Rajendra Pratap Gupta
Registered Speed Post / E-Mail
Dated: March 24th 2011
Shri. Ghulam Nabi Azad
Hon’ble Health Minister
Government of India
New Delhi -110108
Reference: Revision of Mental Health Act 1987 & Mental Health Care Act 2010 ( draft )
Dear Shri Azad ji,
This needs your esteem, kind and personal attention.
I am writing this note on behalf of the Disease Management Association of India – ( DMAI)- The Population Health Improvement Alliance . DMAI works with all the stake holders in the entire continuum of care, for improving the population health of the nation . Over the last few years, we have worked with different stake holders to help define the right priorities in healthcare for the policy makers & the care providers .
Through this note , I am drawing your attention to the revision of the mental health act of 1987 and the proposed Mental Health Care act 2010 (Draft). The process of revision of the Mental Health Act 1987 was initiated about a year back, to make it compliant to the United Nations Convention on the ‘Rights of Persons with Disability’. Disability includes persons with long term mental illness. This convention advocates equal rights for all disabled persons.
Dr Saumitra Pathare ( a private psychiatrist) and Dr. Jaya Sagade (a lawyer) of Pune were in charge of conducting the regional consultations on behalf of the Ministry. Over the last one year, there have been 5 regional consultations with various stakeholders. The major stakeholders consulted have been users, care providers, professional bodies in mental health, mental health institutions and state government representatives. However, it is to be noted that, the Medical Council of India, other specialties of modern medicine, and professional organizations of general health field, have not been consulted. This is important, as the changes which are evident in the draft bill have far reaching consequences in terms of the way the modern medicine is taught and practiced currently.
DMAI- The Population Health Improvement Alliance, is surprised with the outcome of the consultations , and that there was hardly any discussion on the final outcome to patients due to the significant changes which are being brought in terms of the ‘mental health’ field of practice of medicine by way of promulgating this act. Proposed changes are likely to cost human lives , as persons who have not been trained to be physician (Clinical Psychologist, Psychiatric Social Worker, Psychiatric Nurse), will be entrusted with the role of independent examination, diagnosis and admission of patients in mental health facilities. Currently, this role rests with a Psychiatrist who is a medical doctor (MBBS) trained in Psychological Medicine. In modern system of medicine ,only a physician (M.B.B.S )can diagnose a patient, as only he has received training in all the specialties such as Medicine, Surgery, Eye, ENT, Obstetrics & Gynecology, Pediatrics, Orthopedics, Radiology, Dentistry, Dermatology, Anesthesiology, Pharmacology, Preventive and Social Medicine, Pathology, Microbiology, Physiology, Biochemistry, Anatomy etc. , which essentially means, covering all the systems of the body. Unfortunately, Human body cannot be compartmentalized and however we may wish, but we cannot have an Eye specialist who has studied only ‘Eye’ and not done MBBS ( as a basic general qualification and set of skills covering the entire human body system) to examine each and every system of human body. Similarly, we cannot have a Psychologist who has no training of the subjects studied at MBBS level, to diagnose mental disorders by only doing psychological examination!!!!
Only an MBBS trained doctor with the proper understanding of the entire human body system and its functioning, can do a detailed psychological evaluation and come to a diagnosis of whether the patient has a psychological illness or it is some physical illness, which is presenting itself as a psychological illness. In cases of latter, appropriate referral is required and any delay may even be fatal. S/he can also order various tests and imaging and interpret them for aiding in his diagnosis. After a diagnosis is arrived at, s/he can plan and provide physical treatment (ECT), pharmacological treatment or psychological treatment. The role of psychiatric nurse, clinical psychologist or a psychiatric social worker is to assist him by nursing the patient, helping him in psychological interventions, helping him in psycho-social interventions respectively. But the patient is under the overall care of a psychiatrist who is the leader of the mental health team. All the three categories of personnel work under the supervision of a psychiatrist .
A clinical psychologist, PSW ( Psychiatric Social Worker ) or a psychiatric nurse is not trained to be a physician. They have not studied the human body as an MBBS doctor and cannot do detailed physical or systemic examination, investigations and imaging like a psychiatrist. They are in no position to independently examine, diagnose and advise admission of patient. A PSW and Clinical psychologist have not general training in other subjects of modern medicine. Just by talking to patient, how can a Clinical Psychologist or PSW diagnose a mental disorder? They will be severely restricted by their inability to do general and systemic examination and order and interpret investigations and imaging. A Psychiatry examinee will fail in his examination if he did not touch the patient for examination ; however bright drug treatment he may formulate for the patient ; as without a general and systemic examination, a person cannot make a diagnosis of mental disorder. In many cases special investigations and imaging also has to be ordered and interpreted. As per the diagnostic criteria for mental illness, a mental disorder can only be diagnosed after ruling out that the signs and symptoms are not better accounted for by a medical illness or use/abuse of a substance. In this scenario, without proper validation of the reason for the particular condition , what is the validity of diagnosis of mental disorder by a Clinical Psychologist, PSW or a Nurse ? Even the quacks believe that they can diagnose and treat independently. Each such claim needs to be examined objectively in line of their competence and current practice related to their vocation.
In modern system of medicine, which is regulated by MCI, there is no specialization known as Clinical Psychology, PSW or Psychiatric Nursing. The mandate of ‘Rehabilitation Council’ is limited to rehabilitation of persons with disability and practice of modern medicine under Rehabilitation Council is neither required nor allowed. If at all, new independent specialties such as Clinical Psychology, PSW and Mental Health Nursing without any supervisory role of a Psychiatrist is being planned for modern medicine system, then the whole modern medical system (MCI, Indian Medical Association, Other Medical Specialties) must be consulted .
If we go as per the draft, it means that Clinical Psychology, PSW and Mental Health Nursing personnel are as much a specialist as a psychiatrist and can independently examine , diagnose, admit and treat patients with mental disorders.
It is not understandable why a psychiatrist has to do MBBS (study the whole human body) and then specialize in Psychiatry while for the other persons they need to study only psychology or social work and yet be assumed to be qualified to examine the whole body, diagnose, admit and treat patients (albeit without medicines) . The demand to prescribe medicines by non psychiatrist is also going around (and may be later on this will be also be made possible.) There is no institution in the country where a Clinical Psychologist, PSW, Mental Health Nurse examines patients independently, diagnoses a mental disorders, admits patients and treats them. This amounts to practice of Psychiatry under the modern system of medicine and would invite penal provisions of MCI. The sole aim of drafters is to get the bill through and take credit for drafting the bill rather than have a healthy development of the sector. Nowhere in the country there is a Clinical Psychology ward, PSW ward or Psychiatric Nursing ward. The decision to admit is taken by the leader of the mental health team who is a Psychiatrist and it is the Psychiatrist who is overall responsible for treatment of a patient with mental disorder.
One of the reasons given by the people behind the draft of the Mental Healthcare Act 2010, for giving the role of independent examination, diagnosis and admission in bill, is the shortage of psychiatrist in the country. But if we go by the definition of psychiatrist in the bill which is the same as that in the previous Act, ‘an MBBS qualified person with experience and training in Psychiatry can be designated a psychiatrist’ for the purpose of the Act.
At present , there are about 8 lac medical practitioners in the country and these can potentially be designated as psychiatrist. So where is the shortage for the purpose of the Act ? The only purpose which could be served by giving an independent examination, diagnosis and admission to Clinical Psychologist, PSW, Mental Health Nurse in the bill is to later on claim that if they are capable of doing these jobs, then this means that they can practice their trades independently under the modern system of Medicine. This would mean they will be physicians of mental disorders just like a psychiatrist.
The inclusion of Clinical Psychologist, PSW, Mental Health Nurse for purpose of independent assessment, diagnosis, admission to a mental health facility should be deleted and replaced by ‘psychiatrist’ (an MBBS qualified doctor with some training/experience in psychiatry). After this, there will not be a need for defining mental health professional in the Act. If at all it has to be defined, then Clinical Psychologist and PSW shall be designated as Assistant Mental Health Professional as in the present legislation (Section 22 of State Mental Health Rule 1990) and their role clearly specified as being- to assist a psychiatrist.
Further, the supervision and review of the decision of a psychiatrist by a Clinical Psychologist, PSW, Mental Health Nurse in the mental health review commission is not feasible as review is to be done by practitioner of the same specialty i.e. Psychiatrist. Thus, the provision of Psychiatrist in the review commission should be made mandatory.
In a multidisciplinary team such as a mental health team, each team member has a specific role. If everyone will do the same role, which is to independently examine, diagnose and admit, then there could be no team functioning. Rather the role of each mental health person should be clarified in the Guidelines /Rules clearly, so that there is good team functioning and the public is well informed and is not misguided by manipulative persons. Can we imagine a similar provision for a Nurse specializing in Medical, Surgical, OBG, Cardio-thoracic nursing to independently examine, diagnose and admit patients in Medical, Surgical or OBG, Cardio-Thoracic ward respectively? Then why should we consider similar provision for Clinical Psychologist posted with Neurology department?
Psychiatry is a medical discipline as any other discipline. If Clinical Psychologist, PSW and Psychiatric Nurse want to independently examine , diagnose, admit and treat patients without even having the training and skills for the same and government wants to allow the same, then they should be allowed to start their own wards to do so and be responsible for their decisions. If we allow such changes to be brought, this would mean that a Psychiatrist too does not need to do MBBS. Then all the specialties of modern medicine should have direct specialization rather than first spend 5.5 years to be a General doctor. Human body cannot be divided in a compartments. All organs and systems are interrelated. A stroke can present itself as a depression in a mental health facility. What skill a psychologist or a PSW has to diagnose it without doing a full neurological examination or relevant investigations. They will treat for depression while the patient will die. In my view , compartmentalised knowledge is dangerous for the medical profession and defeats the basis of evidence based medicine
We are trying to make Clinical Psychologist, PSW and Mental Health Nurse into Physicians in mental health by giving the role of a Physician to them under the new draft bill on the pretext of shortage of Psychiatrist. However, there are less than a 1000 Clinical Psychologist and PSW both combined in the country. Further, there is no dearth of Psychiatrist under Mental Health Act, as Govt. can very well designate MBBS doctors with some experience in Psychiatry as Psychiatrist (as per the definition and provision in current legislation and the draft Bill). So even the assumptions for the shortage of psychiatrists is not a right justification for this act
The role given to Clinical Psychologist, PSW and Psychiatric Nurse in the draft bill is ; independent examination of patients, diagnosis , admission and then review of decisions taken by a Psychiatrist. Instead of this, in the draft bill, the role of a Clinical Psychologist and PSW- as a rehabilitation professional , and Psychiatric nurse – as a specialized nurse, should have been clarified and focused.
The position of a Psychiatrist as a mental health team leader should be reiterated and the decision of a psychiatrist should only be reviewed by a board having a psychiatrist. These rules could further be clarified In the draft bill psychiatric social worker and clinical psychologist has been mentioned as mental health professional just like a psychiatrist. However, In section 22 of the State Mental Health Rules’1990 (the existing legislation) the PSW and Clinical Psychologist are referred to as Assistant mental health professional. The change in the draft bill under consideration has been done with a view to make their role fit for independent examination, diagnosis, admission to a mental health facility by the drafters, without any regard to the impact of this on the patient care and safety. If they are full-fledged professionals (as they claim) who can diagnose, admit and treat patients, why do they need to be defined as such in the Act. At no place in the draft bill their role has been mentioned separately. At all places they are bunched as mental health professional with no individual roles. At no place it is mentioned that they will function under the supervision of a psychiatrist. If they independently examine, diagnose and admit patients they are then deemed to have an independent role. This will increase the role conflict which is already very high in the mental health team. So much so that at some places there is no team work. In Kerala High Court, there is a case going on, to allow clinical psychologist to independently practice in community to treat patients of mental disorders.
This is a serious issue and needs to be taken up strongly so that untrained people are not given the role of a physician i.e. to practice independently to treat patients.
DMAI insists that the Medical Council of India, Indian Medical Association & patient groups & DMAI needs to be taken in confidence and consulted, as independent examination, diagnosis and admission and also treatment by psychological or psycho-social means is practice of psychiatry under modern medicine and could not be allowed to be done by persons who do not even have a MBBS degree, in view of patient safety and care.
All health personnel shall work within the limits of their competence. In section 43 and 45 of the draft bill related to admission in a mental health facility: a mental health professional (i.e. Clinical Psychologist, PSW, Psychiatric nurse) has a role to examine a person suspected to be mentally ill independently, assess mental illness and its severity and advise admission. This is a role which goes beyond their competence. There are already instances of Clinical Psychologist practicing treatment of mental disorders independently as isolated examples. There is growing demand from clinical psychologist to allow them to practice independently the treatment of mental disorders. This change in the draft bill will allow them to be recognized as persons who can independently examine, diagnose, and admit patients, which will substantiate their claim to practice independently in community rather than under the supervision of a psychiatrist. It’s altogether different matter that they are not trained to examine and diagnose mental disorders as it requires ruling out other physical disorders as well and it requires a person to be a physician to do that. In section 22 of the draft bill : Constitution of district panels of mental health review commission , two members could be mental health professionals (i.e. Clinical Psychologist, PSW, Psychiatric nurse) which may not include a psychiatrist if he is not available, but then how the commission can judge the decision of a psychiatrist if no psychiatrist is in the commission? One needs to have knowledge of psychiatry to assess the correctness of the decision of a psychiatrist in a particular case. Provision of a psychiatrist in the review commission should be mandatory rather than being replaced by non-psychiatrist personnel Mental disorders are medical disorders and should not be treated by non-medicos .
I am quite sure that you will intervene and ensure that the corrective measures are taken to address the lacunae in the bill Also,
DMAI- The Population Health Improvement Alliance has initiated a ‘NCD Policy of India’ initiative, and would be glad to have the views of the ‘Ministry of Health’ involvement on the initiative
I am quite convinced that committed leadership will take cognizance of this note and take measures to implement the suggestions after a debate with all the stake holders in the continuum of care.
Should you need any assistance at my end, do let me know.
With best regards
Rajendra Pratap Gupta
CC. Dr.Manmohan Singh, Sonia Gandhi ,Rahul Gandhi , Dr.Syeda Hameed, Dr.Murli Mahohar Joshi , Montek Singh Ahluwalia ,Shri Dinesh Trivedi , Sitaram Yechury, Members of Parliament , Sam Pitroda , Secy-Health & Family Welfare , GOI, Dr.K.Srinath Reddy, Debasish Panda , Secretary (ME) Governors , MCI DGHS,MOHFW, Dr.Sudhir Gupta , CMO, NCD-MOHFW ,Dr. Suman Sinha, Psychiatrist, IMA , Chief Minister’s of States
DMAI wants the govt to give due weightage to homoeopathy in NRHM
Suja Nair Shirodkar, Mumbai Wednesday, March 30, 2011, 08:00 Hrs [IST]
The Disease Management Association of India (DMAI) has recommended the Public Accounts Committee (PAC) of the central government to increase the role of homoeopathy in the National Rural Health Mission (NRHM), especially for acute illness.
At present homoeopathy is not being leveraged properly under NRHM in spite of it being the cheapest way of treatment in the country. Rajendra Pratap Gupta, president and director DMAI pointed out that the homoeopathic medicines are cheaper and much more accessible to patients thus it is only natural that its potential should be utilised properly under NRHM.
Though the treatment used in homoeopathy is superficially similar to the medicines prescribed by a conventional doctor it differs in their source, preparation and dosage. He observed that in spite of having enough qualified homoeopathic physicians in the country the government is not giving them enough chance to play any role in the national health program. “Today there are hospitals and colleges that cater to homoeopathy and encourage its use then why isn’t the government utilising these resources to increase the demand for homoeopathic medicines among the rural population.
The government should take step to ensure that the people in the rural India can also benefit from this system,” he pointed out. He said that the demand for homoeopathy has increased over the years as more and more people are adopting homoeopathic treatment due to its effectiveness compared to other available methods. Thus it should be put to use more effectively. He added, “Homoeopathic medicines are very cheap, in almost two rupees a patient can get a weeks worth of medicines which will be a great support to the rural population, it would provide them with cheapest alternative that assures best treatment.”
Homoeopathy is a system for the treatment of illness that is based both on the recognition of patterns within the symptoms of the illness and a wider consideration of how the individual is as a person. Although conventional medical assessment also takes these issues in to account, the homoeopathic approach integrates personality type, previous experiences, emotional state, the influence of the environment and other social factors to a greater degree than is usual with standard medical practice.
Rajendra Pratap Gupta
Dear Mr. Manmohan ji,
More than six years back, we handed the reins of a great country to you, assuming that, you were the person who had turned around India in the late 80’s. It was on the basis of the past credentials that you were asked to be the supreme custodian of the nation, its values, its sovereignty and its 1.2 billion people . We were wrong , it was Narasimha Rao who did it , and you just got the credit . Also, i presume, that besides devaluing the currency , and giving into the IMF’s demands, you did not have any alternatives , so unnecessarily , you took the credit after being pushed to the wall. Now where is your economic understanding and knowledge in taming inflation , when inflation is killing the common man for over about years now ??
Your men ( ministers) have looted the nation to the tune of Rs. 3.0Lac crore ( 1.72 Lac in the 2G scam and 70,000 Crore in CWG + other routine scams and bribes will add up to the figure of Rs.3.0+ Lac Crore , and now you are claiming innocence and stating that you have nothing to hide !!
You cannot hide anything Manmohan ji, you are already exposed by the taped conversations and the reports of the CAG ! The technology ( mobile phone licenses ) which gave your men 1000’s of Crores , that same technology ( Taped phone conversations of Niira Radia ) exposed you bare before the common man !! People are now asking you to go under the scanner to be punished and that’s a fair thing to ask, as the nation has been under siege by your men, who have recklessly looted the nation and thrown the laws to the wind . This in itself shows how serious the issue is ? You come from a party that that have never respected democracy , and still believes that Gandhi family is the start and end of all. Congress have even strangulated the democracy & its institutions , and has put to stake the interests of the nation before the interests of the dynasty . Do not forget that Indira became a dictator by imposing emergency , and that’s the party you belong to right now . So when congress arm twists politicians with CBI raids and IT notices , you are just carrying on with the DNA of Indira’s dictatorial policies, that were like ‘ either support us or else get harassed’ . Do you not see that Jagan was denied his father’s role , and Rahul has been appointed the Secretary of Congress due to his Surname !! Does it not prove double standards .
As a head of the gang that has looted the nation of Rs. 3 lac crore , you should be thankful to the opposition that they have not asked for your resignation till now . As head of the gang ( basically , what i am saying is that , you are an offender and have committed a crime of betraying the trust of a billion people ) , you have no right to decide who will probe you and how ? You are a big fat offender in supreme office ? You must voluntarily step down and face the law. You cannot be probed till you are in the seat of the Prime Minister . How can a thief decide who will put him to trial ? and which laws will apply to him ? Aren’t you doing just that ? You are a miserable failure as a PM on all accounts , and people have just got carried away by your fanciful & foreign degrees and your old age for which you are being respected .
You loot the nation first and then cry aloud that you are as Pristine as the silver clouds in the sky ?
I am marking this mail to the top leaders of the opposition to ensure that they reconsider their demand, and ask for your resignation besides JPC. If the leaders fail to do so , the public will punish them for not caring for the interest of the common man ! Manmohan ji , You have failed in your fiduciary responsibility as the custodian of this nations , its democratic values and institutions , and now Sonia , Rahul and you are talking like an opposition party , stating that we will have a five pronged approach to fight corruption ? That too, after systematically looting the nation, you are trying to become saintly policemen ? Were you not the PM when you supported Raja, and said that you are in the loop of all that is happening in the DOT ? You were the one who gave him a clean chit ? Now , it’s your time to surrender to the law of the land for a fair probe, and that is a reasonable demand from the opposition . In that , i as a common man , am adding one more genuine request . People with questionable credentials and dubious record of governance must immediately resign
Time to pay for your sins
Rajendra Pratap Gupta
Email : Office@rajendragupta.in