the implementation of the laws lags behind in various ways, including

the absence of provincial authority responsible for overseeing and

keeping check and balances on the rehabilitation centres

Lack of awareness and knowledge amongst legislature makers. – Cite

schizophrenia case

“Guilty but mentally ill” has been

added to the insanity plea in the USA,
allowing the legal system to monitor
admissions to hospital for patients
with mental illness.

BPS appeal to supreme court: A lack of understanding about schizophrenia means

many patients don’t get the support and treatment they need. It’s a chronic
remitting relapsing illness. Many people recover from it, although they may
have periods when symptoms return, others continue to suffer.

Its causes are not fully understood and there is no cure for it. However,
medications and talking therapies can help manage the condition and people
can live in the community and work.

Suffering from schizophrenia does not necessarily exempt the person from
being prosecuted, but it does need careful consideration by the legal system
about illness and its association with criminality

What is most important is that a court should seek the opinion of a

psychiatrist to evaluate the mental state and capacity of the individual at the
time of the index offence. This will help safeguard the human rights of the
people suffering from mental health problems and help the court reach a fair
verdict.
Road To Recovery- Niha Dagia

‘ It was in 2001 that a Mental Health Ordinance was passed – one, which does not even meet
the criteria set by World Health Organization (WHO). A study suggests that 10 – 20% of the
population of Pakistan suffers from mental health issues, while less than 2% is allocated to it out
of the Health Care expenditure in Annual Budget. Sindh spends about 4.7M out of its 14B health
budget.’

While Mental Health is surrounded by stigmas in our society, acceptance to consider it a

necessity seems nearby. We now have organizations that offer Psychological support; Hospitals
do have Psychiatrists on board even if they haven’t gotten accustomed to providing in-patient
counseling as offered by hospitals abroad

http://nation.com.pk/blogs/22-Oct-2016/supreme-court-s-verdict-on-schizophrenia-highlights-
the-lack-of-awareness-about-mental-health-in

http://nation.com.pk/blogs/30-Oct-2016/supreme-court-s-schizophrenia-verdict-and-the-misuse-
of-mental-health-laws-in-pakistan

https://www.dawn.com/news/1292121

A person suffering from a mental disorder may not be in a position to

rationalise their actions at the time of committing the crime. At the stage of
trial, they may not be in a position to defend themselves. Understanding these
ethical nuances, criminal laws in most countries allow for an insanity plea,
which once proven, can absolve the accused of the crime.

But not every accused who is mentally insane is automatically absolved of all
responsibility for the crime committed. There is a difference between legal
insanity and medical insanity. Medical insanity could include any kind of
mental illness — ranging from permanent disorders like lunacy to temporary
psychosis like bipolar syndrome. Legal insanity demands not only mental
illness but also loss of reasoning power at the time when the offence was
committed. As per the M’Naghten rule, if a mentally ill person had knowledge
that what they were doing was wrong or against the law, they should be
punished for the crime.
In various other judgements of the Indian Supreme Court, it has been
established that in addition to mental illness, aspects like motive for the crime,
previous history in relation to the mental condition of the accused, the state of
their mind at the time of the offence, and the events immediately after the
incident that throw a light on their mental condition (for example, attempting
to hide evidence or absconding to avoid arrest) are also to be factored in.

As soon as a crime is committed, ideally a forensic psychiatrist should get

involved in the case along with the investigating officer. Studying past medical
reports to check on past behaviours or substance abuse, autopsy of the victim’s
body, interviews with the accused and family members are crucial in making a
proper assessment. Unfortunately, we neither have trained forensic
psychiatrists, investigating officers or lower court judges who insist that such
reports be produced during the legal process.

 Conditions inside prisons are also often responsible for worsening the
mental conditions of under-trial prisoners. A study conducted in India in
2011 found that as many as 30% of the prisoners suffered from a mental
disorder and 70% from either a mental disorder or substance abuse. The
lack of legal education and the high proportion of under-privileged among
under-trials further hamper the chances of getting an insanity plea.

Pakistan is a signatory to the International Covenant on Civil and Political

Rights, which urgesstates practicing death penalty to not impose it “on a
person suffering from any mental or intellectual disabilities or to execute any
such person

https://www.dawn.com/news/1291599

Stressing the need for proper mental health assessment and regulation in
prisons, he said: “It is imperative on the government to authorise an official
team of certified psychiatrists to access patients admitted to forensic
psychiatric settings to assess their mental stability for rightful legal
judgement.’’

Psychosis is the most common illness suffered by prisoners; schizophrenia,

clinical depression, personality disorders and addiction are dominant behind
bars. These disorders require frequent check-ups and take time to cure,’’ said
Dr Ajmal.
With the exception of the Central Prison Karachi, other prisons, including the Landhi
jail, female and juvenile prisons, are deprived of a separate psychiatric ward and are yet
to be assigned a consultant for regular visits.

Sindh happens to be the only province to have passed a legislative act that
integrates psychiatric health with the criminal justice system. “The
stigmatisation of mental illness is rampant in society and is in dire need of a
law that protects mental health on a federal level,’’ said Dr Haroon Ahmed,
senior psychiatrist heading the Pakistan Association for Mental Health.

https://www.dawn.com/news/1293240

Amber Darr

At each step in the proceedings, Ali and then his wife pleaded his insanity, first
as a defence and then as a ground for delay of execution. In terms of Section
464 of the Criminal Procedure Code, if on consideration of the evidence of an
independent medical examiner, the trial court had formed the view that Ali
was of unsound mind — ie his judgement was sufficiently impaired to prevent
him from understanding the nature or legal implications of his act — then
under Section 84 of the Penal Code he could not have been held liable for
murder. At each step, however, the courts formed and affirmed the view that
despite his illness, Ali was not entitled to take this plea.

Presently, Pakistan has no recognised authority either for ensuring the welfare
of patients or addressing the concerns of psychiatrists, even in an emergency.

Government facilities for mental patients are limited at best. The large
number of private in-patient facilities are not registered with any authority
and, therefore, unaccountable for the quality of their performance.
Consequently, not only does the care of patients remain the responsibility of
their relatives but they are also vulnerable to abuse at the hands of
charlatans.[Can mention kemari case of teenage patient who was admitted by
his father for the 3rd time in the year as a punishment because of outbursts
owing familial stresses. He wanted to study further and had anger
management issues. He said he had physically attacked his father once.
Seemed functional at the time.]

Given the situation, it falls to the courts to devise guidelines to balance the
need to protect a person who is innocent but unfit to defend himself due to
unsoundness of mind, and the need to protect the public from a person who
has committed an act which would be a crime if it had been done with the
requisite intention.

The UK Mental Health Act 1983 provides a precedent for striking such a
balance. In terms of this law, if the sanity of an accused is questioned in any
proceedings, he may be remanded to a hospital for evaluation or treatment
and the trial may only proceed once he has recovered. Only in more serious
mental health cases, does the question of fitness to defend arise.

The Court of Appeal of England & Wales has also laid down guidelines in R. v
Bird (1990) for cases in which it becomes necessary for the court to sentence a
mentally disordered person. It stipulated that in arriving upon a decision in
this regard, courts should consider whether the offender is sufficiently
dangerous and culpable to a degree that merits a custodial sentence or
whether it may be more appropriate to commit him to a hospital for treatment
along with a community sentence.

Disappointing as the SC’s assessment of paranoid schizophrenia and its

inability to consider Imdad Ali’s welfare along with his culpability may be, the
greater danger lies in the fact that courts subordinate to the SC may rely upon
this judgement as a precedent in determining other similar cases.
This merely increases the responsibility of the judiciary to address future cases
involving the mentally ill with greater sensitivity and to devise legal tests for
determining their liability under criminal as well as civil laws, so that guilty or
not, the mentally ill may be treated with the dignity and compassion that is
their legal and human right.

https://www.dawn.com/news/1255249

Implementation of the Mental Health Act; are we ready?

Raza-ur-Rahman,1Mohammad NaimSiddiqi,2 Syed Haroon Ahmed3

On 10 April 2015, Sindh

assembly passed an amendment that a person who
attempts to kill himself or be accused of blasphemy
should be examined by a psychiatrist and given treatment
if found suffering from a mental illness.

the present health care

systemchallenges will be faced in implementing theMHA
because A) there is no organizational or structural
representation of mental health within the Ministry of
Health hierarchy B) In the pyramidal model of health care
system starting with primary health care at the bottom,
the referral process is inefficient and patients are usually
taken by their families directly to tertiary or specialist
hospitals, rather than to primary-care practitioners.10 C)
the organization of health system in relation to psychiatry
is not uniform e.g. a substantial proportion of the mental
health services are provided by the private sector that
stands as isolated units and have no operational link with
Health Care System.11 D) community psychiatry is viewed
as 'outreach' services from psychiatric facilities and the
application of public health principles to mental health
services has not been tried.

---> One of the solutions could be the formulation of a uniform

mental health programme for Sindh province and fully
integrate it into a decentralized general health care
system. This will require lots of convincing and reshuffling.

http://nation.com.pk/national/25-Jul-2010/female-researcher-freed-from-
illegal-detention
Farzana Panhwar, reknowned researcher was illegally detained by her brother,
stepson into a private psychiatric facility, even after she was declared fit by the
doctors who were overseeing her treatment for the past 11 years.--> Private
psychiatric facilities need to be regularly visited, to keep a check and balance
on the implementation of the rules and to prevent such events from
happening.

Five years since passage of law, Sindh

notifies Mental Health Authority
https://www.dawn.com/news/1355837 /
https://www.dawn.com/news/1313829

The Sindh Mental Health Authority has a functioning board, with lawyers,
psychiatrists etc but there needs to be either recruitment of more doctors to
the board of visitors to pay frequent visits to mental health facilities. Possibly
involve young blood.
[The Board of Visitors would inculde a chairperson who is or has been a judge
of the high court; two psychiatrists, one having a minimum of 10 years’
experience in government service; and one prominent citizen of good
standing.]

SMA should establish a regulatory body of young doctors/body of people

under them to frequent psychiatric facilities regularly, eg fortnightly, in order
to ensure efficient implementation of the SMA act.

Suicide helpline??
Mental health awareness via print/electronic media

Problems-Solutions:

-Lack of implementation of the SMHA-5 years passed

-No mental health social services, eg suicide helplines

-Lack of awareness regarding mental health

Solution: Use of print-electronic media to highlight mental health issues.
-Private and public sector mental health facilities operate independently with no check and
balance.
Solution: Integrate all psychiatric facilities, both public and private into a holistic system, on a
Sindh level. Will ensure better regulation of laws, management and functioning and idea of
performance.

-Illegal detention or admittance to psychiatric facilities by relatives to usurp property->

Farzana Panhwar case*
Solution: SMHA body should set up frequent visits to psychiatric facilities in order to ensure
implementation of the act. Could possibly involve young doctors with less buereaucratic
responsibility to visit facilities, for eg fortnightly.
Definetly need to recruit more members or establish a regulatory body under the main body.

Government facilities for mental patients are limited at best. The large number of
private in-patient facilities are not registered with any authority and, therefore,
unaccountable for the quality of their performance. Consequently, not only does the care
of patients remain the responsibility of their relatives but they are also vulnerable to
abuse at the hands of charlatans.

-Mental health-care facilities for prisoners, including a proper follow-up or rehabilitation

system, are completely
absent in Pakistan.

It is imperative on the government to authorise an official team of certified psychiatrists

to access patients admitted to forensic psychiatric settings to assess their mental
stability for rightful legal judgement.’’

With the exception of the Central Prison Karachi, other prisons, including the Landhi
jail, female and juvenile prisons, are deprived of a separate psychiatric ward and are yet
to be assigned a consultant for regular visits.

-There are no mental health facilities at the primary health care level, most neglect is seen in
rural areas.
Solution: Appointment of mental health practitioner to primary care centres. Like lady health
care workersPsychiatric social workers
-Lack of specialist psychiatrists and services; Forensic, Addiction etc

Solution:-

-Lack of proper teaching mental health issues to Pakistani lawyersSchizophrenia case of

Imdad Ali

- mental health cases would need formation of tribunals. For higher level of
independence and
impartiality of these tribunals, it would be ideal if these tribunals are formed and
regulated by the Judiciary. But in a country where the judicial system is already under a
lot of pressure for quick decision and disposal of pending cases it could be difficult
especially when high turnover of complaints from detained patients, is expected.
Therefore an urgent dialogue is essential between representatives of mental
health profession and legal fraternity to ensure the availability of trained mental
health professionals and advocates for assistance of mentally ill patients.
Establishment of such facilities in Sindh is strongly recommended for better
implementation of Mental Health Act.

-The argument that Mental Health is not only a 'Health issue' but it also has 'social' and
'occupational' component does carry a lot of weightage. Therefore, a) We should remind
the legislators of the current Sindh Mental Health Act their responsibility to provide the
necessary resources (finances) for implementation of the act and b) Build a case that it
should not be the sole responsibility of the health
department to finance mental health care but the Social Welfare department, Finance
department and Local Government should also contribute and take their share
of responsibility.22

CHAPTER-VII
PROTECTION OF HUMAN RIGHTS OF MENTALLY DISORDERED PERSONS
49. A person who attempts suicide shall be assessed by an
approved psychiatrist and if found to be suffering from a mental
disorder shall be treated appropriately under the provisions of this Act NO IMPLEMENTATION