Psychiatric health laws in Pakistan: from lunacy to mental health.

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The South Asian country of Pakistan is the sixth most populous nation in the world.
Although modern-day Pakistan came
into being only 58 years ago, it is heir
to a rich historical heritage spanning
thousands of years, fi rst records of
which date back to the 4,000-year-
old Indus valley civilization. The
sociodemographic and socioeconomic
characteristics of Pakistan today
are shown in Table 1; the major
features are a high fertility rate, a
correspondingly large, young, and
predominantly rural population, and a
poor economy.
One of the major health-care
problems of the country is mental
illness. A systematic review of risk
factors, prevalence, and treatment of
anxiety and depressive disorders in
Pakistan found that the overall mean
prevalence of these disorders in the
community was 34% (range is 29%–66%
for women and 10%–33% for men)
[1]. Factors positively associated with
these disorders were female sex, middle
age, low level of education, fi nancial
diffi culty, being a housewife, and
relationship problems—suggesting that
social factors play an important part in
the aetiology of anxiety and depression
in Pakistan. Other major mental health
problems are developmental disorders,
psychosis, and drug abuse, although
credible estimates for these are lacking.
Islam plays a major role in
determining the value system of
Pakistani society. On the one hand,
society is generally contemptuous of
and biased against individuals who are
mentally ill [2,3]. On the other hand,
good treatment of individuals who are
mentally ill is deemed greatly desirable
under the society’s strong religious and
ethical values.
In this article, we examine the
infrastructure of mental health services
in Pakistan and the Pakistani laws that
govern treatment of individuals who
are mentally ill. We look critically at
how these laws have changed over
time. Changes in these laws refl ect
deeper changes in Pakistani society’s
attitude towards individuals who are
mentally disordered. We stress the
need for further improvement in these
laws and suggest that Pakistani mental
health laws should meet international
standards for the treatment of mentally
ill people.
Mental Health Infrastructure
There are many players and factors
involved in the access, provision,
delivery, functioning, and uptake of
mental health services in Pakistan
(Figure 1; Table 1). Awareness about
Policy Forum
Open access, freely available online
November 2005 | Volume 2 | Issue 11 | e317
The Policy Forum allows health policy makers around
the world to discuss challenges and opportunities for
improving health care in their societies.
Psychiatric Health Laws in Pakistan:
From Lunacy to Mental Health
Ahmed Ijaz Gilani*, Umer Ijaz Gilani, Pashtoon Murtaza Kasi, Murad Musa Khan
Citation: Gilani AI, Gilani UI, Kasi PM, Khan MM (2005)
Psychiatric health laws in Pakistan: From lunacy to
mental health. PLoS Med 2(11): e317.
Copyright: © 2005 Gilani et al. This is an open-access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original author and source
are credited.
Ahmed Ijaz Gilani is in the Department of Basic
Health Sciences, Shifa College of Medicine, Islamabad,
Pakistan. Umer Ijaz Gilani is an intern at Orr Dignam
and Company Advocates, Islamabad, Pakistan.
Pashtoon Murtaza Kasi is a medical student at Aga
Khan University, Karachi, Pakistan. Murad Musa
Khan is in the Department of Psychiatry, Aga Khan
University, Karachi, Pakistan.
Competing Interests: The authors declare that no
competing interests exist.
*To whom correspondence should be addressed.
E-mail: aigilani@yahoo.com
DOI: 10.1371/journal.pmed.0020317
DOI: 10.1371/journal.pmed.0020317.g001
Figure 1. The Players and Factors Involved in the Access, Provision, Delivery, Functioning, and
Uptake of Mental Health Services in Pakistan
(Image: Aslam Bashir, Aga Khan University)

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mental illness is still poor in Pakistan.
Such illness is generally attributed to
supernatural causes—it is considered to
be a curse, a spell, or a test from God.
Those who experience mental
illness often turn fi rst to religious
healers, rather than mental health
professionals, since patients and their
families tend to have great faith in
these healers. Religious healers use
verses from the Koran to treat patients.
Next, patients turn to traditional
and alternative healers, who are also
popular in Pakistani society.
Help from the mainstream health-
care system is usually sought late in
the course of the illness. In Pakistan’s
health-care system, a pyramidal model
is followed, starting with primary
health care at the bottom (Figure
2). However, the referral system is
ineffi cient and, particularly in the
case of individuals who are mentally
ill, patients are usually taken by their
families directly to tertiary or specialist
hospitals, rather than to primary-care
practitioners. It is, however, important
to note that many mental illnesses can
be treated and managed by primary-
care practitioners. The private sector
also plays a major role in providing
psychiatric care. For those who can
afford it, private psychiatric care is an
option frequently used.
Recent Improvements in Provision
Pakistan has come a long way since
it gained its independence in 1947,
when there were only three psychiatric
hospitals in the country. Today around
20 medical colleges support psychiatric
wards. At the moment, there are some
4,100 beds in the public and private
sector and about 342 practicing
psychiatrists, mostly located in major
cities (Table 1) [4]. Behavioural
sciences and psychiatric training form
an essential part of undergraduate
medical training.
The National Mental Health
Programme, developed in 1986, aims
at achieving universal provision of
mental health and substance-abuse
services by incorporating them
into primary health care. Via this
programme, primary-care physicians
are being trained, and training manuals
are being developed for lady health
visitors (a type of health worker who
provides a variety of services to urban
and rural communities, including
basic nursing care, maternal and
child health services, and training of
community workers [5]). In addition,
junior psychiatrists are being trained
in community mental health. The
importance of including spiritual
healers in the mainstream health-
care and referral system has also been
recognised by the National Mental
Health Programme, as they are
frequently the ones having fi rst contact
with individuals who are mentally ill.
Pakistani Law and Mental Illness
The law has important implications
for the lives of all citizens, including
those who are mentally ill. The laws
governing the treatment of mentally
ill people give a clear indication of a
country’s attitude towards such people.
The relationship between a society’s
attitude and the law is a dynamic one,
and a two-way affair.
In Pakistan, until 2001, the major
source of laws relating to individuals
who are mentally ill was the Lunacy
Act of 1912 [6] (Box 1), enacted by
the colonial government, at the time,
for the whole of British India. After
the partition, Pakistani law continued
to be based on the relics of its colonial
past, although sporadic changes
were brought about in the light of
drastically changed conditions and the
requirements of an Islamic republic.
The Lunacy Act of 1912, however, like
most other laws, remained in effect,
despite occasional protests by the
medical profession and society at large.
On February 20, 2001, the Pakistan
Mental Health Ordinance came into
effect [7]. The Lunacy Act of 1912
consequently stood repealed. The
2001 ordinance has brought about
signifi cant changes in the law “relating
to mentally disordered persons with
respect to their care and treatment
and management of their property
and other related matters” [7], as the
preamble of the ordinance boldly
proclaims.
The ubiquitous presence of
ordinances is a peculiar feature
of Pakistani law. Ordinances are
presidential orders, tantamount
to valid law, passed in emergency
situations or in the absence of a
sitting Parliament. Theoretically,
they lapse after three months if
opposed by an act of Parliament. In
reality, ordinances form an important
part of Pakistani law, and like the
Pakistan Mental Health Ordinance,
Table 1. Socioeconomic and Demographic Variables and Psychiatric Facilities in Pakistan
Category Variable Value
Sociodemographics [14] Population 153.7 million people
Fertility rate 4.14 children born/woman
Percent of population that is rural 66.98%
Infant mortality rate 90 deaths per 1,000 infants born
Number of people in average household 6.5 people
Literacy rate 59% males; 35.4% females
Socioeconomics Gross domestic product US$347.3 billion
National debt US$33.9 billion
Annual per capita income (purchasing
power parity)
US$2,200
Proportion of GDP spent on health 0.7%
Proportion of GDP spent on mental health Not determined
Mental health facilities [4] Total number of psychiatric beds 4,100
Number of registered psychiatrists
(in the year 2000)
342
Number of registered neurologists 210
Number of registered psychologists 450
Please see http://www.pak.gov.pk for more information.
GDP, gross domestic product.
DOI: 10.1371/journal.pmed.0020317.t001
November 2005 | Volume 2 | Issue 11 | e317
Box 1. The Lunacy Act of 1912
The Lunacy Act [6] was enacted in
1912 for British India. Until recently,
it was the most important piece of
psychiatric legislation in Pakistan. The
statute is divided into four major parts
dealing with defi nitions of crucial terms,
rules pertaining to reception, care,
and treatment of individuals who are
mentally ill, and procedural rules for
establishing whether or not an individual
is mentally ill. Even a cursory glance at the
statute reveals it as woefully inadequate
and obsolete for the needs of a modern
state. In 2001, the act was replaced by the
Pakistan Mental Health Ordinance [7].

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permanently hold as much legal value
as any act passed by Parliament.
How Did the 2001 Ordinance
Change the Law?
Before 2001, one of the most striking
features of the Pakistani law regarding
mentally disordered people was the
sustained usage of archaic, imprecise,
and often undefi ned terms. The
term “lunacy” is a classic example
because, despite being shunned by
the psychiatric profession for being
inhumane and imprecise, it still
formed a part of the outdated Lunacy
Act’s title and was used, along with
its derivatives, throughout the act.
Lunatic was defi ned as “an idiot or
person of unsound mind” (section
4), a defi nition that, on account of its
vagueness, has also given rise to much
case law [8,9].
The 2001 law has discarded such
outmoded and imprecise terms as
“lunatic”, “criminal lunatic” (an
oxymoron, given that “lunatics”
cannot be held responsible for their
acts), and “asylum”, and has provided
its own more comprehensive set of
defi nitions. The ordinance uses the
term “mental health” as a part of its
title and defi nes the converse—mental
disorder—as “mental illness, including
mental impairment, severe personality
disorder, severe mental impairment,
and any other disorder or disabling
of mind…” (section 2(1)(m) of [7]).
For all of these categories of mental
disorder, comprehensive defi nitions
have also been provided. For example,
severe personality disorder is described
in the 2001 law as persistent disorder
or disability of mind (whether or not
it includes signifi cant impairment
of intelligence), which results in
abnormally aggressive or seriously
irresponsible conduct on the part of
the person concerned.
The term “mentally disordered
prisoner” replaces “criminal lunatic”;
similarly, instead of “asylum”, “health
facility” and “psychiatric facility”
are used wherever suitable. A very
pragmatic step forward has been
the introduction of a defi nition of
“informed consent” for treatment. In
light of the new defi nition, consent
would only be considered valid when
it is informed, that is, when the patient
(or guardian or nearest relative, in
case of a minor) has been adequately
informed of the purpose, nature, likely
effects, and risks of the treatment,
including the likelihood of its success,
any alternative, and the costs to be
incurred. By addressing this pertinent
issue, an important gap in the law has
been bridged.
Terminology deeply refl ects the
mood of those who use it. The
adoption, by Pakistani society and law,
of more scientifi cally appropriate,
precise, and humane terms indicates
that a more empathetic attitude has
replaced an earlier attitude of summary
dismissal and a lack of understanding
towards individuals who are mentally
disordered. This is, indeed, a positive
development.
An important development
brought about by the new law is the
establishment of the Federal Mental
Health Authority, comprising seven
“eminent psychiatrists of at least 10
years standing” (section 3(3)(v) of
[7]) and seven other members, largely
bureaucrats. This body has been given
the responsibility of overseeing the
state of mental health provision in the
country, setting up national standards
of care and treatment, and performing
a host of other tasks.
But instead of making immediate
changes needed by the mental health
system of the country, this authority
makes only promises. Its objectives are
long term and to an extent vaguely
defi ned. The effect that this institution
will have on the lives of individuals
who are mentally disordered is hard
to judge from what the law says about
the institution; the effect depends,
rather, on how the institution
performs in the future.
Fewer Days of Forced Detention
Under the Lunacy Act of 1912, the
combined effect of sections 13–16
was to allow the detention of people
alleged to be “lunatics” for a period of
ten days, extendable by the magistrate’s
permission to a maximum of 30 days,
before an actual inquiry was held to
establish the detainee’s mental status.
Given the rampant corruption and
widespread abuse of power endemic in
the Pakistani legal system, this provision
was bound to be exploited. The recent
trend in legal reform in Pakistan has
been towards restricting police powers
of arrest and detention. This trend
refl ects the realisation that the police
have a reputation for abusing their
powers.
In the new 2001 ordinance, section
19(2) clearly limits the period of forced
detention under the above-mentioned
circumstances to a maximum of
72 hours. During this time period,
examination by a psychiatrist or the
psychiatrist’s nominated medical
offi cer has to be ensured, and necessary
arrangements must be made for
starting care and treatment. It is hoped
that this will prevent the widespread
abuses of the law that often occurred
before 2001.
A patient who is mentally ill on
leave from a psychiatric facility may
be ordered to be brought back by the
magistrate in the area on the advice of
the treating psychiatrist.
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DOI: 10.1371/journal.pmed.0020317.g002
Figure 2. The Usual Model of Seeking Help for Mental Health Illnesses in Pakistan
(Image: Aslam Bashir, Aga Khan University)

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Criminal and Civil Liability
One of the most important legal
issues that arise with regard to
people who are mentally disordered
is the issue of the extent of criminal
and civil liability. In British law, for
instance, individuals who are mentally
disordered qualify for the “defence of
insanity and automatism”, which leads
to a legally stipulated reduction in
their liability for criminal offences (see
Book 4, chapter 2 in [10]). Similarly,
in Pakistani civil law, individuals
who are mentally disordered do not
have the capacity to enter into valid
contracts and, hence, cannot be held
liable for breach of contract (section
3(3)(v) of [7]).
The new ordinance, just like its
precursor, leaves the crucial question
of the extent of criminal and civil
liability of people who are mentally ill
unanswered, which means that the law
on this matter has to be derived from
other sources of criminal and civil law.
The new ordinance, therefore, has had
no bearing whatsoever on one of the
most crucial questions of law pertinent
to individuals who are mentally
disordered: how will it be determined
that someone is or is not mentally
disordered?
Human Rights
The latter half of the 20th century
has seen the rise of the doctrine of
human rights. Chapter VII of the new
ordinance concerns the protection
of human rights of persons who are
mentally disordered, and in this
manner, it is a great advance. Besides
stressing the requirement of informed
consent, it grants patients the right to
confi dentiality, stipulating, “No patient
shall be publicised nor his identity
disclosed to the public through press
or media unless such person chooses to
publicise his own condition.” Moreover,
suicide, per se, is not to be considered
a sign of mental illness, though persons
attempting suicide must subsequently
be assessed by an approved psychiatrist
to ascertain their mental status.
A list of four distinct offences has
been created by section 52 (chapter
VIII) of the ordinance. These
crimes are (1) wilfully making false
statements so as to discredit someone
as mentally disordered, (2) negligence
of a manager of the estate of a person
who is mentally disordered or such
person’s refusal to submit accounts,
(3) ill treatment of a patient by the
staff of a psychiatric facility, and (4) ill
treatment or exploitation, including
the traditional practice of induced
microcephaly (Box 2), of any person
who is mentally ill by members of the
public at large. Punishments have been
prescribed for these criminal offences,
which include fi nes and imprisonment
ranging from six months to fi ve years.
Doctors Are Not above the Law
The section of the new ordinance most
relevant to the psychiatric profession,
perhaps, is section 56 (chapter XI),
which deals with specialised psychiatric
treatments. It stipulates that all
electroconvulsive treatments shall
preferably be administered under
general anaesthesia and advised by a
psychiatrist, not a medical offi cer or
anyone else, and that the reasons for
not using other available methods must
be recorded.
Also, contrary to popular clinical
practice, the ordinance states that
“administration of long acting anti-
psychotic depot injections shall only
be carried out upon the advice of
a psychiatrist for a period specifi ed
in the prescription and such cases
shall be reviewed periodically”. Such
stringent measures can help prevent
excesses being committed by the
profession, though, at times, these
restrictions might be found to be
overly rigid. Finally, the most stringent
controls have been placed on the
practice of psychosurgery, obviating
any possibility of it being performed,
except when found to be absolutely
crucial by a comprehensive, stipulated
panel of doctors.
Together, the introduction of
these measures shows the attention
that has been devoted towards
streamlining the provision of medical
help for individuals who are mentally
disordered and towards bridging the
gaps in the law. The fl ip side may be
that such detailed legislation might
open the fl oodgates to those who wish
to sue psychiatric professionals, though
it is likely that such litigation will be
rare. There is a lack of professional
expertise regarding cases of personal
injury caused by medical negligence.
Another factor that makes litigation
rare is the strong traditional belief in
predestination—the belief that ill fate
or death is fi xed, and thus someone’s
negligence cannot effect it to a large
extent.
The Road Ahead
The recent changes in the law do
signify its dynamic nature. The law’s
response to changed social and
professional attitudes, in the form
of the new ordinance, though much
belated, is a fi tting one. But, as we have
indicated in this article, many gaps in
the law still remain. Also, steps such
as the establishment of the Federal
Mental Health Authority can only be
judged by performance over the course
of the coming years.
We fi rmly believe that the road ahead
in the mental health laws of Pakistan
also lies in seeking to comply with
international standards. Despite the
progress made in comparison with the
old law, the current law still falls short
of standards in relevant international
conventions.
The Universal Declaration of Human
Rights [11] and its extension with
regard to individuals who are mentally
disabled—the Declaration of the Rights
of the Mentally Retarded [12]—can
be useful guides to action. Briefl y put,
the latter declaration makes seven
guarantees to individuals who are
mentally disordered: (1) equal rights to
the maximum degree of feasibility; (2)
proper education, care, and treatment
for self-development; (3) the right
to economic security and a decent
standard of living; (4) the right to live
with one’s own family or the closest
possible alternative; (5) the right to
a qualifi ed guardian, if necessary;
(6) protection from exploitation,
Box 2. Induced Microcephaly:
The Making of “Rat Children”
According to a legend, infertile women
are blessed with children when they pray
at the shrine of Shah Dola, a saint buried
in Gujrat, Pakistan. But the fi rst-born child
in such situations, says the legend, is
always microcephalic and must, therefore,
be handed over to the custodians of
the shrine. The microcephalic children
(the “rat children” of Shah Dola) are
severely handicapped both mentally
and physically, but are considered close
to God and, thus, are given charity. It is
alleged that this phenomenon is actually
the work of criminal gangs, who use
iron rings to induce microcephaly in
otherwise healthy infants to exploit them
as beggars [13].
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abuse, and degrading treatment, and
restricted civil and criminal liability;
and (7) the right that any restriction of
rights must be legally monitored, must
not be arbitrary, and must be subject to
appeal and periodic review.
Although these conventions cannot
be incorporated into our domestic
law, per se, they do provide standards
that we must strive to meet. The
recent ordinance has brought us one
step closer to such compliance. But
many problems still remain, so it has
become ever more important that the
law be subjected to periodic review
by a team of experts who measure
its performance with reference to
the above-mentioned standards, and
suggest the necessary reforms. �
Acknowledgments
The authors are indebted to Unaiza
Niaz, Umama Naeem, and Abdul Wahab
Khan for their inspirational teaching of
psychiatry. Thanks are also due to Ajmal
Rizvi (Multimedia Designer, Aga Khan
University) for his fi nal help on the fi gures.
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