of other ethical principles. The role of families  which among others has been credited for better course and outcome for certain major mental illnesses such as schizophrenia in India as compared to the West, has been completely overlooked. Thus, it seems ironical that the much needed , and much awaited new mental health law envisioned to protect the rights of mentally ill should take such a narrow view of “rights,” should ignore important assets and resources, and adopt concepts en masse which are alien, impractical and unenforceable. Instead of making the process of caregiving destigmatizing and easier, the MHCB creates more hurdles. With a heavy reliance on judiciary, MHCB proposes clinically ill-informed legal binding on service providers and too much legalization of medical services that can cause more harm to the persons with mental illness and their families, and violate several of their rights. A few examples are premature discharge of the person with mental illness, incomplete treatment, and a restricted period of 1 month for supported admission. Psychiatrists not having a decisive say in matters of treatment and discharge will jeopardize the medical care of the mentally ill. Entrusting nonclinicians to take decisions which are completely clinical even in absence of psychiatrists (for example decision of MHRB when the psychiatrist is absent) as if mental illnesses are social maladies and not biological/medical disorders is not in the best interest of patients. Further, it increases stigma and discrimination and is at risk of taking away warranted treatments from the persons who need these.
Finally, it has been proposed that “A balanced ethical approach would consider the patient's right to treatment, their relationships and interactions with society and not solely the patient's right to liberty and autonomous decision-making.”
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Conflicts of interest
There are no conflicts of interest.
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