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AsianJournalofPsychiatry
journalhomepage: www.elsevier.com/locate/ajp
TheMentalHealthcareAct2017ofIndia:Achallengeandanopportunity VasudevanNamboodiria,SanjuGeorgeb,⁎,SwaranPreetSinghc
a InstituteforMindandBrain,Kuranchery,Thrissur,Kerala,680581India
b RajagiriSchoolofbehaviouralsciencesandresearch,RajagiriCollegeofSocialSciences(Autonomous),RajagiriP.O.,Kalamassery,Kochi,Kerala,683104India
c WarwickMedicalSchool,UniversityofWarwick,CV47AL,UnitedStates
ARTICLEINFO
Keywords: MentalHealthcareAct2017 India Psychiatry


ABSTRACT
TheMentalHealthcareAct2017replacedtheMentalHealthAct1987,subsequenttoIndia’sratificationofthe UnitedNationsConventionontheRightsofPersonswithDisabilitiesin2007.TheMentalHealthcareAct (MHCA)2017upholdspatientautonomy,dignity,rightsandchoicesduringmentalhealthcareandthusmarksa boldstepinIndia’smentalhealthlegislation.ThisnewLawmarksamajorshiftinthewaymentalhealthcareis delivered,asitaimstoprotectandpromotetherightsofpeopleduringthedeliveryofmentalhealthcare.Within thisAct,acapacitousindividualcannotbecoercedintoreceivingtreatmentformentalillnessandinpatient admissionscanbe ‘independent’ or ‘supported’ ‘Supportedadmission’ replacesinvoluntaryadmissionfromthe previouslegislation.Statementalhealthauthoritiesandmentalhealthreviewboardswillplayamajorrolein theimplementationofthenewAct.TheMentalHealthcareAct2017isaimedatbringingaboutradicaltransformationtomentalhealthcareinIndia.
1.Introduction
TheMentalHealthcareAct2017isaboldstepinanewdirectionfor mentalhealthlegislationinIndia.Indiaisthesecondmostpopulous countryintheworldandishometoasixthoftheworld’spopulation. (TheWorldHealthOrganisation,2019).Indiabecameanindependent countryin1947andaRepublicin1950.Indiaisaunionof29States andsevenUnionTerritories.IndividualStatesareruledbydemocratically-electedStategovernments.Althoughmosthealthcareisfunded bytheindividualStategovernments,ratherthantheCentralgovernmentofIndia,mentalhealthlegislationenactedbytheParliamentof IndiaisapplicabletoallStatesandUnionTerritoriesinIndia.Arecent NationalMentalHealthSurvey(NMHS)estimatedtheone-timeprevalenceofanymentalillnessinIndiatobe10.6%(2016)(National MentalHealthSurveyofIndiaetal.,2016; Gururajetal.,2016).NMHS estimatedthetreatmentgapformentalhealthdisordersinIndiatobe 83%.ThisisinkeepingwiththeestimatedtreatmentgapbytheWHO consortium(2004).(Demyttenaereetal.,2004)
2.MentalhealthlegislationinIndia
BritishIndia(priorto1947)hadseverallegislationsgoverning mentalhealthcare(LunacyActs,IndianLunacyAct,etc.).TheRepublic ofIndiaenactedTheMentalHealthAct1987(TheMinistryofHealth
andFamilyWelfare,GovernmentofIndia,1987),toreplaceitscolonial predecessor,TheIndianLunacyAct,1912.TheMentalHealthAct, 1987,didnotcontributemuchtowardsprotectionoftherightsofthe mentallyill.TheMentalHealthAct,1987wasrepealedin2018andthe newActisTheMentalHealthcareAct,2017(TheMinistryofLawand Justice,2017).TheMentalHealthAct1987providedlegalprovisionfor healthcareofpersonswithmentalillnessrequiringinpatienttreatment. Thelackofprovisionforanindependentjudicial/quasi-judicialreview ofthedecisionforcompulsoryadmissionwasamajordrawbackofThe MentalHealthAct1987.Therewasnoprovisiontoensurethatcompulsorytreatmentwasleastrestrictiveofthepatient’srights.ThepreviousActwasapplicableonlytospecialistmentalhospitalsandthus excludedalargeproportionofpeoplereceivingmentalhealthcarein generalhospitalsettingsfromthepurviewoftheAct.
IndiaratifiedtheUnitedNationsConventionontheRightsof PersonswithDisabilitiesin2007(CRPD,2006).Thisnecessitateda reviewoftheexistingMentalHealthActtoensurecompliancewiththe Convention.IncompliancewiththeConvention,thenewActis firmly rootedintherightsofpeoplewithmentalillnesses.Itmakesapresumptionofequalityinfrontofthelawforpeoplewithmentalillnesses, unlessanindividualhasimpaireddecision-makingcapacityformental healthcaredecisions.ThenewActfocussesjustonmentalhealthcare, ratherthancareofpersonswithmentalillness(forexample,welfare andmanagementofpropertyofamentallyillpersonarenotcovered
Received27February2019;Receivedinrevisedform6July2019;Accepted7July2019 ⁎ Correspondingauthor.
E-mailaddresses: vasudevan.namboodiri@gmail.com (V.Namboodiri), sanjugeorge531@gmail.com (S.George).
URLs: http://drvasudevan.mailbox@gmail.com (V.Namboodiri), http://sanjugeorge531@gmail.com (S.George).
https://doi.org/10.1016/j.ajp.2019.07.016
1876-2018/©2019ElsevierB.V.Allrightsreserved.
underthisAct).ThepreambleofthenewActreadsasbelow:
“TheMentalHealthcareActistoprovideformentalhealthcarefor personswithmentalillnessandtoprotect,promoteandfulfilthe rightsofpeoplewithmentalillnessduringdeliveryofmental healthcareandservicesandformattersconnectedtherewithorincidentalthereto”.(TheMinistryofHealthandFamilyWelfare, GovernmentofIndia,1987)
3.CoreprinciplesofIndia’snewmentalhealthcareact
MentalHealthcareAct2017,upholdspatientautonomy,dignity, rightsandchoicesduringmentalhealthcare.Forthe firsttimeinthe country’shistory,accesstomentalhealthcareisdescribedasarightof everycitizen.Incontrast,physicalhealthcareisstillnotstatedasaright foreveryIndiancitizen.ThisiscommendableforacountrylikeIndia withlargeunmetpsychiatricneed(Demyttenaereetal.,2004).Capacitytomakedecisionsregardingmentalhealthcareforoneselfhasa pivotalpositioninthisAct.Thecapacityfordecisionsonmental healthcareisarticulatedintheActasabilitytounderstandrelevant information,(or)appreciationofconsequencesofdecisions(or)ability tocommunicatethedecisions(Section 4 ofthisAct).Mentalhealthcare foracapacitousindividualcanonlybeprovidedsubjecttoinformed consent.Acapacitousindividualisthesoledecisionmakerforher/his mentalhealthcare,irrespectiveofthementalillnessorrisksinvolved. Unlikeinmanyotherjurisdictions,acapacitousindividualcannotnow beforcedinpatienttreatmentformentalhealthinIndia,evenwhenthe risksrelatedtomentalhealtharehigh.Evenattimesofincapacity, patientchoiceistobelistenedto.
Toensurethatpatientchoiceisrespectedeveninindividualswith impairedcapacity,thisLawusesthreetools:advancedirectives,nominationofrepresentativesandsupporteddecision-making.
3.1.Advancedirectives(Sections5-13oftheAct)
Anycapacitousindividual,irrespectiveofthepresenceofmental illness,canexecuteanadvancedirectivetohelpdesignthecarethey willreceiveduringanincapacitatingmentalillness.Validadvancedirectivesarelegallybinding,unlessrevokedbytheMentalHealth ReviewBoardoracourtoflaw.Amedicalpractitioneroramental healthprofessionalshallnotbeheldliableforanyunforeseenconsequencesoffollowingavalidadvancedirective.Advancedirectives areexpectedtoberegisteredwiththeMentalHealthReviewBoard (Section82(1)(a)oftheAct).Advancedirectiveshavenoplaceinthe careofacapacitousindividualorattimesofemergencytreatment.
3.2.Nominationofrepresentatives(Section14oftheAct)
Eachpatientcannominatearepresentativetosupportdecision makingattimesofimpairedcapacityfordecision-makingregarding mentalhealthcare.Nominationsaremadebythepatientandaccepted bythenominee.Thenominatedrepresentativeislegallyboundtogive duerespecttothepatientchoice,willandpreferences,whilemaking decisionsforthepatient.Intheabsenceofanominatedrepresentative, otherrelatives,carersandspecificappointees(followingthespecific protocolintheAct)fromtheStatecanassumetheroleofanominated representative.Anominatedrepresentativecanmakedecisionsforthe patientonlyattimesofincapacity.
Supporteddecision-making replacessubstitutedecisionmakingin timesofincapacity(ofthepreviouslegislation).Inthepreviouslegislation(TheMentalHealthAct,1987),mentalhealthcaredecisionswere madeforthepatientbythetreatingteamintheirroleasthesubstitute decisionmakerforthepatient.ThenewLawinstructsnominatedrepresentativestomakedecisions,onlyaftergivingduecredencetopatientchoice,bestinterests,willandpreferences.Supportedadmissionis aconceptintroducedinthenewActtoreplaceinvoluntaryadmissionof
thepreviousAct.Supportliesonacontinuumrangingfromminimalto nearcomplete.Peoplerequiringhighlevelsofsupportfordecision makingarelikelytorequiresupportedadmissionandtreatment.
3.3.Remitofthelaw
Thelawcoversall ‘substantive’ mentalillnessesincludingsubstance misusedisorders.Intellectualdisabilityis,however,excluded.Mental illnessasperSection2(s)ofthisActis asubstantialdisorderofthinking, mood,perception,orientationormemorythatgrosslyimpairs(a)judgment, (b)behavioror(c)capacitytorecognizerealityorabilitytomeettheordinarydemandsoflife. PeoplewithsubstancemisusedisordersareexplicitlybroughtunderthepurviewoftheAct.
Allinstitutionswherepeoplewithmentalillnessresidefortreatmentandcare(excludingfamilyhomes)areconsideredasmental healthestablishmentsrequiringregistrationwiththeauthorities.This includesallrehabilitationhomes,prisons,placesforreligioushealings and institutionsofferingcomplementarytherapies.Generalhospitals providingmentalhealthcare(inisolationorincombinationwith physicalhealthcare)alsocomeundertheremitoftheAct.Thisisclearly awelcomestepforward,asthepreviouslegislationwasrestrictiveinits remit.
UnlikethepreviousMentalHealthActofIndia(1987),thecurrent lawisrestrictedtomentalhealthcare(ratherthancareofthementally ill).Thereisaseparatelegislation,enactedin2016,tocovercertain otheraspectsoflifeofpeoplewithdisablingmentalillness(Rightsof PeoplewithDisabilitiesAct,2016)(MinistryofSocialJusticeand Empowerment,2017).Thischangeis firmlygroundedontheprinciple ofequalitybeforelaw(Article12)ofTheUnitedNation’sConvention onRightsofPersonswithDisabilities.
3.4.Rightsofpersonswithmentalillness
Inadditiontotheconstitutionalrights,everycitizenofIndianow alsohasarighttoaccessState-providedmentalhealthcare. Discriminationbecauseofmentalillnessinanysphereoflifeisillegal (includingforinsurancepurposes).ThisStatutealsoprohibitsdiscriminationtoaccessmentalhealthcareongroundsofsexualorientation(article377oftheIndianPenalCodewhichcriminalizedconsensualhomosexualitywasstruckdownbytheSupremeCourtofIndia in2017(Anon.,2018).
TheLawpresumesthateveryonewithmentalillnessiscapacitous formentalhealthcare(untilprovedotherwise)andenshrinestheright toprotectionfromcruel,inhumananddegradingmedicaltreatment. Thelawdemandsequalityofmentalhealthcareandphysicalhealthcare.
TheLawalsoviewsaccesstomentalhealthcareinthecommunityas agovernmentalresponsibilitytopeoplewithmentalillness.Freelegal aid,accesstomedicalinformation,accesstocommunityliving,confidentialityofmedicalinformation,accesstopersonalcontactsand communicationareallrightsofpatientsreceivinginpatientmental healthcareenshrinedunderthisStatute.
3.5.Admissionstomentalhealthestablishments
AdmissionstomentalhealthestablishmentsunderthisActcanbe either ‘independent’ or ‘supported’ .
Independentadmissions(Section85–86) arevoluntarilyrequestedby capacitouspatients,withfreedom(andresponsibility)tomakedecisionsandcareplans.Thereisnolimittothetimeperiodforindependentadmissions.Independentadmissionsdonotnecessarilyrequireapsychiatristtobepartoftheprocess(evenfordischarge)and theyarenotrequiredtobereportedtotheMentalHealthReview BoardsundertheLaw.Dischargerequestsmadebyindependentpatientsaretobehonoured,unlesscriteriaofcapacityandrisksallowa retentionfor24hforanassessmentforsupportedadmission.
OneofthecoreprinciplesoftheActisparityformentalhealthcare andphysicalhealthcare.Independentadmissionsrequiretopassa thresholdofseverity.Besidesaninformedchoicetoaccessinpatient mentalhealthcare,thisActlimitsindependentadmissionsonlytothose whopassaseveritycriterion.Thiscanbecomeabarriertothosewho seekinpatienttreatmentbelowthethreshold.Thisisopinedasagainst theprincipleofparitywithphysicalhealthcare(Kumar,2018).
Supportedadmissions(Section89) replaceinvoluntaryadmissionsof thepreviouslegislation.Theaimistousesupporttominimizeinvoluntaryadmissions.Impaireddecisionmakingisessential,though notsufficient,forsupportedadmissions.Supportedadmissionsaretobe usedonlywhenthereisnolessrestrictiveoption.Thepatientisexpectedtobenefit(asjudgedbytheadmittingclinician)fromthehospitalization.Riskstoself,othersorofself-neglectshouldberecent (whatcanbe ‘recent’ isopentoindividualinterpretation).Supportis meanttobefromanominatedrepresentative(patient-nominatedor appointedbytheState).Supportedadmissionscantakeplacewith minimalornoagreementfromthepatient.Thelawmandatesthateven patientswithimpairedcapacityfordecisionmakingformental healthcareneedtobesupportedandinvolvedindecisionmaking,asfar aspossible.TheLawviewssupportasbeingonaspectrum,ranging fromminimalrequirementofsupporttoneartotalsupport.
Supportedadmissions(Section89)requiretwoindependentprofessionalexaminationsandrecommendations(apsychiatristanda medicalpractitioner/mentalhealthprofessional).AllsupportedadmissionsaretobeintimatedtotheMentalHealthReviewBoardswithin aweek.TheMentalHealthReviewBoardsarequasi-judicial,ledbya judge.Theyhavepowerstodischargeapatientfromsupportedadmission.
TheStateisboundtoprovidefreelegalaidtopatientsappealing againstsupportedadmission.DecisionsbytheReviewBoardsaretobe withinsevendaysofappealandthemaximumdurationforaninitial supportedadmissionisthirtydays.
3.6.Extensionofsupportedadmission(Section90)
Supportedadmissioncanbeextendeduponrenewal.Extensionscan varyfrom30daystoamaximumof180days.Eachrenewalmustbe approvedbytheMentalHealthReviewBoard.TheLawmandatesthat thetreatingteammustmakeeveryefforttomovethepatienttoa settingoutsidethehospitalassoonaspossible.Anextensionofsupportedadmissioncanbemadeontherecommendationoftwoindependentpsychiatrists.Therearealsoprocessesforappealand hearingbytheMentalHealthReviewBoards(describedbelow). Extensionscanonlybeusedattimesofpersistentrisksandpriortosuch anextension,everyeffortmustbemadetoensurelesserrestrictive optionsinthecommunityareexplored.
4.Discharges
Alldischargesfromhospitalsneedtobecoupledwithdischargecare planninginvolvingpatients,cliniciansandnominatedrepresentatives. Compulsorycommunity-basedtreatmentisnotpossibleunderthisAct. However,thelegislationbindstheStatetoprovideeasilyaccessible communitymentalhealthcareandrehabilitationservices.Individual StatesandUnionTerritoriesareexpectedtocreatespecificrulesunder theActregardingserviceprovision.Iftheminimumservicesprovided bythegovernmentformentalhealthcareisnotavailableinthedistrict, theLawdemandsareimbursementofexpensesincurredbythepatient toaccessmentalhealthcareelsewhere.InIndia,withitshighmental healthserviceavailabilitygap,eligibilityforreimbursementmaynotbe sufficienttoensurethegapgetsbridged.
5.MentalHealthReviewBoards
TheseBoardsconsistofaDistrictJudgeEquivalent,independent
psychiatrists,otherindependentcliniciansandlaypeople.Though thereisaprovisionforanindependentpsychiatristtobeamemberof theBoard,theBoardcanpotentiallybeconstitutedevenwithouta psychiatrist.Inadditiontomandatoryindependentreviewsandappeals bypatientsandnominatedrepresentatives,theBoardsarealsoentrustedwithresponsibilitiesofreviewofadvancedirectives,reviewof nominatedrepresentatives,approvalsofextensionsofsupportedadmission,andECTsforminorsandpsychosurgeries.Anyappealsagainst decisionsbytheMentalHealthReviewBoardsaretobeattheHigh CourtoftheState.TheCentralandStateMentalHealthAuthorities overseetheimplementationofMentalHealthcareAct.
TheMentalHealthReviewBoardsandMentalHealthAuthorities arestillinstagesofinfancy.Althoughithasbeenthirteenmonthssince theActcameintoforce,theseboardsarenotfunctionalentitiesyet.The Actisambitiousandisaimedtobringoutdrasticchangeinthedelivery ofmentalhealthcare.
6.Miscellaneousprovisions
Thereisadistinctprovisionforemergencymentalhealthcareby anyregisteredmedicalpractitionerforamaximumperiodof72hor untilamentalhealthassessmentiscompleted(whicheverisearlier).It isclarifiedthatadvancedirectivesdonotapplytoemergencysituations.
Unmodified electroconvulsivetherapy,chainingandsterilizationas treatmentformentalillnessesareexplicitlyprohibited.Certainprocedureslikepsychosurgery,ECTforminorsandrestraintsarenotprohibited,butshouldbesubjecttopriorapprovalfromtheMentalHealth ReviewBoard.
ThedutiesofPolicetoassistpatientsandfamiliestoensureprotection,safetyandaccesstomentalhealthcareforpeoplewithmental illnessareexplicit.UnlikeintheearlierAct,theroleofthejudicial magistrateindecisionsofadmissionanddischargeofpeoplewith mentalillnessfrominpatientsettingsisminimized.
Section115ofthisActmakesapresumptionofseverestressfor suicideattemptsandrecommendsthattrialundertheIndianPenal Codeistobeavoidedforsuicideattemptsduetostress.Thedutyofthe governmenttoprovidecare,treatmentandrehabilitationforpersons attemptingsuicideismarkingachangeintheperspectivetowards suicideinIndia.
Supportedadmissionsrequiretheongoinginvolvementofanominatedrepresentativeduringtheinpatientmentalhealthcare. Applicationsforsupportedadmission,decisionsformentalhealthcare forpatientswithimpairedcapacityduringasupportedadmissionand requestfordischargeareexplicitdutiesofthenominatedrepresentatives,evenduringaState-providedinpatientmentalhealthcare.Thesecanbeviewedbothasempoweringandburdensome09
InIndia,withitshugejudicialbacklogincourtsystems(Anon., 2019),theadditionalresponsibilityinrelationtotheMentalHealth ReviewBoardsrequiresexplicitcommitmentofresourcesfromthe State.Legislatoryreformisanecessary firststepforchangesinthis direction.ThereisacriticismthatIndianmentalhealthlegislationisfar moreprogressiveoftheactualstateofmentalhealthserviceatthetime ofenactment(Kumar,2018; Duffyetal.,2018).
Oneoftheoptionstoensureleastrestrictivenessoftreatmentisthe availabilityofcompulsive(or ‘supported’ inthespiritofthisAct) treatmentinthecommunity.Thisavenueislargelyunaddressedinthis Act.Compulsivetreatmentinthecommunityisassociatedwitha markeddiminutioninthemorerestrictivehospitalstayforpersonswith mentalillnessrequiringlong-termadmissions(Tayloretal.,2016).The shiftoffocusfrommentalillnessestomentalwell-beingandfrom hospital-basedmentalhealthcaretocommunity-basedcareisanincreasinglyrecognizedneedofthehourforIndia’smentalhealthcare system(Murthy,2018).Thislegislationfallsshortofempowering communitybasedmentalhealthcare(Table1).
Thenewlegislationhasreceivedmixedresponsefrommentalhealth
Table1
ComparisonofthepreviousandthecurrentmentalhealthlegislationsofIndia. MentalHealthAct1987(TheMinistryofHealthandFamilyWelfare,Governmentof India,1987)(Repealedin2018)
Applicableonlytospecialtymentalhospitals (excludedgeneralhospitalsprovidinginpatientmentalhealthcarerunbythe State).
MentalHealthcareAct2017(TheMinistryofLawandJustice,2017),ineffectfrom2018
Applicabletoallsettingswherepeoplewithmentalillnessresideforcareofmentalillness (includingthoseprovidingtraditionalcare).
Admissions – Voluntary,InvoluntaryandReceptionOrderfromtheMagistrate.Admissions—‘Independent’ and ‘Supported’ Noprovisionforindependentjudicialreview/appeal.Provisionforquasi-judicialreviewandappeal(MentalHealthReviewBoard).
Compulsoryinpatienttreatmentformentalillnessposingrisks(irrespectiveofthe capacityoftheindividual).
Supportedinpatientadmissionandtreatmentareonlyforincapacitousindividualsmeeting athreshold(includingrisks).
Protectsandpromotestherightsofindividualsduringmentalhealthcare.
Substitutedecisionmakingforpeopleundergoinginvoluntarytreatment.Promoteschoicesoftheindividualthroughsupporteddecisionmaking,advancedirectives andnominationofrepresentatives.
Nospecialsafeguardsforminorsrequiringpsychiatricadmission.
Separateprovisionforminoradmissionsundersection87,withadditionalsafeguards.
Alargeroleforjudicialmagistrateinadmissionsanddischargedecisions. Minimal,ifany,roleforjudicialmagistrateinadmissionanddischargedecisions.
RemitoftheLawincludednotjustmentalhealthcare,butcareofpeoplewith mentalillnessesincludingguardianship.
professionalsacrossthecountry.Insummary,thenewActdemandsa drasticchangeintheday – to-daypracticeoftheaveragemental healthprofessional(DuffyandKelly,2017).
7.Thefuture
Bothmentalhealthprofessionalsandthejudiciaryareinuncharteredterritoryhere.Advancedirectives,supporteddecisionmakingandnominationofrepresentativesareallrelativelynewissues formentalhealthprofessionalsinIndia.Thedutyofcareforamentally illpersonlackingcapacity,hasshiftedfromthementalhealthcare professionaltothenominatedcarersandtheState.States,whichwere notactivelyinvolvedinbringingaboutthiskeylegislationchange,and theiralreadystretchedjudiciariesshould findadditionalresourcesto deliverthecomprehensivecarebeingpromisedinthenewAct.India hastakentheinitialstepsofjudicialreformtoupholdtherightsofthe personswithmentalillness.Thelegislationiswidelyregardedasprogressive,withahighlevelofconcordance(incomparisonwiththe legislationsofotherjurisdictions)withtheUnitedNationsConvention onRightsofPeoplewithDisabilities(DuffyandKelly,2017).Thereare provisionsintheLawtoensurethatthegovernmentisduty-boundto trainallitsmentalhealthprofessionalsintheuseofthisActintheirday – to-dayclinicalpractice.Thelawisambitiousandaspirationalinits spiritandoffersopportunitiesforIndiatorevampthecareofitscitizens withmentalhealthdifficulties,upholdingtheirrights.
Financialdisclosure
We,allauthorsofthispaper,statethatwehaveno financialintereststodisclose/declare.
Conflictofinterest
None.
Theremitofthelawisjustmentalhealthcare.
Acknowledgement
None.
References
TheWorldHealthOrganisation.CountryProfile:India.https://www.who.int/countries/ ind/en/. NationalMentalHealthSurveyofIndia,2016.2015-16:Prevalence,Patternand Outcomes.NIMHANSPublication.ISBN:ISBN:81-86478-00-X.. http://indianmhs. nimhans.ac.in/Docs/Summary.pdf .
Gururaj,G.,Varghese,M.,Benegal,V.,Rao,G.N.,Pathak,K.,Singh,L.K.,NMHS CollaboratorsGroup,2016.NationalMentalHealthSurveyofIndia,2015–16. Prevalence,PatternandOutcomes
Demyttenaere,K.,Bruffaerts,R.,Posada-Villa,J.,Gasquet,I.,Kovess,V.,Lepine,J.P., etal.,2004.Prevalence,severityandunmetneedfortreatmentofmentaldisordersin theHealthOrganizationWorldMentalHealthSurveys.JAMA291,258190[PubMed] TheMinistryofHealthandFamilyWelfare,GovernmentofIndia,1987.TheMental HealthAct. https://mohfw.gov.in/sites/default/ files/2077435281432724989_0_0. pdf
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CRPD,U.,2006.ConventionontheRightsofPersonsWithDisabilitiesandOptional Protocol.UnitedNations,NewYork MinistryofSocialJusticeandEmpowerment,2017.GovernmentofIndia:Rightsof PersonsWithDisabilitiesAct.TheGazetteofIndia(Extraordinary)28th December 2016,PartII,Section(I).Canbeaccessedfrom. http://disabilitya ffairs.gov.in/ upload/uploadfiles/files/RPWD%20ACT%202016.pdf
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Kumar,M.T.,2018.MentalhealthcareAct2017:liberalinprinciples,letdowninprovisions.IndianJ.Psychol.Med.40(2),101
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Murthy,R.S.,2018.Futureofmentalhealth.AsianJ.Psychiatr.38,A7–A11
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about resignation and the like of that, and make it out somehow to be the right thing after all."
"But you see there are two aspects of the case, friends," said Mr. Herbert, determined to set himself right with the downhearted villagers in the matter, and aware that what he said would be repeated in many forms amongst them. "There is the side of the human actors in the circumstances which have occurred, and before God and man a great wrong is done, and the widow and the fatherless are oppressed. God is displeased, and will make it felt at the right time and way, so far as the oppressor is concerned; and He does not require us to close our eyes and hearts, and not see and feel with indignation and disgust, as honest, true men should. But as He has not seen it good to interfere and hinder their doings, we are constrained by the knowledge of His word and ways to the conclusion, that in His providence He has something better in view—some yet unseen benefit to work out for His troubled children, which shall far exceed and outvalue all they are losing now. And in this aspect we are bound to cultivate resignation and exercise patience. We are to trust God in fact, and be sure that He will never fail them that trust in Him."
"Amen," said Mr. Spadeley; "and is that the way the poor lady feels about it, sir?"
"Yes, I am glad to say that I have quoted nearly her own words, and what I am sure she wishes all her friends to feel. And it is the right view to take of all the disagreeable things of life when once we take our stand upon the 'Rock of Ages,'—eh, my friends?"
"Very good, sir," said the landlord; "and if one turns to making the best of it, it do seem as if the old place might have fallen into worse hands than Squire Hazelwood's."
"That is true, Mr. Turnbull; he will not let things go to ruin, and perhaps may help forward some of our little plans among his tenantry, so let us hold by God's promises and hope for the best. You know where to find them, for I saw the good old book upon your parlour table the other day. Ana you, Mr. Spadeley, must have much knowledge of them from your position and duties among us."
"Well, sir," said Mr. Spadeley graciously, "I do have to look out for pretty texts for the tombstones often, for you see when the country folk bring no verses of their own composing, and not boasting much of a gift that ways myself, I fall back upon the Bible, and we're sure to come at something comfortable. But that reminds me of poor old Hayes. Have you seen him lately, sir?"
"The gardener at the Moat? Yes, I see him every day, and a more true, simple-hearted believer in our Lord Jesus Christ does not lie ready for the summons home."
"Amen, and right, sir. Well, you see when I knew he wasn't going to get better, I thought I would ask him about his epitaph, for he must have a head-stone, and it shall be a good one, and I naturally wanted something nice to carve on it. And what do you think he chose, sir? It do downright get over me. None of the pretty verses I told him of would do."
"'Chief of sinners,'" suggested Mr. Herbert. "I know he feels like that."
"Well, he did name it, and I said out flat, No, I wouldn't put it; I'd have more words to make my work worth while. So he thought a bit, and then he said, 'Few and evil have the days of the years of my life been,' and there he's stuck
ever since, and I can't move him, so I shall have to do it, I s'pose, for I wouldn't rile a passing spirit."
"And," said the clergyman, "since you don't mind the work, my kind friend, you shall add something to it at my expense whenever the time comes, and it shall be this, 'Blessed is he whose transgression is forgiven, whose sin is covered.' 'Unto Him that loved us, and washed us from our sins in His own blood, be glory and dominion for ever.' I feel sure our dear old brother will not object to that addition."
"Well, he's a real gentleman, our young parson is, though I say it, that's part of the profession in a way," said the clerk and sexton, resuming his pipe, as the clergyman bade them good-night and walked away.
"A real Christian, too, I should say," added Mr. Turnbull; "though they did say he'd been among the Methodies. Never mind that; he's the right sort to comfort the poor lady and her children in their troubles."
"Ah! Poor, dear lady!" ejaculated the sexton. "I mean to beg a last favour of her before she goes, that she'll be sure to come back to be buried in the old vault under the cedars, —for I shouldn't like anybody to do it for her but me, nor for her to lie anywhere but amongst her own kin, and I dare say our parson would like to read the service over her his own self. Good-night, and thank you, landlord; I shall just call in and see how Hayes does to-night, and tell him about the epitaph, and cheer him up a bit."
"Joe," said the landlord of the Falconer's Arms a few days after to his ostler and factotum,—"Joe, we've got to horse the carriage that's to carry away the family from the Moat, d'ye hear?"
"Yes, sir."
"Well, Joe, somebody must drive;" and the landlord smoothed his grey hair, and rubbed it up again, and looked perplexed, while Joe looked stolid.
"Joe, my lad, you must drive them," at last said the landlord, well knowing how hard a task he was setting to one whose whole family and lifetime had been comforted and helped by the kind lady at the Moat.
"Sir, master, don't ye now; I can't do it, indeed I can't. I'd sooner be thrashed." And poor Joe looked almost tearfully earnest.
"So would I, Joe, but I can't do it myself; and after all, it will be better for a friend to do it; they'll feel it less themselves than if I got a stranger, and they always like your driving, Joe; yes, you must do it, that's all about it."
After a pause, during which Joe might have been cogitating the possible consequences of a flat refusal,—
"Which 'osses, master?" said he gloomily.
"The black ones, Joe—black harness and all—just like a funeral. I shan't let my spanking bays go on no such an errand. And if Squire Hazelwood should be here, he'll see mourning, that's all."
"Mourning enough," thought Joe, walking off, and grumbling to himself. "The beautifullest, nicest, best lady in all the country round, and as good a pair of children as ever was set eyes on! What will us do to show our love and our trouble all at once, I wonder? Why, if ever poor Joe gets to heaven, it's cause she taught me the way. And I'm to drive her away from the only home she's got on earth! I wish I
could take her straight to paradise among the angels she's like; wouldn't I! And never come back no more. Well, don't be a fool, Joe, but do your duty as she's bid you; that's the best way to show gratitude and love to her. But if we goes with them old black 'osses' funeral paces, we'll have all the village sobbing round us, and none of us can't stand that. I must drive and whip and shout my best for all sakes, and so you old 'osses must just step out for once."
"It's quite true, Joe," said his particular friend, Jane Spadeley, whom he met quite by accident as he went to look after the black horses in the lower meadow; "Squire Hazelwood has ended the bargain, and they say he's coming as soon as possible, so missus will be off in a day or two."
"But you are going with 'em, I suppose, Jane. As for Squire Hazelwood, I don't want to hear nought about him, but what about the missus, and poor Miss Maude, and Master Guy?"
"Why, Joe, they won't let me go with them, that's my trouble," and Jane's tears began to struggle into her eyes, though all through a trying interview with her mistress she had bravely bidden them back.
"Won't let you go?" said Joe in amazement; for the thing seemed incredible. He would have let her do anything she wished.
"No; and why they won't breaks my very heart to think of. They can't afford to keep a maid to wait upon them now. I've begged and begged, and I've offered to go without any wages, and eat next to nothing, but it's of no use; and missus cried, and took my poor hand as if I'd been a lady, and dear Miss Maude put her arms round me and kissed
me, and we were all in a pretty state, when in burst Master Guy. He looked round for a moment, and though he seemed choking, he said,—
"'Cheer up, mother, cheer up all of you! We'll all come back to the old place some day when I'm a man,' and with a great stamp of his foot, he rushed away again. But it brought us to, and did us good, even to think of such a thing."
"Poor Master Guy! Poor dear lady!" said Joe. "What can we do for them?"
"Why, Joe, she says we can do the very best thing for them all—we can pray for them, and ask that they may say truly and honestly, 'Thy will be done.'"
"It's very hard," said Joe, slashing the grass with his whip, "and goes right agin the grain."
"It's part of the victory, she says," continued Jane, "and must be fought for, and won."
"Gee up, whoa," said Joe, throwing his halter over the neck of one of the calm black horses as he came up with the creature, out of which all frolicsome spirits had long departed. "Thee's got a bit of ugly work to do, so see thee does it kindly."
It was a bit of ugly work, enough to displease all the animal creation of the Falcon Range.
Captain Guy Falconer, the younger son of the late owner of the Moat, had come home from active service with his regiment abroad, to die in the prime of manhood of a neglected wound.
But not before having, both by precept and example, impressed all around him with the conviction that to him "to die was gain," and that his triumphant faith had enfolded the young wife and children whom he must leave behind, and placed them in his heavenly Father's arms, to be cared for, and brought to Him in due time.
And this treasured remembrance now soothed the pain of an uprooting from home and its associations, such as neither she nor her husband had ever contemplated. For the elder Mr. Falconer had long held a lucrative and honourable appointment abroad, and only used his inheritance at home to drain its resources, and to supply his own and his elder son's extravagances, leaving the mansion and grounds to the tenancy of Captain Falconer's family with the impression that the estate must one day follow its long antecedent history by descent in the male line to the lawful heirpresumptive, the only son of Guy and Blanche Falconer.
Mr. Geoffry, the elder son of the now deceased proprietor, had neither inclination nor health for the English climate, hated the responsibilities of a landlord, was childless, and devoid of affection or sympathy for the brother whose interests he did not scruple to set aside, and whose admired and devoted wife he rejoiced to humble and oppress.
The late turn of affairs had revealed something of this to the boy, who had hitherto considered himself born to a respectable though encumbered inheritance, and the tumult of feeling roused within taught him an unexpected lesson upon the very unsatisfactory foundation of earthly hope, and the treacherous failure of human character unsustained by Christian principle.
For Master Guy had found himself in several violent passions, had indulged in more unbecoming language concerning his uncle and grandfather than had ever been heard from his lips before, had flung his lesson books into a corner, trampled down the flowers in his own particular garden, shaken his young fist at the aggravating birds that sang on cheerily among the trees, and exhausted himself in a flood of tears, with his arms clasped round the neck of a sympathising pony.
The ferment of feeling among tenants and dependents did not serve to lessen his disgust and indignation; wherever he went, kind hearts resented, and thoughtless tongues commented, until poor Guy regarded himself as the most injured of mortals, and his own the most blighted of prospects, to say nothing of those of his mother and sister.
In a state of utter self-abandonment, dreading the event of the morrow, hating to think of the last night in the dear old home, the boy had wandered from spot to spot endeared by happy childish memories, until he could bear no more, and as if the tomb would be a desirable end to all his troubles, went last to the quiet resting-place beneath the cedars.
