Disability in mental illness is a condition in which the patient has shown symptomatic recovery with available treatment modalities, but has deficits that result in significant problems with personal care, interpersonal, social, and professional functions, and impaired quality of life that may require aggressive rehabilitation. [20,21] Balakrishnan et al.[22] scientifically examined various aspects of the Persons with Disabilities Rights Act, 2016,[23] particularly with respect to certification guidelines. They highlight the lack of clarity around screening tools, resource allocation and the need for inclusive education. They recommend increased concentration and restraint for patients with disabilities due to specific mental illness and learning disabilities; and decentralization of disability certification, such as certification of severe or profound intellectual disability in the primary health centre (PHC) itself. This would avoid inconvenience to end-users, reduce the workload in tertiary psychiatric centres, be cost-effective and time-consuming, and lead to increased recruitment of mental health professionals, in particular qualified psychiatrists and clinical psychologists at the PHC itself. However, this certification should be carried out by a medical committee, which necessarily consists of a qualified psychiatrist and a clinical psychologist, and not by other professionals such as paediatricians. The Mental Health Care Act, 2017 (MHCA 2017)[1] explicitly addresses the rights of patients with mental illness (PWMI) and defines the ethical and legal responsibilities of mental health professionals and government. PWMI rights are on par with fundamental human rights and must be clearly taken into account, as they belong to a vulnerable group in terms of assessment, treatment and research. These rights are reflected in the ethics of psychiatric care, which refers to respect for autonomy; the principle of non-evil, charity and justice; confidentiality (and disclosure); border offences; informed consent (and involuntary treatment); etc.[2,3] I will discuss ethical, legal and related issues related to the manuscripts published in this issue of the journal. “All approaches to medical ethics, whether empirical, legal, sociological, theological or philosophical, should aim to be useful in practice. Good medical ethics should help inform and guide those directly involved in moral issues in medicine and health care. This means that, above all, good medical ethics are clinically relevant. [24] “You have to reconcile idealism and pragmatism, how much is feasible and how much you have to try.
[25] It is important that medical ethics not become archaic and impracticable laws; But science-based, achievable, ethical-minded guidelines should be updated regularly. In this context, a retrospective review of the files was carried out on patients hospitalized in forensic pathology. [8] About 73.9% of the sample was transferred from prisons and 26.1% from honorable courts. Based on the alleged offence, 21.7% of subjects were referred for the legal capacity assessment. The majority of them (30.43%) were accused of killing close family members such as a husband or child. In the retrospective analysis, about half of the study sample had an illness at the time the crime was committed. About 30.4% of people were diagnosed with psychotic disorders and 47.8% with mood disorders. Significant clinical improvement was reported in 87% of patients, which is encouraging. It remains to be seen whether the improvements achieved will last in the long term, especially those transferred from prisons. Also, how do these patients feel after discharge from psychiatric hospital and after release from prison, due to non-adherence to treatment and other prognostic factors? This study focused only on females; Do male forensic patients feel differently? Diagnosis is paramount to effectively treat psychiatric patients, which is based on an adequate history of other significant people, as psychiatrists cannot rely solely on mental state examination.
When people are admitted against their will to public tertiary hospitals by honorable courts and prisons, there is no proper history. This is more common among people transferred from prisons. We try to talk to the prison doctor and the caregivers. Supervisors cannot be found or do not want to discuss. Due to ignorance of mental disorders, the only medical history obtained from the doctor is that the patient is irritable or has suicide threats. This is not enough to arrive at a diagnosis. Therefore, the lack of adequate medical history is a major problem in a forensic psychiatric setting. The treatment of these patients is therefore generally based on hospital observation. Recently, India has placed greater emphasis on the training of judicial and prison doctors, which is a welcome step.
There is also an urgent need for a judicial policy that requires the presence of caregivers and/or family members while they are referred to psychiatric hospitals. In their article on MHCA 2017, the authors[4] critically assess the advantages and disadvantages of the new ACT. They praise the law to support PWMI`s rights (especially insurance) and recommend decriminalizing suicide and the lesbian, gay, bisexual, transgender, questioning/queer (LGBTQ) community. They also mention the non-representation of the Indian Psychiatric Society and the inadequate treatment of the caregiving burden suffered by caregivers. PWMI caregivers are true ambassadors for mental health; They sincerely understand the true service that psychiatrists have rendered in this country for many decades. There is no doubt that PWMI`s human rights must be protected at all times; However, it cannot be one-sided. There is an equal and strong need to involve caregivers in the design of mental health policies that are ethical and legal, while being adapted to their needs and the realities of this developing country, such as poverty, illiteracy, ignorance of mental illness, stigma, discrimination, etc. Given the new challenges posed by MHCA 2017, such as mental health assessment, living will, designated representative, etc., the authors stress the need to actively engage with “the media, police, NGOs, human rights activists. and the police. [4] In their article “Psychiatrists on Trial: Indian Scenario”[9], the authors discuss the legal aspects of psychiatric care when psychiatrists are called in as experts. They believe that “psychiatric residents often do not come into direct contact with the judicial process.” There may be three reasons for this.
First, many residents are trained in psychiatric units in general hospitals (especially private colleges) that are not directly affiliated with forensic psychiatric units. They have a peripheral assignment of only about 2 to 4 weeks at such centers.
