HISTORY Earliest mention of mental hospital in India are of hospitals like those of Veera Rajendra Deva of IX century A. D.

referred to in the inscription found in the inner sanctuary of a temple dedicated to Lord Venkateswara Thirumukicudal, Chingleput District, Tamil Nadu, It mentioned a hospital, a school and the expenses for maintaining the hospital and for the festivals of the Deities. This Veera Choleswara Hopital contained 15 beds; attached to the hospital were a physician-surgeon, 2 male and female nurses, servants, I gatekeeper, 1 washerman and I potter. The duty of the male nurses was to bring herbs and firewood and prepare medicines whereas the female nurses duty was to administer doses, feed the patients and do the cooking. There was no specific mention about the segregation of the psychiatric patients (Subba Reddy 1971). We can also understand the attitude of the public which is one of compassion and adesire to help people with mental illness in tamil epic Manimekalai where a classical catatonic schizophrenia patient has been described. The Arabic medicine took the form of the Unani system during the Muslim period. Najabuddin Un Hammad (1222 A. D.) made a special study of mental diseases and described 7 varieties of the illness. There was a mental hospital at Dhar, near Mandu in Madhya Pradesh, which was established by Mahinood Khilji (1436-1469) and Maulana FazularLah Hakim was its physician. There is some clear evidence that modern medicine and hospitals were first brought to India by the Portuguese during the 17th Century in Goa. However, the segregation of the people with mental illness in mental asylums and their supervision were entirely of British origin. Before the 1912 Act came into effect, the various enactments controlling the care and treatment of the mentally ill of the then British India could be enumerated as follows: 1. The Lunacy (Supreme Courts) Act, 1858 (Act XXXIV of 1858). 2. The Lunacy (Districts Courts) Act, 1858 (Act XXXV of 1858). 3. The indian Lunatic Asylums Act, I 858 (Act XXXVI of 1858). 4. The Military Lunatics Act, 1877 (Act XI of 1877). 5. The Indian Lunatic Asylums (Amendment) Act, 1886 (Act XVIII of 1886). 6. The indian Lunatic Asylums (Amenditsent) Act, 2889 (Act XX of 1889). 7. Chapter XXXIV of the Code of Criminal Procedure, 1898. 8. Section 30 of the Prisoners Act, 1900. The first three Acts were enacted immediately after Queen Victorias proclamation and India came under the rule of the british Crown.

INDIAN LUNACY ACT:

Indian lunacy act was introduced by honble Mr. Jenkins with the aim to consolidate and amend the law relating to lunacy. The council of government general of India met on 10th January 1912 under the presidency of the honble sir Guy Fleetwood Wilson and refereed the Indian lunacy bill to select committee. It contained eight chapters and 101 sections. It was conceived on the basis of prevailing british law. it Was not based on any mental health policy or programme. Main objectives were: 1) Protection of the society from the mentally ill persons who had become a danger or nuisance for the civilized and sane society. 2) Protection of citizens from being detained in psychiatric facilities without sufficient cause. Mental retardation was excluded from the purview of the act. Chapter one defined terms like asylum, lunatic, criminal lunatic. Chapter two was about the reception, care and treatment of the lunatics. Role of magistrates in issuing reception order for the lunatics described.time and manner of issuing of medical certicificates for the patients described. Chapter three deals with the visitors committee and discharge of patients Chapter four deals with judicial inquisition of lunacy in the presidency towns of fort Williams, Bombay and madras. Chapter five deals with in judicial inquisition in non presidency towns. Chapter six deals with establishment of asylums. Chapter seven about expenses of lunatics Chapter eight deals about the rules The rights of mentally ill were not considered in the act It basically worked on the principle of dangerousness of mentally ill and necessity to keep them segregated from the society much in tune with the Victorian philosophy.

MENTAL HEALTH ACT 1987: Earlier mental health legislations in India, i.e. Indian Lunatic Asylum Act 1858 and Indian Lunacy Act (ILA) 1912, were primarily concerned with custodial aspects, and human rights aspects were hardly addressed in these laws. After the Second World War, Universal Declaration of Human Rights was adopted by the UN General Assembly in 1948 and India was a signatory to it. Therefore, it became pertinent to make appropriate changes in the ILA, 1912, which was in force at that time in India. The need of a new law led the Indian Psychiatric Society (IPS) to submit a draft Mental Health Bill in 1950. But the government initiated the process for enactment only in 1978 and introduced the Mental Health Bill in the Lok Sabha. After a long and protracted course, Mental Health Act (MHA), 1987 was finally enacted in 1987. After framing of the Mental Health Rules in 1990, it was finally notified to come into force in all the States and Union Territories only on April 1, 1993. Terminologies used in the act New term:previously used terms Psychiatric hospital :Nursing home Asylum Mentally ill person : Lunatic Mentally ill prisoner :Criminal Lunatic Other important terminologies used in the act 1. Reception order: Means an order for admission and detention of a mentally ill person in a psychiatric hospital or nursing home. 2. Psychiatric hospital or nursing home: It is a hospital for the mentally ill persons maintained by the government or private party with facilities for outpatient treatment and registered with appropriate licensing authority. Admitting a mentally ill to a general nursing home is an offence. 3. Medical officer: A registered medical practitioner. 4. Medical officer in-charge: Is a medical officer who is in-charge of a psychiatric hospital or nursing home. 5. Mentally ill person: Is a person suffering from mental disorder, other than mental retardation, needing treatment.

6. Mentally ill prisoner: Is a mentally ill person, ordered for detention in a psychiatric hospital, jail or other places of safe custody POSITIVE CHANGES: More humane approach to problems of mentally ill persons by changing the terminology e.g. lunatics and criminal lunatics have been replaced by the term mentally ill person and mentally ill prisoner etc. new chapters on management of their property and protection of human rights have been included Creation of Central and State Mental Health Authorities- a welcome step to safeguard the interests of the mentally ill person under one authority Procedure for admission and discharge of voluntary patients have been simplified and liberalized. In this act, no consent from two visitors is required as well as no written request is required Minor can be admitted with the consent of a guardian under this act. This provision is not there in the Indian Lunacy Act, 1912 Separate provision for admission of involuntary patients under category admissions under special circumstances Special centres for special population like drug addicts, under 16 years, mentally ill prisoners etc. Establishment and maintenance of psychiatric hospitals and psychiatric nursing homes in private sector which was not in the earlier law Discharge procedure have been made easy and more simplified due to global awareness law like protection of human rights of mentally ill persons, stringent penalties for people who subject mentally ill patients to physical or mental indignity. Provision of cost of maintenance and management of properties of mentally ill persons Establishment of outpatient services in every psychiatric hospital and nursing home. Prohibition on any research on subjects without proper consent. CRITICISM Although this act has provided some respite both to the patients and the professionals but has become inadequate with time and has various shortcomings which act as a barrier in providing mental health services (Prateek Rastogi, 2005). The legislation does not promote community-based mental health

care and widespread access to mental health services or incorporating mental health care into primary health care. The Mental Health Act should be amended so that it gives priority in protecting the rights of persons with mental disorders, promotes development of community-based care and improves access to mental health care. However, whatever fallacies that have come to the fore ever since this law was enforced are due to following facts: At the time of conception of law, private psychiatry was still in infancy and the growth and development of private psychiatry was neither foreseen nor predicted. That might be the reason the law in its current form seems to be biased against private psychiatry. The field of psychiatry itself has grown by leaps and bounds and the scope of this branch has widened beyond the horizons predicted before. Hence so many changes have crept into this field that the law after two decades already seems outdated. However all this criticism should not shift our focus from the fact that this law at the time of its enactment, was definitely a breakthrough and distinctly miles ahead of the then obsolete and anarchic Indian Lunacy Act,1912. Critical aspects of MHA 1987 as a whole The act doesn't reflect the govt. policy on mental health framed in 1978 as well as Mental Health Programme No attention to WHO guidelines Legal considerations have been given more weight age in comparison to medical ones Failed to remove the criminal flavor by keeping the power of criminal court to exert its control over admissions and discharge of non criminal mentally ill persons No importance to family and community psychiatry There are no provisions for punishing the relatives and officers requesting unnecessary detention of a person to such hospitals Once a person is admitted to mental hospital he is termed insane or mad by the society. There should be provisions in the act to educate the society against these misconceptions

Much stress is laid on hospital admission and treatment. This again increases the cost of health care. No provisions are made for home treatment The act has no provision for transportation of an unwilling patient except by police Rehabilitation is always the Achilles heel of psychiatry, this act provides no provisions for rehabilitation and reintegration of the patients into the community. This act presumes a utopian scenario where there are sufficient beds for all the psychiatrically ill patients when reality is far from it. Admission of patients and discharge even though simplified has still a lot of red tapism which may prevent the health facilities to be extended to the neediest at the right time. No provision has been provided for the patient admitted under special circumstances to be treated beyond ninety days. Only way left is is an application before the magistrate for a reception order.

Mental health act is divided into 10 chapters consisting of 98 sections. The short details of the chapters, the inadequacies in them and suggested improvements are being described below: Chapter I: Deals with preliminaries of the act, definitions and provides for change of offensive terminologies used in Indian Lunacy act 1912. Suggested changes: Change of older terminologies to newer ones might be good from practical aspect as it will be helpful in removing the social stigma attached to the illness. This change should be implemented in practiceand not on paper. 1. medical practitioner according to law can be even an Ayurvedic or homeopathic medical officer in government service whereas It Should be a qualified psychiatrist with adequate training in psychiatry. 2. Mentally ill person: person who is in need of treatment by reason of any mental disorder other than mental retardation The definition does not specify the types of mental illness to be included; this can lead to misuse of the term and is attached with stigma for the person labeled "mentally ill". Mentally retarded subjects have been excluded. Mentally retarded subjects need separate services in the form of rehabilitation, prevention etc. A law for helping victims of mental illness should not exclude victims of profound mental retardation

from its purview, as they too are in great need for treatment and care. They too should have access to psychiatric Hospitals. If the law presumes that profound mentally retarded persons could be adequately taken care of in the existing institutions for the mentally retarded, it is certainly not based on ground realities. 3. Licensed psychiatric hospital or licensed psychiatric nursing home: means a psychiatric hospitalor psychiatric nursing home as the case may be licensed, or deemed to be licensed, under the Act Definitions of psychiatric hospitals and psychiatric nursing homes (Section2q) excludes government general hospitals, and is discriminatory. In this case a uniform policy should be adopted as the integration of mental health services into mainstream health resources will only be possible then. Chapter II: Deals with the procedures for establishment of mental health authorities at central and state levels. Suggested changes: Licensing authorities do not have a doctor who may be in a better position to assess the facilities and services of these centers. There should be budgetary provisions in the law. Chapter III: It lays down the guidelines for establishment and maintenance of psychiatric hospitals and nursing homes. There is a provision for licensing authorities to process applications for license which have to be renewed every five years. Suggested changes: No mention is made of incorporating General hospitals and centers in this act rather they are prohibited. Such hospitals if taken along may provide a better health care. Licensing process should be made simpler. Provision should be there for checking the working of licensing authorities and powers vested in them to be limited. Chapter IV: It deals with the procedures of admission and detention of mentally ill in psychiatric hospitals. Suggested changes: 1. Emergency situations: To be an emergency, it must be demonstrated that the time required to follow substantive procedures would cause sufficient delay and lead to harm to the concerned person or others Involuntary admission and treatment only on the assessment and advice of a qualified mental health/medical practitioner Emergency treatment must be time limited (say within one week) and substantive

procedures for involuntary admission and treatment if necessary must be initiated as soon as possible and completed within this period Emergency treatment should not include: Depot injection, ECT, Sterilization Psychosurgery and other irreversible treatment. 2. Admission under special circumstances (involuntary patients) (Section 19). There should be set Criteria for involuntary admission. 3. Procedure for involuntary admission (suggestions): Two accredited medical practitioner, of which one should be a psychiatrist, to certify mental disorder. Provision for regular time bound review of involuntary admissions by review body. Discharge procedures to be flexible and easy, to prevent unnecessary detention To review processes regarding people who are admitted/treated involuntarily. Establishment of independent and impartial court like body with a judicial function (Mental Health Tribunal). This body to assess each involuntary admission and treatment. In developing countries like ours paper review of straightforward cases can be done and hearings only for more contentious cases to entertain appeals against involuntary admission/treatment Further detention requires reception order from a magistrate Overly legal, cumbersome and complicated for patients and their family Magistrate to take final decision/no mention of a psychiatrist Review Body should review the cases at periodic intervals and should have the power to discharge the patients if withheld unnecessarily. Authorize or prohibit intrusive and irreversible treatment for examples Psychosurgery/Sterilization. In developing countries like ours with limited resources the review body mentioned previously can perform the following functions: Regular inspection of mental health facilities Regular monitoring of patients welfare and well being Providing guidance for minimizing intrusive treatment Keeping records and statistics To make recommendations to concerned authorities Chapter V: It deals with the inspection, discharge, leaves of absence and removal of mentally ill persons. Suggested changes: This section does make provision for appointment of visitors for every psychiatric hospital/nursing home. "Inspecting Officer" means a person authorised by the State Government or by the licensing authority to inspect any psychiatric hospital or psychiatric nursing home. The number of visitors should not be less than five, of whom at least one should be a psychiatrist or at least a medical officer and two social workers.

However most of the time inspecting officer is a medical officer without proper training or guidelines to conduct the inspection of a psychiatric hospital/nursing home. Although the act provides for a simpler discharge procedure but no provisions are made for after discharge care and rehabilitation, of patients. Much stress is laid on hospital admission and treatment. This again increases the cost of health care. No provisions are made for home treatment. Chapter VI: It deals with the judicial inquisition regarding alleged mentally ill persons possessing property and its management. Suggested changes: Property and inheritance rights are protected under Indian law although the legal determination of capacity to assume full control of one's property or to control one's inherited assets does not require the opinion of a medical professional, thus increasing the possibility that subjective bias could prevent individuals recovered from mental illness from controlling their own assets. Chapter VII: It deals with the maintenance of mentally ill persons in a psychiatric hospital or psychiatric nursing homes. Suggested changes: No provision for patients with no estate and no relative, the state should be made responsible for such patients. Mental health legislation should include integration with NMHP and NGO's to improve community and primary psychiatric services. Legislation should ensure the introduction of mental health interventions into primary health care. In developing countries like ours delivering mental health services through primary health services is the most viable strategy. Integrated care reduces stigma associated with mental illnesses and also promotes mental health Chapter VIII: It deals with the protection of human rights of mentally ill persons. Suggested changes: Once a person is admitted to mental hospital he is termed insane or mad by the society. There should be provisions in the act to educate the society against these misconceptions. Indian common law provides a patient with a right to informed consent and confidentiality of patient records, although the Mental Health Act only requires informed consent for experimental treatment. It is provided that research on such subjects can be carried out by consent of guardian or if such research is of direct benefit to him for purposes of diagnosis or

treatment. Is it not like treating them as inanimate objects? This provision violates human rights and should be amended. Indian law severely curtails the civil and political rights of mentally ill individuals. Hindu and Parsi personal laws preclude the right of mentally ill individuals to marry and sanction divorce if the spouse is likely to remain mentally-ill. Madness certificate of the mental health professionals are used by husbands to divorce, desert or throw out wives from their matrimonial homes. Chapter VIII & Chapter IX: These sections pertained to Penalties and Procedures and Miscellaneous Other changes that ought to be incorporated into a new law or introduced through amendments: There should be provision in the law for treatment of the destitute. The act should also ensure that the Human Rights of the mentally ill patients are protected and that it follows the WHO guidelines. There should be provisions in the law for the after care of the mentally ill after discharge from the hospital to ensure their full integration back into the society.

MENTAL HEALT CARE DRAFT 2010: Mental health care act draft 2010 consists of nine chapters and 67 sections. The proposed act is a comprehensive specific and consumer oriented. Its might herald a new era for the persons with mental illnesses where their rights might be protected. From being considered dangerous enough to be institutionalized in 1900s to people with rights equal to each and every other human is a big step. Change in terminology: Mentally ill person to persons with mental illness Psychiatric hospital to mental health facility Licence to registration POSITIVES: Chapter one deals with definitions of terminologies and change of terminologies. Definition of mental illness is more comprehensive and specific as compared to the earlier act. Inclusion of substance use disorders in the definition of mental illnesses is a positive development. Change of terminologies will lead to less amount of stigma associated with mental illness and takes a step towards treating mental illness on par with physical illnesses. It has also widened the terminology of mental health professional which will increase the pool of professional able to these tasks though at the cost of some loss of precision. Provisions for caregiver figures and nominated figures gives a person with mental illness a array of choice who he or she wants as a primary support figure. All institutions medical, non medical, government and private where persons with mental illness reside or are admitted come under the purview of the act makin them answerable to the authorities and furthering the cause of rights of people with mental illness. Chapter two elaborately deals with rights of the persons with mentally ill which is the most positive development of this act. Right to equality and non discrimination will help the people with mental illness being treated on apr with physical illness. Right to information empowers the patient to know the nature of his illness, the right to choose or refuse a particular

treatment, and to make an informed choice. Persons with mental illness form one of the most vulnerable section of the society with the right to legal aid they are empowered to fight for what is rightfully theirs. Chapter three elaborates the duties of the government towards mental health. Targeting the stigma associated with the illness the positive aspect of this section which had not been projected in previous acts. These provisions will help in better integration of mental ill persons into the society.

Chapter I: Preliminary Section 1 : Short title 7 Section 2 : Definitions 7 Section 3 : Mental Illness 8 Section 4 : Competence 9 Section 5 : Advance Directives 10 Section 6 : Nominated Representative 11 Chapter II : Rights of Persons with Mental Illness Section 7: Right to Access Mental Health Care 13 Section 8: Right to Community Living 14 Section 9: Right to Protection from Cruel Inhuman and Degrading Treatment 14 Section 10 : Right to Equality and Non-Discrimination 15 Section 11 : Right to Information 15 Section 12 : Right to Confidentiality 15 Section 13 : Access to Medical Records 16 Section 14 : Right to Personal Contacts and Communication 16 Section 15: Right to Legal Aid 17 Section 16 : Right to make Complaints about Deficiencies in Provision of Services 17 Chapter III Duties of Government Section 17 : Promotion of Mental Health and Preventive Programmes 17 Section 18 : Creating Awareness about Mental Health and Illness and Reducing Stigma associated with Mental Illness 17 Section 19 : Human Resources and Training 18 Section 20 : Co-ordination within Government 18 Chapter IV Mental Health Review Commission Section 21 : Constitution of a Mental Health Review Commission 18 Section 22 : Constitution of District Panels of the Mental Health Review Commission 19 Section 23 : Disqualification and Removal 19 Section 24 : Terms and Conditions of Service 20 Section 25 : Decisions of the Commission and the District Panels 20 Section 26 : Applications to the District Panel 20 Section 27 : Proceedings before the District Panel 21 Section 28: Functions of the Mental Health Review Commission 21 and District Panel of the Mental Health Review Commission 6 DECEMBER 2010 4 | P a g e

Section 29 : Appeals 22 Section 30 : Budgetary Provisions for the Commission and District Panels 22 Section 31 : Power to make regulations 22 Chapter V State Mental Health Authority Section 32 : State Mental Health Authority 22 Section 33 : Composition of the State Mental Health Authority 23 Section 34 : Chairperson and Executive Officer of the State Mental Health Authority 23 Section 35 : Functions of the State Mental Health Authority 24 Section 36 : Proceedings of the State Mental Health Authority 24 Section 37: Budgetary provisions 25 Section 38: Power to make Regulations 25 Chapter VI Mental Health Facilities Section 39 : Registration and Standards for mental health facilities 25 Section 40 : Procedure for Registration and Inspection of Mental Health Facilities 26 Section 41: Certificates, Fees and Register of mental health facilities 29 Chapter VII : Admission, Treatment and Discharge Section 42 : Independent (without Support) Admission and Treatment 29 Section 43 : Admission of a Minor 30 Section 44 : Discharge of Independent Patients 31 Section 45: Admission and treatment of persons with mental illness, with high support needs, in a mental health facility, upto 30 days (Supported Admission) 32 Section 46:Admission and treatment of persons with mental illness, with high support needs, in a mental health facility, beyond 30 days (Supported Admission beyond 30 days) 33 Section 47: Leave of Absence 35 Section 48: Absence without leave or discharge 36 Section 49:Transfer of persons with mental illness from one mental health facility to another mental health facility 36 Section 50: Emergency Treatment 36 Section 51: Prohibited Treatments 37 Section 52: Restriction on Psychosurgery for Persons with Mental Illness 37 Section 53: Restraints and Seclusion 37 Section 54: Discharge Planning 37 Section 55: Research 38 Chapter VIII : Responsibilities of Other Agencies Section 56 : Duties of police officers in respect of persons with mental illness 38 Section 57: Order in case of person with mental illness who is ill treated or neglected 39 Section 58: Conveying or admitting a person with mental illness to a mental health facility by a Magistrate 39 Section 59 : Prisoners with mental illness 40 Section 60: Question of Mental Illness in Judicial Process 40

Chapter IX : Penalties and Miscellaneous provisions Section 61: Penalties for establishing or maintaining a mental health facility in contravention of Chapter VI 40 Section 62 : General provision for punishment of offences 41 Section 63 : Special relaxation in requirements for States of the North East Council 41 Section 64: Protection of action taken in good faith 41 Section 65 : Effect of the Act on other laws 41 Section 66: Power to remove difficulty 41 Section 67 : Repeal and Saving 42

Limitations: Mental retardation is conventionally spared from the mental health act. Despite gross defects in mental capacity that exists in them, they do not get the benfits of the act which is the torchbearer for the welfare of mentally ill. Mental retardation has been covered under PWD act and NTA act but is it enough, these acts also fail to address the civil and criminal responsibilities of these patients. The definition of medical practitioner includes Indian medicine and homeopathy. The definition for psychiatrist includes any medical practioner with experience in psychiatry as state may consider. Capacity to certify competence also will be questionable. Specialization in psychiatry better equips a practioner to deal with complex issues which may change the course of a patients life. Mental health professional terminology has been used as an umbrella terminology for clinical psychologist, psychiatric social worker and psychiatric nurse. Each of them have their areas of expertise and their roles should be stipulated accordingly.

The functioning of mental health professionals will be autonomous, leaving a lingering doubt whether it will be better if under the supervision of a psychiatrist. District panels of mental health review commission, members could be mental health professionals if psychiatrist is not available, will the commission be competent enough to judge the decisions of a psychiatrist. The concept of advance directive is questionable! Why would a healthy person write on the way he would like to be treated in an event of an unexpected mental illness. Electroconvulsive therapy should not be used as an emergency treatment , what guides this law? Populist misconceptions about ECT or scientific principles?

 Competence assesement leaves a lot of lacunae, leading to subjectivity to creep in, instead of usage of standard instruments for assesement ofcognition, judgement, memory, etc. Registration of the each hospital treating mentally ill patients as in patients. In a country where private sector forms the major chunk of the health care. Can each psychiatrist who treats mentally ill patients as in patients asked to register??