Points of View

Part 1 - I want to break free

- Amita Dhanda

Part I is an article published in the Times of India, 5th January 2006.

The rights of persons with psychosocial disability are conspicuous by their absence. The institutional 'treatment' to which they are subject runs against Article 21 of the Constitution, which provides that no person shall be deprived of his right to life and liberty except according to procedure established by law.

Over the decades, the Supreme Court has ruled that this deprivation cannot occur by way of any procedure incorporated in legislation but one which is just, fair and reasonable. The Mental Health Act, 1987, provides care and treatment of persons with psychosocial disability primarily through the compulsory deprivation of life and liberty.

It leans overwhelmingly in favour of compulsory care. It lays down procedures by which a person who has voluntarily sought mental health treatment can be compulsorily detained; however, there is no reverse process where hospital authorities are obliged to seek consent for continuance from the institutionalized person.

Those convinced of the benefits of compulsory care view health and healing as passive processes in which only the provider of treatment is seen to have a role. However, many survivors say that the continuous humiliation of compulsory care negates whatever benefits such treatment might have to offer.

Those who cite cases of persons who lost their lives due to absence of compulsory treatment do not mention those who took their lives due to the indignity of such treatment. Even if one concedes that compulsory institutionalization is required, it is necessary to examine whether institutions live up to their role.

Government affidavits, fact-finding commissions and journalistic investigations suggest that institutional conditions are counter-therapeutic. The facilities are not adequate to meet the requirements of the estimated number of persons with psychosocial disability.

There are 42 mental hospitals unevenly spread over different parts of the country - some regions have as many as seven institutions, while others have none. This shortfall caused the Supreme Court to rule that at least one mental hospital shall be established in every state.

The directive was issued without considering whether mental health can be promoted in total institutions (Goffman's concept and term) far away from home. The kind of treatment meted out in institutions is another important issue.

Electro-convulsive therapy is administered without anaesthesia in a number of such institutions. Even as a petition in the Supreme Court seeks a ban on this therapy, the Indian Psychiatric Society has tried to demonstrate how anaesthesia is contra-indicated for some persons with mental illness.

It is argued that if electro-convulsive therapy is to be provided only with anesthesia, the cost will place it out of the reach of many. Except in war-like situations, doctors seek therapies other than surgery if anaesthesia is contra-indicated for a patient.

This rule of routine medical practice is not available to persons with psychosocial disability. If electro-convulsive therapy is integral to the treatment of persons with psychosocial disability, then would not their right to life require that such treatment be made available without considerations of cost to the recipients?

The issue has been played out as a scientific controversy in the apex court, with the recipient of such therapy having no say in the matter. There is also a controversy over the drugs administered at the psychiatric institutions. Earlier, a budget limit would determine what kind of drugs could be administered to persons with psychosocial disability.

However, the Supreme Court in the Ranchi Hospital petitions lifted the budgetary constraint and ruled that the therapeutic needs of the patient and not the cost of the medicines should determine what kind of drugs shall be prescribed. Despite this ruling, one keeps hearing that drugs are in short supply.

Most troublesome of all drug-related reports are those which describe how the inmates of psychiatric institutions are used as subjects of drug trials. Superintendents of psychiatric hospitals defend the practice as providing much-needed treatment to the inmates.

Section 81(2) of the Mental Health Act bars a "mentally ill person" under treatment to be used for purposes of research except with his consent; if he is incompetent to provide such consent, consent of his guardian is required. The statute thus allows a mentally ill person to be used as a guinea pig, since the guardian could well be the superintendent of the psychiatric hospital.

Even a person wrongfully admitted into a psychiatric hospital cannot engineer her own exit unless she has external assistance. Section 81(3) does prohibit the interception of correspondence of an inmate. However, this prohibition is also not absolute and can be breached if the communication would be prejudicial to the treatment of the ill person.

To conclude, the Mental Health Act 1987 has not been premised on the rights of persons with psychosocial disability. A rights based law would unequivocally accept the humanity of the rights holder and allow her opportunity to assert it. Constraints would be the exception and freedom the rule.

The writer is professor of law, NALSAR, Hyderabad.

Part 2 - I too want to break free!

Dear Prof Dhanda,

First of all let me wish you a very prosperous 2006.

This is with reference to your article in the Times of India, dated 5th January 2006. As the article deals mostly with the treatment of persons with psychosocial disability, I wanted some clarifications from you, the Mother of mental health Law in India.

1. I want to know how a person who is already disabled can be treated. Only an ill person can be treated. Do you mean the maintenance dosage or prevention of relapse?
2. You have talked about deprivation of life and liberty and talk about "compulsory care". There are 17,000 beds and 3600 psychiatrists to a population of one billion. Even if we accept conservatively (2% as per WHO estimates) there are one crore persons who are severely mentally affected in India. How can there be any compulsion? As admitted by modern psychiatrists nearly 30% of the mentally ill do not, and I repeat do not, respond to any treatment. Even as you say all the beds are compulsorily filled in India. Where are the rest? You will have to accept that these people are in home, or in the streets wandering, or you can go and find them in any temple, Sai ashrams, Andamayee ashrams, or at the Velankanni, Sardana shrines of Christians or at Muslim shrines of Erawady, Ahmednagar, etc.

In US, after the Kennedy Act of 1960 was passed, persons were given the right to have only access treatment voluntarily; and this resulted in 1 lakh 80 thousand Mentally ill persons languish in prisons instead of in mental health institutions as they were before 1960.

It has been reported that a person who killed other people as per private instructions from God, was executed. This person apparently continued to hear voices till his last day. Do we want that system here in India?

You have criticized the Supreme Court order of 2002 which directs all state governments to establish institutions like NIMHANS in Bangalore (National Institute for Mental Health and Neuro Sciences) and AIIMS in New Delhi (All India Institute of Medical Sciences) in every state capital.

It is serious business for parents and others who have to keep violently mentally ill offspring at home and have to travel from far away places like Bengal, Assam, Tripura, Jammu and Kashmir in unreserved compartments to Bangalore and wait for admission.

You must come one day and stand at the OPD of this institution and see how national integration is effected in a pathetic way. The establishment of institutions like AIIMS in every state is a necessity.

I want all those who advocate home-based treatment for violent mentally ill persons to keep them for a day in their house or work as an attendant for them when they are kept as inpatients in a hospital. You have talked about the kind of treatment meted in these hospitals as another important issue.

Fine! But you rake up the old controversy of ECT vs. Modified ECT. This is an academic issue involving two sets of psychiatrists camouflaged as if the pain of the mentally ill is the concern. Of course you know ECT itself has no scientific basis as is Modified ECT. But they do work in some cases.

This issue was taken up by the MNC drug companies so that usage of prescription drugs increases. You ask any student psychiatrist and they will tell you how difficult it is to detect the seizure in modified ECT resulting in over stimulation. In fact, modified ECT has gone into the realm of anesthesia in Psychiatry, thus patients are put to more ECTs to induce the undetected convulsion.

I know you mean well for the patients, but psychiatrists are also not against the patients too. Modified ECT is a case for 5 star hospitals that have this facility to fleece the patients. I would have mentioned here about the lack of basic amenities after a patient normally attempts suicide and the treatment given like stomach wash, stitching a cut wrist etc.

As attempted suicide is a police case; instead of accepting suicide as part of symptomatology, which always cannot be prevented in spite of best efforts of any hospital - there is a tendency to hide the situation by placing the onus on the parents/carers.

In fact as per the FDA, SSRIs medication predisposes these acts. I am happy you have talked about the budget limit of psychiatric drugs. India accepted the Millennium Development Goals but the WHO essential drug list does not contain even CLOZAPINE, discovered in the 1990s, what to talk of other atypicals!!!!

Now WTO and the Indian Patent Act 2005 and psychiatric drugs in the mailbox are another story but for the carers it is life and death like AIDS medication, but without the hype and publicity. You have very rightly pointed out the pitfalls in clinical trials and desperate patients and informed parents fall for the trap of the 'miracle-drug-that-cures' in the pipeline and readily sign any papers.

I remember the drug trial of Respirodone in 1996 and families who were administering Clozapine switched over to this new wonder drug developed by a psychiatrist who had a son suffering from schizophrenia. I was given the choice but the weekly cost of 8 thousand rupees once the 6-month free dosage was over was just not possible for me.

But I know at least two families did so and their wards never recovered from the induced relapse. Sadly, even Clozapine does not work for their child anymore. I wish you had talked of the lie in the statement of objects in the Act of 1987 wherein it states that "No stigma should be attached to mental illness as it is curable" This is the greatest lie ever written in a law, which remains even today without any challenge.

The British built into the Indian Lunacy Act of 1912, provisions basically to usurp the property of Indian rulers. Appointment of guardians should be allowed as it was allowed to Europeans in the guardians and wards Act of 1837 to the parents, especially to parents of wards who have no other claimant. Courts should come into play only when there is a property dispute.

The appointment of guardians in a Court, in cases with no dispute has not wherein there is no dispute has not concluded in spite of all the good intentions of court, lawyers etc for the last two years!!!!!! Section 25(4) states that the carer of a violent mentally ill person should take proper care or face fine of 2000 rupees.

Those wandering 500 odd mentally ill women who are lodged in the Banyan in Chennai are testimony to the bankruptcy of this provision. There is a really fascinating story published in the Tamil paper - Daily Thanthi (Coimbatore edition of 27th December, 2005) wherein the local police rounded up about 20 odd wandering mentally ill and finally had to abandon in the streets again due to the difficulties they faced at the local mental hospital, court, old age homes, orphanage, etc.

It is such issues which require the urgent attention of intellectuals like you so that wandering mentally ill who used to have prisons before have some facility like the Banyan of Chennai. The most important issue personally for me is "My Right to Die in Peace" My only daughter who is schizophrenic is declared 65% disabled as per the IDEAS scale of the Social Justice Ministry.

This ministry spent 1137 crores of its funds of which not even one paisa was spent on disability due to mental illness, despite it being one of the disabilities mentioned in the PWD Act of 1995. They make clever use of the ignorance of the carers to differentiate between Mental illness and Psycho-social disability.

The carers of the blind know that they must not approach an ophthalmologist, but the director of a school for the visual handicapped. A carer for the deaf and dumb thus approaches the principal of a school for the hearing impaired and not an ENT specialist, and the situation is the same for those with orthopedic handicaps!

But the parents of children with mental illness persist in seeking all solutions from the psychiatrist alone. Section 5(1) (b) prohibits a person of unsound mind to hold any office in the central coordination committee!

Questions that remain deep in our hearts and remain only there is - who will look after them? Where will they stay during bouts of violent behavior? If they cannot be physically restrained then how are they to be treated at home? or brought to a hospital voluntarily?

These are not academic questions but real ones being faced by carers everyday.

Best wishes

- Johann Samhuanand