The law – and a stigmatic name

Two papers presented at The Third International Conference on Schizophrenia organised by the Schizophrenia Research Foundation (SCARF), Chennai, ­focussed on subjects of greater interest to laypersons. We publish abstracts from them here as, with ­increasing incidence of the ailment in Chennai, its ramifications are ever wider.

Schizophrenia and mental capacity legislation

Kartikeya Krishnamurthy
Consultant Psychiatrist,
Royal Hospital, Chesterfield, UK

The Mental Health Act of UK has been strengthened by other measures taken in the UK. Among them are an administrative measure taken by the UK Government in 1991 called The Care Programme Approach, and, more recently, the Mental Capacity Act 2005. Efforts such as these have ­resulted in better care for ­mentally ill persons ­suffering from illnesses such as Schizophrenia.

In India we have the Mental Health Act 1987, but it does not ensure ade­quately safe care of the ­mentally ill either in their best interests or in a least restrictive way. ­Unfortunately, the onus of looking after patients with chronic mental illness like Schizophrenia is with the family and the legally bound relative can be fined Rs. 2000 under Section 25 of the Mental Health Act. It is important that care of persons with chronic mental illnesses such as Schizophrenia is made the responsibility of the State as in most of the developed countries. This would result in Government making provisions to support the carers of mentally ill in various ways and reduce their burden. Only then can people with chronic illnesses such as Schizophrenia and their carers reap the full benefit of legislation like the Persons with Disability Act in India.

In this context, it is important to understand the concept of Mental Capacity and the need for appropriate legislation to prevent exploitation of persons with chronic mental ­ill­nesses like Schizophrenia. Mental Capacity refers to the capacity of a person to make his or her own decisions. Mental Capacity Law in the UK states that a person is unable to make decisions if he cannot understand, retain, weigh up, and communicate his decision. This lack of capacity occurs frequently in people who have chronic mental illnesses like Schizophrenia during the period when they manifest active signs and symptoms and when they have relapses.

Legislations like the Mental Capacity Act would ensure that anything done on behalf of persons like Schizophrenics who lack capacity must be in their best interests. Further, anything done for or on behalf of people who lack capacity, like Schizo­ph­renics, must be done with least restriction on their basic rights and freedom.

The implication for psychiatric institutions in India is that persons with a diagnosis of ­illnesses like Schizophrenia, ­Bipolar disorders and other ­psychotic conditions, who are likely to lack capacity in the course of their illness, should be treated with least restriction on their basic rights and freedom. Patients with voluntary board status should not be admitted to closed wards in situations where they lack capacity. This is because they lack capacity to consent. It would mean unlawful detention of a person lacking in capacity.

If they are at risk to others or themselves, they should be detained under appropriate ­sections of the Mental Health Act 1987 only till such time as they are at risk. They should be allowed to appeal against their detention and such appeal ­processes should be facilitated. Community treatment and treatment in open wards in least restrictive ways should be the preferred option. The patient’s informed choice would have to be taken into consideration if he or she has the capacity.

Further, such legislation would ensure that whatever is done during the treatment of persons who lack capacity should be in their best interests, which would mean there should be no adverse influence of politicians, community leaders, relatives with vested interests, and others in decisions with regard to admission, detention, treatment, discharge and aftercare of such patients.

India is developing rapidly in several areas such as computer sciences etc. It is time we move forward to ensure in our country better care for persons with illnesses such as Schizophrenia and other psychotic illnesses. We need further administrative and legislative measures to strengthen existing legislations like the Mental Health Act and Persons with Disability Act.

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The case for a new name for Schizophrenia

Toshimasa Maruta
Department of Psychiatry,
Tokyo Medical University

In 2002, the Japanese Society of Psychiatry and Neurology changed the official name of “Schizophrenia” (seishinbun­­retsubyo, lit. split mind disease) to a term meaning “loss of ­coordination disorder (togo-shicho-syo)”. The effect of merely changing a possibly stigmatic term to something new may be moot, yet there has been discussion on whether a change in the English terminology would be clinically and scientifically desirable.

To attempt to gain insight into the thinking concerning this point among international psychiatric authorities, we sent out a questionnaire to members of the Section on Classification, Diagnostic Assessment and Nomenclature of the World Psychiatric Association. Only about 25% responded, perhaps because of the sensitive/political/clinical implications of the main question – whether the term ‘schizophrenia’ is stigmatic and should be changed. Of the 50% of those who did respond, a slightly greater number (10, 50%) wished the term to be changed than those who did not (35%), while 2 (10%) gave ambiguous answers and 1 (5%) gave none.

However, regardless of whether the respondents were for, against, or equivocal, there was a strong common refrain, namely that there must be greater education of the public concerning the varieties of ­conditions that this term (or its successor) is used to cover. The comments of all the responders (psychiatry experience 5-50 years) indicated that this is an extremely important topic in terms of improving patient care in future.