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In our country plenty of legal orders interact with mental disorders in order to protect the interests of mentally ill, society and the state.These legislations are enacted to protect the society from dangerous manifestations of mental illness. There are guidelines regarding restrain, admission and discharge, procedures of civil and criminal action with regard to mentally ill. But do these laws discuss about proper care and treatment? Are there provisions for post discharge care and rehabilitation?
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WORLD MENTAL HEALTH DAY 10TH OCTOBER 2010 Dr.Sujnanendra Mishra, MD (OBGYN)
„There is no health without mental health“ (World Federation on Mental Health)
WHAT IS MENTAL HEALTH ? The World Health Organization defines mental health as • a being of well-being in which the individual realizes his or her own abilities, • can cope with the normal stresses of life, • can work productively and fruitfully, and is • able to make a contribution to his or her community"
What is a mental illness? It is when someone lacks the ability to manage day to day events and/or control their behavior so that basic physical and emotional needs are threatened or unmet.
These disorders can affect persons of any age, race, sex, religion, or income. Mental illnesses are not the result of a personal weakness, lack of character, or poor upbringing.
What is mental illness like? Mental illness is a physical condition just like asthma or arthritis. But still society believes that a person who is mentally ill needs to show more willpower - to be able to pull themselves out it.
mental illness …..It is also like telling a person who has an amputated leg to run across the room. But a person who has mental health issue has a “broken brain”.
Concepts of mental health • mental health is broader than a lack of mental disorder . • The concepts include • subjective well-being, • perceived self-efficacy, • autonomy, • competence, • intergenerational dependence, and • self-actualization of one's intellectual and emotional potential, among others.
Risk Factors: The causes of mental ill-health • Certain factors can indicate an increased risk of physically violent behaviour . • The risk factors should be considered on an individual basis.
The causes of mental ill-health • Social • psychological and • physical
Interaction of Individual (biological), psychological and social factors in the development
Social factors life events • bereavement, • job loss, • severe trauma; • chronic social isolation • lack of social supports. • adversity • unemployment, • poverty, • illiteracy, • child labour and violence);
psychological • poorly developed coping skills and • low self-esteem.
physical. • poor nutrition, • infection, • physical trauma, • endocrine and • genetic factors.
The consequences and impact of mental ill-health Mental ill-health burdens in terms of suffering, disability, and mortality, • loss of economic productivity due to people • being unable to work, being ill while at work or • absent from work, or • from accidents at work. • Premature death of people with mental illness (for example, from suicide or from physical illness) • loss of a breadwinner for the dependent family, which can lead to poverty. • mental ill-health leads burden to families. • prevention and treatment programmes fails due to • reduced access ,and • reduced success .
Positive mental health • factors that influence positive mental health may be clustered into three key categories: • At structural level • At community level • At individual level
structural level • A satisfactory • living environments, • housing, • employment, • transport, • education and • a supportive political structure.
community level • a sense of belonging, • social support, • a sense of citizenship and • participation in society
Individual level • ability to deal with • thoughts, • feelings • to manage life, • emotional resilience and • the ability to cope with stressful or adverse circumstances.
Schematic of the principal parts of the conceptual overview of the factors associated with mental health
Myths of Mental Illness • Mental illness is caused by bad parenting. Fact: Most diagnosed individuals come from supportive homes. • The mentally ill are violent and dangerous. Fact: Most are victims of violence. • People with a mental disorder are not smart. Fact: Numerous studies have shown that many have average or above average intelligence.
Facts and Myths about Mental Illness 1.Mental health problems only happen to other people • Fact: 1 in 4 of the adult population will suffer from mental health problems in any one year, and one in six experiences this at any given time. It is estimated that approximately 450 million people worldwide have a mental health problem- World Health Organisation (2001) 2. People with mental illness are violent and dangerous • The risk of being killed by a stranger with a severe mental health problem is roughly 1:10,000,000, about the same probability as being hit by lightning*. The number of homicides by people with schizophrenia is around 30 per year. This is 5% of all homicides, the prevalence of schizophrenia in the population being 1% or less –
Facts and Myths about Mental Illness 3. People with mental illness are poor and/or less intelligent • Mental illness, like physical illness, can affect anyone regardless of intelligence, social class or income level. Celebrities such as Stephen Fry, Nick Drake, Paula Yates, Kurt Cobain, Virginia Woolfe, Brooke Shields and Winston Churchill have all experienced mental illness. 4. People who self-harm are attention-seekers • This is untrue. Most people who self-harm do it in secret and it’s only when they need to seek medical attention, that they come to the attention of others
Facts and Myths about Mental Illness 5. People with poor mental health are weird • Everyone suffers from low mood and 1 in 4 of the population will experience mental ill health at some point in their lives. Think of 12 people you know. Are 3 of them rocking in the corner muttering to themselves? 6. Mental illness is caused by emotional weakness • People do not choose to become mentally ill. As with other medical conditions, like heart disease or diabetes, it has nothing to do with being weak or lacking will-power.
Facts and Myths about Mental Illness 7. Once you’ve had a mental illness, you never recover • People can and do recover from mental illness. Medications, psychological interventions, a strong support network and alternative therapy treatments from cognitive behavioural therapy to improved diet and exercise habits are also very effective in leading to a complete recovery 8. Since ‘care in the community’ was started, people with mental health problems have been left to roam the streets • Even before the closure of the old large scale psychiatric hospitals, around 95% of people received care and treatment for mental illnesses in the community. What has changed is the type of accommodation and treatment available. For example, people requiring long term care in a hospital are usually no longer in the same building as those requiring short term admissions.
Facts and Myths about Mental Illness 9. All people who suffer from depression are suicidal • Suicide is not a mental illness. Not everyone who is depressed will consider suicide. It is as inaccurate as saying that all football fans are hooligans. However it is true to say that individuals experiencing a mental health problem are, generally, associated with a higher risk of suicide. If you suspect someone is feeling suicidal ,help them – it could help save their lives. 10. If I seek help for my mental health problem, others will think I am "crazy" • Early treatment can assist with a faster recovery. If you broke your arm would you delay getting a cast applied incase people thought you were weak? Not likely!
KEY ISSUE • Culture, religion, and media play important roles in how the relationship between mental illness and suicide is addressed in different countries
Manifestations of Mental Disorders • Disturbances of thought and perception • Dysregulation of mood • Inappropriate anxiety • Impulse control and behavioral problems • Cognitive dysfunction
Positive Symptoms Positive symptoms are characterized by abnormal thoughts, perceptions, language and behavior. • Delusions:False beliefs/thoughts win no basis in reality • Hallucinations: Disturbances of sensory perception (hearing, seeing or feeling things not there) • Disorganized Thinking/Speech: Jumping from topic to topic, responding to questions with unrelated answers or speaking incoherently • Disorganized Behavior:Problems in performing directed daily activities. • Catatonic Behavior: Lowered environmental awareness, unresponsiveness, rigid posture, resistance to movement or instructions and inappropriate postures.
Negative Symptoms Negative symptoms are characterized by restrictions in range and intensity of emotional expression, communication, body language and interest in normal activities. • Blunted (or flat) Affect: Decreased emotional expressiveness, unresponsive immobile facial appearance, reduced eye contact and body language. • Alogia: Reduced speech. Responses are detached and speech is not fluid. • Avolition: Lacking motivation, spontaneity, initiative. Sitting for lengthy periods or ceasing to participate in work or daily activities. • Anhedonia: Lacking Pleasure or interest in activities that were once enjoyable. • Attention Deficit: Difficulty in concentrating
Stigma and Discriminationon Mental Health Grounds • “I feel reluctant to admit I’ve got mental health problems; • the stigma and rejection are too hard to face.”
Key facts • Stigma and discrimination can affect people long after the symptoms of mental health problems have been resolved. • Discrimination can lead to relapses in mental health problems and can intensify existing symptoms. • Over 80 per cent of respondents feel that tackling stigma and discrimination should be a priority.
Key facts Stigma and discrimination limit people’s aspirations and can make it difficult to work, access services, participate in communities and enjoy family life. • Fewer than four in ten employers say that they would consider employing someone with a history of mental health problems, compared to more than six in ten for someone with a physical disability. • A third of people with mental health problems report having been dismissed or forced to resign from their job. • In one survey, 44 per cent of people with mental health problems felt that they had experienced discrimination from GPs . • 18 per cent said they would not disclose their condition to a GP.
INDIAN MHA (1987), DETAILS OF THE ACT, OBJECTIVES, HIGHLIGHTS & CRITICISM
INDIAN MHA (1987) • Prior to 1993, Indian Lunacy Act (ILA), 1912 was governing the mental health in India • In 1947, when Indian Psychiatric Society came into existence, ILA, 1912 was considered insufficient to safeguard the rights of mentally ill patients • IPS drafted a mental health bill and submitted it to govt. of India in 1950 • It took another 28 years for govt. to present it in the LokSabha • After a gap of another 8 years the bill was adopted as Mental Health Bill by RajyaSabha in 1986 and the LokSabha in 1987 • This bill received President’s assent in May, 1987 but finally came into force after 6 years in April 1993
INDIAN MHA, 1987 (CONTD….) Terminologies used in the act
INDIAN MHA, 1987 (CONTD….) • Other important terminologies • Reception order: Means an order for admission and detention of a mentally ill person in a psychiatric hospital or nursing home • 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 • Mentally ill person: Is a person suffering from mental disorder, other than mental retardation, needing treatment • Mentally ill prisoner: Is a mentally ill person, ordered for detention in a psychiatric hospital, jail or other places of safe custody
OBJECTIVES OF THE ACT • 1. To establish central and state authorities for licensing and supervising the psychiatric hospitals. • 2. To establish such psychiatric hospitals and nursing homes. • 3. To provide a check on working of these hospitals. • 4. To provide for the custody of mentally ill persons who are unable to look after themselves and are dangerous for themselves and or, others. • 5. To protect the society from dangerous manifestations of mentally ill.
OBJECTIVES OF THE ACT (CONTD….) • 6. To regulate procedure of admission and discharge of mentally ill persons to the psychiatric hospitals or nursing homes either on voluntary basis or on request. • 7. To safeguard the rights of these detained individuals. • 8. To protect citizens from being detained unnecessarily. • 9. To provide for the maintenance charges of mentally ill persons undergoing treatment in such hospitals. • 10. To provide legal aid to poor mentally ill criminals at state expenses • 11. To change offensive terminologies of Indian Lunacy act to new soother ones.
Procedure for admission and discharge ofmentally ill • A mentally ill person (not a minor) may make a request for admission as a voluntary patient; in case of minor his guardian may make such request. On such request, medical officer in-charge after enquiry within 24 hrs, if thinks necessary may admit such person. • The medical officer shall discharge such patients on request by him or guardian as the case may be, unless he finds such discharge against patient's interests. • Such cases will be referred to medical board, which if decides the same, then patient will be further admitted for a period not exceeding 90 days for treatment.
POSITIVE CHANGES IN THE MHA, 1987 • A mentally ill may be admitted as inpatient on a request by friends or relatives. Such request should be supported by medical certificates to the effect. • In such cases medical officer in-charge may admit the patient if he thinks necessary. • Request for admission may also be made by a police officer if such mentally ill person is dangerous to himself or others. • Such persons will be discharged by magistrate on request by friends/relatives or after they are certified to be sane by the board of experts.
POSITIVE CHANGES IN THE MHA, 1987 (CONTD….) • 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 • There are new additions in this law like protection of human rights of mentally ill persons, penalties, cost of maintenance and management of properties of mentally ill persons • Prohibition on any research on subjects without proper consent
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,1987 • No attention to WHO guidelines • Legal considerations have been given more weightage in comparison to medical ones • Failed to remove the criminal flavour by keeping the power of criminal court to exert its control over admissions and discharge of non criminal mentally ill persons • There are no provisions for punishing the relatives and officers requesting unnecessary detention of a person to such hospitals
CRITICAL ASPECTS OF MHA 1987 AS A WHOLE (CONTD….) • No importance to family and community psychiatry • 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
Every law has its own advantages and disadvantages although existing law gives an excellent approach to the problems of mentally ill. But some of the provisions need a proper rethinking. No law once framed can be adapted forever. There should be proper amendments from time to time. Conclusion
Conclusion Overall, mental health is an issue that effects everyone. And hopefully, throughout the years, education will curve the sigma of these brain disorders so that hate, bias judgment and discrimination will be gone.