Situational Analysis of Forensic Mental Health in Bangladesh


 Forensic Mental Health in Bangladesh is an unattended domain of mental health services. With about 17% of the population suffering from mental disorders per year and more than 80 thousand prisoners in the country, there have not been any studies to look into forensic mental health situations. This research has given an overview of the health and legal systems through qualitative research focusing on a desk review and key informant interviews. Findings show that though there are guidelines in the law and regulatory codes in the judicial systems, implementing those guidelines is not seen in many cases. There are several areas in the health system in terms of capacity, service and resources which needs to be addressed by the government for supporting the healthcare providers, lawyers, judges and mentally ill or disabled people. Our study also portrayed the current referral mechanisms connecting both legal and health systems while addressing different cases of forensic mental health. Finally, discussing the implications of the findings, we presented recommendations from our study and other literature.


Introduction
Bangladesh, a densely populated country in Southern Asia, has achieved several achievements in health outcomes, such as increasing family planning, vaccination rates, and sanitation and decreasing maternal and neonatal mortality and deaths from communicable diseases (Director General Health Services, 2018a). However, mental health and related systems in the country are yet to progress further to ensure health and promote wellbeing for its 162 million population. While currently, 16.8% of adults and 13.6% of children suffer from mental disorders (Director General Health Services, 2019b), the country is spending approximately 0.08 USD per capita on mental health, which is only 0.05% of its health budget (Director General Health Services, 2018a;World Health Organization, 2020).
With an estimated 260 psychiatrists (0.16 per 100,000 population), 700 nurses (0.4 per 100,000) and 565 psychologists (0.34 per 100,000), the mental health services are concentrated in major urban areas and highly dependent on a few hospitals in Dhaka -the capital city of the country. However, with a widespread stigma among the people (Ahmed et al., 2015;Hossain, 2018;Islam & Biswas, 2015) and professionals (Barn, 2008) in the country, the accessibility to mental healthcare is low in general people (Firoz et al., 2006;Nuri et al., 2018). The situation may worsen for prisoners whose healthcare facility is often overlooked (Rahman & Ali, 2018). There are 67 prisons in Bangladesh in which the number of central jails and district jails are 12 and 55, respectively. The central jails are located in the divisional cities, and the capital city has four of those. The capacity of the jails in the country is about 42,450 prisoners (World Prison Brief, 2021). However, 80 to 90 thousand prisoners live in jails (Ferdousi Sultana Begum, 2016).
With a pluralistic health system in Bangladesh (Organization, 2015), all healthcare services are managed and supervised by the Directorate General of Health Services (DGHS) under the Ministry of Health and Family Welfare (MOHFW). The well-organized court system is a replica of the British judicial system, which was widely accepted in the original constitution of Bangladesh (Panday & Hossain Mollah, 2011). Several laws, codes, and regulations address the health and wellbeing of the prisoners (Government of the People's Republic of Bangladesh, 2006Bangladesh, , 2018 People's Republic of Bangladesh, 1860Bangladesh, , 1898Bangladesh, , 2007. However, very few studies (Every-Palmer et al., 2014;Mullick et al., 1998;Rahman & Ali, 2018) focused on the health situation of the prisoners in the country, and none focused on forensic mental health. The need to improve forensic mental health has been long recognized in developed countries (Cohen & Eastman, 2000;Nakatani, 2011). Forensic mental health is defined from both legal and health perspectives (Mullen, 2000). It is an area that addresses both assessment and outcomes of the mental illness and disorders with the help of the health system among the offenders identified by the legal system and ultimately determines the legal outcome based on the health outcomes of the individuals.
Understanding the situation of forensic mental health in the country can benefit both health and legal systems to enhance the services, practice and roles of the actors related to the systems. Our study thus aimed to capture the current situation of forensic mental health in Bangladesh, focusing on the rules, regulations, practice, gaps and opportunities in both health and legal systems.

Methods
The study was a multi-method study comprising of a desk review and qualitative research method. For the desk review, we adopted a two-fold approach: 1) we searched a local online database named Bangladesh Journal Online and two international databases called PubMed and Google Scholar, 2) we searched local websites for relevant laws, legal acts and guidelines.
The keywords we used for searching were 'forensic', 'mental health ', 'psychiatric', 'prisoner', 'lunatics', 'jail', 'medico-legal' and Bangladesh. We followed the COREQ guidelines (Booth et al., 2014) to collect the qualitative data. Two of the authors (ZA and SS) interviewed five key informants: three from the health system and two from the judicial system. One of the interviewers was a full-time researcher at LifeSpring Consultancy Limited, trained on Public Health research, and the other was a Psychologist by training; both were male.
The respondents were selected purposively based on their relevant background, affiliation with the topic of interest, experience and availability. They were contacted over the phone to communicate the research objectives, rationale and schedule a time for the interview. We used a semi-structured guideline as a tool for the interviews; the desk review informed the questions in the guideline, and we piloted the guideline with one psychiatrist. Three of the interviews were done face-to-face at the respondents' offices, and two were conducted over the Zoom platform. No repeat interviews were carried out. All interviews were digitally audiorecorded with the prior consent of respondents, transcribed and coded. The characteristics of the participants are as follows: We used the framework approach method (Pope et al., 2000) to analyze qualitative data from the interviews and conducted a thematic content analysis (ZA). After coding and developing themes (ZA, SK) from the transcripts, we moved towards the interpretation (ZA, YA).

Results
We presented the results based on the points that emerged from the desk review and the themes obtained from the qualitative data analysis. Existing laws and regulations and the classification of cases are described based on the review of the legal documents. Academic learning and studies or projects on forensic mental health are portrayed based on both desk review and thematic analysis. Public organizations and services, treatment procedures, cost of treatment, referral and reporting systems, security of cases, gaps and recommendations regarding forensic mental health are the major themes identified from the qualitative data analysis.

Existing laws and regulations
Several acts in Bangladesh address and mention cases related to forensic mental health. Different acts and rules mentioned the cases of forensic mental health in different terms. To present the findings from the review of legal documents, we have mentioned the terms precisely as they were used in the relevant document. For the rest, we referred to the cases as 'forensic mental health patients' while describing our findings from the interviews.
The latest law was enacted by repealing the Lunacy Act, 1912(Act No. IV of 1912 and was named the Mental Health Act, 2018. The law addressed the duties and responsibilities of relevant actors for mentally ill and mentally disabled people befitting the current need as much as possible. It ensured the provision of health care, protection of dignity, property rights, and rehabilitation, and overall welfare of persons suffering from mental health problems.
The penal code, which is the main criminal code of Bangladesh, is based on the penal code of the British Indian Empire enacted in 1860 by the Governor General-in-Council in the Bengal Presidency. No person within Bangladesh is punishable without the provisions under the panel code. Section 84 of the penal code, where general exceptions of punishments are mentioned, said that if a person cannot understand the nature of his/her act due to 'unsound mind', it would not be considered an offense. A similar rule is also mentioned in the Code of Criminal Procedure, which lay down the procedure for hearing, punishing or acquitting an accused. It came into force on the first day of July 1898. However, regarding defense, section 98 mentions that any person has the same right of private defense against a person of an unsound mind, which he would have if the offender were someone with a sound mind. Suppose any person abets in the commission of suicide of an insane or delirious person. In that case, the act is punishable with death or imprisonment of life, or imprisonment for a term not exceeding ten years, and shall also be liable to fine.
The Jail Code contains the rules for the Superintendence and management of jails in Bangladesh. Its acts and regulations regulate the establishment and management of jails, the confinement and treatment of persons therein, including the lunatics and the like, and the maintenance of disciplines amongst them. When a mentally ill person is accused of criminal activity and detained, the rights of such persons will be followed as per the provisions mentioned in the jail code after detainment by authority or court.
Rules and regulations related to forensic mental health patients in the abovementioned documents are portrayed below:

Rights of mentally ill citizens
The mental health act states that the law requires the state to ensure the rights of treatment, property, dignity, and education for the people affected by mental illness. Also, the penal code says that nothing is an offence done by a person who, at the time of doing it, because of the unsound mind, is incapable of knowing the nature of the act unless the outcome of the act is causing grievous hurt or death. The penal code also mentions that anyone abetting the suicide of an insane person shall be punished with death or life imprisonment. The Code of Criminal Procedure states that if an accused person is found to have an unsound mind and incapable of making his defense, s/he can be released by the court or magistrate, ensuring proper security of the person and others and his/her appearance when required.
"If an accused person is seen to become unsound for a transitory period, then the court may direct to recover his soundness, and till that time the trial shall be postponed."

Treatment for mentally ill citizens
The mental health act also dictates that the government can build hospitals or units in the district hospitals to treat mentally ill people. It notably stated that there should be separate arrangements in such facilities for mentally ill persons who are addicted, under trial, or convicted. By law, a guardian of a mentally ill person is considered to be a mother or father.
In the absence of parents, a relative can apply to be a guardian to the court, and the court will appoint the relative to be a guardian only if that is not considered harmful to the mentally ill person.
The mental health act also says that a non-protesting patient (who cannot give an opinion regarding treatment or admission due to mental illness or disability) can be admitted to a hospital with the permission of his/her guardian or relative. The rationale of such a patient's admission will be reviewed by the mental health review and monitoring committee after every 28 days of the admission. After admission, a designated medical officer must decide within 24 hours after assessing the patient's mental health.
The mental health monitoring and review committee is responsible for implementing the mental health act, 2018 in every district. The committee is formed with the District Commissioner (DC), Deputy Director of District Social Services Office, District Women Affairs Officer, a Psychiatrist or Psychologist designated by the DC and Civil Surgeon. However, practically, it is the civil surgeon on whose authority the treatment or assessment of a forensic mental health patient is initiated; this is aligned with section 464 of the criminal procedure code. The court can also authorize a specific doctor or psychiatrist for the evaluation; this was evident by the following statement: "When an accused person is said to have an unsound mind, then the court refers the case to the civil surgeon to assess whether the person has an unsound mind or if he is incapable of taking any defense to protect himself from the legal system. The court can also authorize a doctor or psychiatrist. Usually, where there is a medical college with a department of psychiatry, then a board is formed containing three members. They determine if the accused is of unsound mind. Then we call the doctor who assessed him or the board chairman to the court to testify how they assessed. The judges may not all understand the technical matters, but we get an explanation and analytical view to understand how severe the unsoundness is in the accused and if he is totally incapable of taking defense in any case. If the doctor confirms that he is incapable, then we either release the accused or postpone the trial so that after his recovery, we can re-trial."  For the admission of an unwilling patient (a patient whose treatment is warranted but the patient denies taking it), permission can be obtained from the patient's guardian or relative or a designated police officer, or a designated medical officer. Such patients can be admitted for 72 hours in an emergency under the recommendation of a designated medical officer. If a psychiatrist recommends, the patient can be admitted for up to 28 days for treatment or assessment. A more extended stay will require permission from the review and monitoring committee. The law states that for immediate and prolonged treatment of unwilling patients, designated medical officers or psychiatrists or the committee must consider the health and security risks of the patient and the public along with considering suicidal tendency, the tendency of wandering around on the road, and being violent.
A mentally ill patient accused of a criminal offense can be admitted to a hospital upon the order issued by a magistrate, called 'Reception order.' The rest of the rules for treatment and stay will be the same as mentioned above.
If a mentally ill patient is homeless or has no guardian or relative available, s/he can be transferred or sent to the nearby public mental hospital by a representative of the local government or a police officer of the local jurisdiction. The hospital will be responsible for treating the patient and sending relevant documents to the local government or police station office as soon as possible.
Any person who is a relative or guardian of a mentally ill person can apply to the court to assess the psychological status. The court then issues an order for a designated medical officer to assess and report the mental disability of the person within a designated period. When found mentally disabled, the court will issue an order for the person's treatment and maintenance of his/her belongings. In the absence of parents, the court can appoint a manager for maintaining the person's property who will be responsible for handing over the properties to either the owner released from the mental hospital or to his/her successors.

Punishment for negligence in treatment
Government can enter, visit, cease, fine and punish if the hospitals break any of the laws. However, any document related to a patient's illness cannot be ceased or published without the patient's or guardian's prior consent. If the license of any private hospital is canceled due to any offense otherwise not resolved, the hospital's authority will be responsible for transferring the patients to another hospital. After the treatment, the hospital is responsible for sending the person to the nearest social welfare center or rehabilitation center and followup treatment.

Punishment for falsification
Any health professional who has been responsible for treating a mentally ill patient is punishable by the law for intensionally falsifying any report.

Designated officers to handle forensic mental health patients
Jail code says that the central jail and each district jail should have one Welfare Officer and one Psychologist, and the central jail should have one Sociologist appointed by the government. A sociologist should carry out investigations on the background of the prisoners, circumstances and reasons for their misconduct, the success of rehabilitation and reformative programmes in the post-release period. The psychologists must assist the prisons administration in classifying the prisoners that will help prison officials draw up training and customized treatment programs for individual prisoners for their recovery. However, from our interviews with relevant officials, we did not find any evidence of jails having psychologists or sociologists or any classification mechanism; these findings are supported by a published research article on analyzing the barriers in prison administration in Bangladesh in 2018 (Rahman & Ali, 2018).
In reality, an appointed medical officer handles the cases in jails. When the cases are referred to public hospitals or a particular mental hospital, the designated psychiatrists, psychologists, and nurses take care of the cases. During the treatment, if the court finds that the accused does not have any guardian, it can refer the patient to a bigger mental hospital, ensuring the patient's safety and accommodation for as long as needed. After completing treatment, a designated social welfare officer is responsible for placing the person in a government's rehabilitation center for cases without any parent or relatives.
"If there is any accused, who has no one to take his custody, then the court may order to continue his treatment in a hospital such as Pabna Mental Hospital, and the government will bear the cost. When the person gets well, they will let the court know."

Classification of cases in the documents
While most forensic mental health patients are found in jails, the classification presented by the jail code was found to be most encompassing as well. The jail code has a dedicated chapter (no. 33) that only talks about such cases, and they were mentioned as 'lunatics'. It divided them into five classes under rule no. 1024: I. Class 1: Persons who have not committed a crime and are supposed to be lunatics placed under medical observation.

II.
Class 2: Persons accused of a crime and supposed to be of unsound mind placed under the observation of the Civil Surgeon. III.
Class 3: Persons accused of a crime and found incapable of making their defence owing to unsoundness of mind and detained, pending government orders. IV. Class 4: Persons who had committed a crime and have been acquitted on the ground of being insane when the crime was committed, detained, pending the orders of, or at the pleasure of, government. V. Class 5: Prisoners who have become insane after their conviction and admission into jail.
Persons of class (1) are called in the code as non-criminal lunatics. Others are called criminal lunatics in the jail code. Class 1 to class 3 and class 5 lunatics can be either non-protesting, unwilling, or mentally disabled. Class 4 lunatics are considered mentally disabled until they get better after treatment.

Academic learning on forensic mental health
There are no separate courses for learning forensic mental health in the country. However, according to the psychiatrists we interviewed, forensic psychiatry is taught in the curriculum for the degrees of Doctor of Medicine ( "To make a separate course, some efforts are being seen to start a short course such as a sixmonth or one-year long course by any foreign institution. But, at the moment, there is no such course in the country managed by the government."  On further inquiry, we found that a local NGO worked with some foreign organizations to introduce an online course on forensic mental health for psychiatrists and lawyers. A few meetings had been organized with the psychiatrists working on forensic psychiatry before the COVID-19 pandemic.
In the MD course, students learn about forensic mental health from the book named 'Shorter Oxford Textbook of Psychiatry' in which there is a chapter on Forensic Psychiatry. The chapter covers general criminology, causes of crime, the association between mental disorder, specific offender groups, psychiatric aspects of specific crimes, psychiatric aspects of being a victim of crime, the role of the psychiatrist in the criminal courts, the treatment of offenders with mental disorders, the management of violence in health care settings, risk assessment, and psychiatric reports. One of the respondents mentioned that they did not put much emphasis on the chapter.
"We had a chapter on this topic during the MD course, and there would be a question in the exam form that chapter which we would have to answer to pass. That is all we had to do about forensic psychiatry."  Although there has been no regular formal training in the judicial system, before joining, the judges and magistrates receive classes from the psychiatry professors that cover mental health topics rather than forensic psychiatry. One official from NIMH was mentioning: "Our professors sometimes take classes of magistrates and judges before their joining in the judicial system. They have 'mental health' on their curriculum."  A member of the supreme court of Bangladesh mentioned that a few judges were selected to go to Australia for training on forensic evidence as a part of judicial capacity building; however, he could not confirm that forensic mental health was included in the training.

Studies or projects on forensic mental health
From our review and the responses from the interviews, we did not find any research work focused on forensic mental healthcare services or care in the country. However, we found references of a few research works on forensic psychiatry cases in the prison population and those referred to mental hospitals, mainly focusing on their psychiatric disorders, profile, and morbidity. Most of those studies were published in a local journal named Bangladesh Journal of Psychiatry and are not publicly available. One study published in 1998 found that 91% of the referred prisoners had psychiatric disorders, and major psychiatric disorder patients were found to be accused of major crimes (Mullick et al., 1998). The study did not mention the treatment or referral history.
There were mentions about the number of beds in a situation analysis of mental health and the health systems in Bangladesh in 2015 (Islam & Biswas, 2015). A correspondence on Necrophilia in a forensic morgue staff in Bangladesh published in July 2021 (Bose et al., 2021) referred to the gaps between mental health assessment of the rare cases and the trial process. According to the authors, in this particular case, the accused was not referred to be assessed for having an 'unsound mind' before sending him to jail, indicating disapproval of the mental disorder he had.
We could not find any projects done on forensic mental health in the country; this was also reflected by the statement of one professional from the judicial system: "To my knowledge, there is not much work done on forensic mental health in the country. In the present legal system, the practice on it is very scarce. I mean, it is not institutionalized anywhere; this is a new topic to many."

Public organizations and services on forensic mental health
Only one hospital in Bangladesh, named the National Institute of Mental Health (NIMH), has a dedicated forensic psychiatry department delivering indoor and outdoor services for patients. It is a tertiary care hospital which is located in the capital city of the country. Another one named Bangabandhu Sheikh Mujib Medical University (BSMMU) Hospital also provides extensive services to forensic mental health patients though it does not have any dedicated department for the service. Also, 36 public medical colleges in the country, each of which has a Psychiatry Department, can provide services under forensic mental health. However, some cannot provide reports due to not having any professors in Psychiatry or enough resources on their premises which was evident by the statement of one academician and practitioner of NIMH: "But in some places, due to not having a professor or enough number of Psychiatrists, sometimes the service... I mean, giving the reports becomes difficult. Nonetheless, treatment is provided as every medical college as most have psychiatrists, and so, patients of forensic psychiatry get the treatment."  With the cases referred from the country's judicial system, the forensic psychiatry department of NIMH also takes care of mental health patients from other public service organizations such as fire services, law enforcement agencies, educational institutions, and banks. It also deals with mental disability and mental illness cases, especially when an authority or government asks for assessment reports on mental health status to evaluate their need of receiving a pension or public allowance. An example shared by one of the respondents was that the police sometimes refer vagrants to the forensic psychiatry department of NIMH for psychological evaluation and reporting. Many vagrants who are mentally ill or disabled are referred to Pabna mental hospital, which is a 500-bed hospital to treat mentally ill cases.
"There are medical college hospitals with psychiatry departments where they can be treated, but when we consider rehabilitation or residence for such cases, then there is only the one in Pabna."  Usually, mental health hospitals prepare an opinion or report by forming a board comprising psychiatrists, and a professor of psychiatry often leads it. We found an example in the NIMH, where a board responsible for overseeing the legal cases had a professor, two associate professors, and an assistant professor. Otherwise, individual psychiatrists of other medical colleges can also provide reports.
Besides the mental hospitals under MOHFW, there are six Shelter Homes, six Safe Homes and Centres for Vagrants for adults, 13 Children's Training and Rehabilitation Centers and three Children Development Centres for children and adolescents under Social Welfare Ministry to which forensic mental health patients are often referred. A mentally ill or disabled person is referred to these centers in three cases: 1) when there is none to take care of the person, such as homeless people, 2) when their punishment period is over, and they have no parents or relatives to go to, and 3) when they are minor (a boy or girl below 18 years old) and in contact of law.

Treatment procedures
At the public medical colleges and NIMH outdoors, psychiatrists can provide treatment to forensic mental health patients. However, only 15 forensic inpatient beds were available in NIMH for admitting such cases; this number has reduced to teneight for males and only two for female patients during the pandemic. The respondent from there was mentioning: "The beds are always full. Usually, a patient stays in the wards for about two weeks on average. Thus, we are serving 16 male patients and about four female patients each month.
Besides these, every day, we see five to ten cases at the outdoor."  Treatment usually starts after a patient is referred to the mental hospital. According to the jail code, medical observation can be done in the cells by the medical officers. A case can only be transferred to a mental hospital when the Medical Officer certifies that s/he is fit, both mentally and physically, to travel safely. Every precaution should be taken to secure that the lunatic is cared for whilst in transit to the Mental Hospital. According to NIMH officials, patients are referred from jails without any in-depth investigation.
"In these cases, they usually refer when they find any abnormal behaviour in the prisoner.

We consider the observation notes. However, the quality of those observation notes is not satisfactory. We find similar observations for most of the patients such as 'patient is depressed', 'patient does not eat' etc." [KII-3]
At NIMH, after receiving a patient, the patient is firstly assessed by an assistant professor or associate professor, then kept under observation for one or two days; if the diagnosis cannot be confirmed, then a board is formed to assess, discuss and diagnose the case. Rarely, the court or the Directorate General of Health Services suggest having someone particular on the board.

"An external board sometimes creates difficulties such as the patient may have to stay longer. It also gets difficult for us because we have a lack of psychiatrists." [KII-3]
Before releasing a case from the mental hospitals, doctors write on the discharge paper about the medications, treatment rules, pieces of advice and follow-up schedules in the native language. Patients are interviewed by the doctors when they come to follow-up to know about their adherence to the treatment. From the interviews, it was evident that a case can be referred to the mental hospital multiple times because of relapse, which may occur for various reasons.

"We cannot keep a patient admitted for a longer period because the numbers of beds are limited and patients are always coming for admission… Sometimes there are resistant cases that may not be improved, and also, we do not know how the patients are taken care of in jails, and if s/he receives the medication properly, that may also be a cause for relapse." [KII-1]
The treatment depends on the condition or disorder of patients in all cases; however, their destination after successful treatment differs. Such as a convicted criminal will be continued on trial or be imprisoned or receive capital punishment (death or life sentence) after successful treatment. Mentally disabled cases, non-protesting and unwilling patients with no criminal records are either handed over to their parents and relatives after the treatment or transferred to a rehabilitation centre in case of their absence.

Cost of treatment
Every service available at the public hospitals for forensic psychiatry patients is delivered free of cost. The inpatient beds are also non-paying services in NIMH.

Referral and reporting system
Patients of forensic psychiatry are referred to the public hospitals in four ways: 1) the court or magistrate directly sends patients who are not fit for trial to the hospitals and issues orders for treatment, 2) the jail authority refers an offender who is on trial or detained in the jail to the hospital, 3) the central police hospital and hospitals outside the capital city refer patients to the public medical college hospitals in Dhaka or NIMH via the magistrates, and 4) the local administration, police or court can refer patients directly to mental hospitals.
A referral and service flow mechanism is shown in figure 1, depicting all major actors in both judicial and health systems. The jails refer patients to mental hospitals for two purposes: receiving treatment or getting assessed if they are fit to testify.
Patients outside the capital city are referred to the public hospitals in Dhaka when local medical college hospitals do not have any psychiatry professor or cannot form a board to decide about the patient. Also, the hospitals might not always have an appropriate security system for the criminals or accused prisoners, making them refer cases to the capital city as per one of the respondents.
"The old medical colleges did not have any professor on Psychiatry until recently; the associate professor was the highest position."  The jail authority also refers to the patient via the medical officer of jail, a governmentappointed physician responsible for overseeing the health issues of the imprisoned population. Reportedly, no psychiatrist or psychologist is appointed to the jail.
"Those who work there are, of course, government officers; some may be BCS officers, and some may work under a project, also sometimes, the home ministry of the government appoints medical officers there. However, as far as I know, there is no psychiatrist there, nor do those medical officers have any psychiatry training."  "There is a high possibility that the medical officer recruited in the Jails are not experts in psychology or psychiatry; they may be a general physician or expert in other health problems, but not on mental health." [KII-2]

Figure 1: Referral flow in the forensic mental health service in Bangladesh
According to the Jail Code, magistrates, an official entrusted with the administration of the laws, can order medical officers of jails to report the state of mind of a supposed lunatic sent to jail for observation. The Superintendent of the jail ascertains from the medical officers whether, in their opinion, it is necessary to take any special precautions to prevent the supposed lunatic from doing injury to himself or others. The Superintendent will then ensure that necessary precautions are taken (Rule 1025, Jail Code). Detention of a non-criminal supposed lunatic cannot exceed ten days and is supposed to be under medical observation. However, if the medical officer certifies about the necessity of further detention, then a Magistrate or the Commissioner of Police can authorize the extension of the detention up to a maximum period of thirty days from the date of the first order of detention. After the authorized period, the Jail Superintendent is responsible for informing the magistrate who warranted or ordered the detention and requesting a release order or order to transfer to the mental hospital. If the order delays for more than seven days, the Superintendent is responsible for reporting the issue to the Inspector General of Prisons for necessary action (Rule 1026, Jail Code). This rule also applies to the criminal lunatics of class (1) and class (3) (Rule 1028).
Non-criminal lunatics are not included in any statistical returns relating to jails. The court under whose warrant they are received should provide all the relevant costs (maintenance and clothing, transfer to a Mental Hospital) (Rule 1027, Jail Code). However, twice in a year, the Superintendent needs to forward a report to the Inspector General, in respect of each lunatic in his custody, showing the physical and mental state of health of the lunatic at the time, and during the interval since the previous report was submitted (Rule 1045, Jail Code).
If any normal prisoner begins to show signs of insanity which in the opinion of the Medical Officer are not feigned, the Superintendent of the jail can put the prisoner in a separate cell for medical observation (Rule 1029, Jail Code). If not found to be dangerous, noisy, or filthy in habit, then lunatics of classes (1) to (4) inclusive may be detained either in the jail hospital or in the under-trial prisoners' ward at the discretion of the Medical Officer. Upon confirming the insanity, the Superintendent submits a report to the Inspector General, with the view of obtaining the orders of government for his removal to a Mental Hospital (Rule 1030, Jail Code). The Jail authority is responsible for taking every precaution so that the lunatic prisoner is properly cared for while in transit to the medical hospital. Before dispatch, a medical officer must certify that the person is mentally and physically fit to travel safely (Rule 1031, Jail Code). The procedure of the assessment is not mentioned in any case. Only in Rule 1035, it was mentioned that while the assessment, the medical officer should carefully record any disability or marks of violence exhibited by such person. Female lunatics must always be accompanied by a female warder or attendant (Rule 1033, Jail Code). With every lunatic transferred either from a Mental Hospital to jail, or vice versa, full details of his medical history up to date shall be forwarded (Rule 1043, Jail Code).
In our exploration, it was unclear if the referral system mentioned in the jail code is practically followed and at what point the cases are referred to the mental hospital from the jails. This was affirmed by the following statement of the senior psychiatrist in the National Institute of Mental Health when the rules of the jail code were mentioned: "The examples you are giving is probably from the other countries or any developed country, that they can assess or decide whether the treatment of such cases will continue there or in mental hospitals and whether in the outdoor setting or indoor setting. However, in our country, they do not have such training to my knowledge. Although we regularly train some of the doctors from different sub-districts on mental health with the help of DG health, those who are at the primary healthcare setting. So, if anyone reaches them, then they can assess and refer appropriately. Such training sessions are conducted with the initiatives from DG Health, some of those are for three days, some for six days and some last longer than that. We orient them on mental health. Now, among the trainees, there may be doctors from the jail. Otherwise, jail doctors may have received such training when they worked in the subdistrict level. But those who deal with such cases from there, I mean those who work in the jail hospitals or police hospital, we have not got them in our training sessions on mental health or forensic psychiatry."  Therefore, based on the response from the interviews, it was evident that, commonly the forensic mental health patients are referred to the mental hospitals by the central police hospital, unlike mentioned in the jail code.
"We constantly get such cases: that someone in the jail shows symptoms, they take them to the central police hospital, members in the police force are also referred to us directly from there when they show any such symptoms."  To refer a patient, documents used usually are outdoor tickets or emergency tickets from the hospitals, official letters from the concerned authority, and letters with signatures from the concerned medical officers.
For reporting, the hospital is responsible for sharing the diagnosis and treatment details in a form or discharge paper to the authority who referred the case. We found no evidence of any digital record maintained in the hospital facility.

Security of forensic mental health patients
According to rule 740 of the jail code, a strict watch shall be kept over all prisoners confined in cells to prevent them from committing suicide or injuring themselves. It also states that every lunatic, suspected lunatic, or prisoner suspected of suicidal tendencies under medical observation in cells shall be carefully watched both by day and night.
"If it is observed that the accused person may be harmful to himself or others, in that case, he can put in a confined place such as in a mental hospital, and when it is found that he has recovered from his unsoundness, then he will be brought back to court for re-trial. As per the criminal law in Bangladesh, this is the usual procedure."  A prisoner who is sent to a cell for medical observation shall be frequently visited by the Warder on duty, who shall send information to the Medical Officer of any change which may take place in the prisoner's condition. When the prisoner is under observation, he shall receive such food as the Medical Officer may consider necessary.
According to rule no. 1232 (1) a prisoner will be documented in the hospital register only if s/he is under medical observation or treatment for more than 48 hours. However, dangerous, noisy, and filthy lunatics are not put in the hospital; they are kept in separate cells (rule no. 1038 and 1239).

Gaps and recommendations
Forensic mental health is not focused in the academia of the country as a separate discipline. Also, as the development of the mental health sector is relatively new in Bangladesh, experts believe that it will take time to focus on forensic psychiatry in medical colleges.
"If the field of psychiatry is developed, we can expect forensic psychiatry to develop as well.
Currently, there are only four Professors in Psychiatry in the public medical colleges. Very recently, eight positions for the professor in psychiatry have been created; this will help develop the field hopefully."  The respondent, a senior professional at NIMH, also shared that students were also reluctant to take higher degrees in Psychiatry because of the stigma and dilemma of having a secured career. However, he mentioned that the situation is changing these days, and people are now aware of psychiatrists' need for their wellbeing.
Also, as the services regarding forensic mental health are centralized and mainly capitalbased, only six public hospitals in the capital city manage the cases referred from all over the country.
"We should increase the number of psychiatrists and psychologists and thus increase the access to mental healthcare so that people can avail the services regarding forensic psychiatry wherever they are."  Presently, hospitals in the capital city receive cases from cities located at the farthest corner of the country. Such cases are first referred to the central jail, after which they reach the hospitals in the city referred by the jail. The professionals interviewed considered this lengthy procedure of first transferring patients to central jail and then to the mental hospitals as a resource and time-consuming. Therefore, they recommended that the services on forensic mental health should not be centralized and be expanded all over the country. According to them, this can be done by increasing psychiatric nurse practitioners, occupational therapists and rehabilitation professionals.
"We should increase the forensic psychiatry services in the hospitals outside Dhaka so that they do not have to come to Dhaka directly when admission is needed. Also, it would be easier if training or short-course could be arranged on forensic psychiatry for the providers in jail hospitals and central police hospitals so that they could at least provide primary mental health care services."  According to the respondents from the judicial side, mental health is itself a non-prioritized issue in the judicial system. There is no specialized focus on mental wellbeing for the criminals, accused or convicted individuals.
"If we look into the children development centers, that is not a jail; a reformation center. But those also do not focus on mental health; they do not usually have any guidance from experts to help them gain cognitive development. There should be such assessments and quality service. These are not available there; I have not found any … We have seen some occurrences recently in a center where the adolescents revolted against the Superintendent; that resulted in another criminal act, right? That is why I think that they are not properly taken care of."  NIMH officials thought that the government could introduce short courses or training for relevant providers if officials shared their recommendations in different forums to facilitate such an approach. Healthcare providers think forensic psychiatry should be included in the MBBS course curriculum and emphasized more in the MD, FCPS and MPhil courses. Also, they suggested that collaboration between judicial service providers and health providers could bring out such initiatives or training programs as an outcome.
"We have to go to court to testify cases, and what happens there is that we have to make the advocates and judges understand every word, even with spelling. That is why I feel that we must make some liaison to share knowledge that can reduce both sides' cost and time.
Sometimes we see that the people on the legal side have preoccupied ideas that mental cases would be like crazy all the time, and they do not want to understand that there can be other forms of expressions for mentally ill cases."  "Both sides should be oriented on related topics. This is because lawyers do not know much about the disease and severity of those. Also, doctors do not know much about the judicial system. Short training sessions arranged by both sides can help, and we can see positive changes within a short period."  The feeling is mutual in both the health system and judicial system that different actors in the legal system should have a certain level of understanding of forensic mental health. The respondents thought that the policymakers might not know well about judges and magistrates' needs regarding forensic mental health.
"The technical terms they use in the assessment report are not easy for us to understand. So, it is tough for me and others like me to get these. So, I think here lies a problem in the system. … I think that as there is a definitive guideline for law implementation, the authority may not be much aware or concerned about the fact that these technical terms are creating issues while trial or interrupting decision making."  "The judge, lawyers and police should know this matter. Otherwise, how would they know if what the doctors have certified is right or wrong? When they do not have any orientation on the mental illness, it is normal that will not understand most of the assessments."  It was opined by the respondent that for training on forensic mental health, the home ministry could include the topic in the police training. For the lawyers and judges, the ministry of law, the supreme court, bar council and Bangladesh Judicial Administration Training Institute can come forward.
"In my 13 years of career in the judicial system, I have received many training programs. But so far, I have seen, any training on mental health is not provided. This is of course needed, and maybe the Directorate of health can take any initiative, then it will be beneficial for the judiciary as well as for the people of the country."  There are opportunities to work with the juveniles in the rehabilitation or development centers to provide them with psychological support and education to facilitate their upbringing, learning, and wellbeing, ultimately preventing antisocial behavior and further crimes. Most of the respondents agreed that more psychiatrists and psychologists could engage regarding the children's development in the rehabilitation centers. Also, the monitoring and supervision are suggested to be protocol-guided and subjected to performance evaluation. Also, two of the respondents shared that public awareness of psychiatric diagnosis can prevent casualties and crime.
"We can see that many offenses can be prevented if people are properly educated and aware of psychological disorders."

Case examples
We found some case examples from the respondents who are mentioned below in brief: 1. A death-sentenced prisoner who was a senior citizen was referred to a mental hospital in the capital city several times and had continued to come for treatment for about five years. [KII-1] 2. A case who was Indian and found to cross the border somehow to enter Bangladesh was referred to a mental hospital in the capital city whose language and culture was unknown.
[KII-1] 3. A police officer murdered his wife, who thought his wife was unfaithful, later was found that was his delusion. [KII-3] 4. A female murdered her little daughter, thinking of her as evil and raped by the devil.
The female developed the symptoms in side-effects of some steroid drugs used to hear voices and get the foul odour from her daughter's body. [KII-3] 5. A male accused of drug abuse claimed to have insanity and was referred to a medical college. The primary assessment was that the accused had got symptoms of mental illness after being captured by the police but was not categorized as having an 'unsound mind' after a medical board assessed him. He was then sent to trial.  4. Discussion: The development of mental health services and policies is relatively new in Bangladesh. The government has taken initiatives recently to address the needs by introducing the mental health act, creating a National Mental Health Policy and finalizing a National Mental Health Strategic Plan 2020-2030 (World Health Organization, 2020). Though the latter two policy documents are not yet public, by reviewing the Mental health act, 2018, it can be said that a broadened service provision will be considered in the upcoming strategic implementation of the policies. The need for the legal systems merging into mental health capacity-building strategies and training becomes therefore imperative. As medical officers of jails are the first assessors of most forensic mental health patients, their orientation and training to assess patients properly can reduce the time and cost required to refer and assess the patients to mental hospitals. Recruiting psychologists and thereby classifying prisoners as the Jail code mentions can enhance the process of treatment and trial as well.
Findings from our study indicated that the doctors with only MBBS, whom the government recruits as medical officers, have elementary knowledge of forensic psychiatry from their academic curriculum. The academic learning on forensic mental health, case detection, counselling, treatment and judicial regulations can therefore be included in the next update of the medical graduation curriculum. Also, training the judicial lawyers and judges on mental illness and prevalent disorders will enhance the decision-making process during criminal proceedings. Learning from the examples in other countries can help in this regard because similar to our findings, legal experts lack the understanding of medical interpretations in other countries with even advanced legal systems (Canela et al., 2019;Math et al., 2015).
Issues in the country's mental health system recognized by the key actors in the health and legal systems, such as centralized psychiatric services and inadequate inpatient forensic units, have also been focused on in other studies (Barn, 2008;Firoz et al., 2006). Offenders with mental disorders are diverted to different hospitals in other countries (Every-Palmer et al., 2014). It is understandable that in our context, referring offenders for evaluation to the capital city from all over the country cannot be a sustainable solution. However, a reason for this reality might be the non-existence of functional health facilities in the district jails, as mentioned in the jail code (Rahman & Ali, 2018). Therefore, the solution lies in increasing the number of healthcare facilities in jails.
Respondents in our study indicated the absence of continued psychiatric care for forensic patients to avoid relapse and recidivism, a concern seen in other contexts (Nakatani, 2011). Training of medical officers on mental healthcare and psychological wellbeing and the relevant actors in the legal system on social welfare as suggested by the respondents in this study can change the scenario.
Countries with advanced healthcare systems have raised concerns about psychiatric practice in prisons (Bhugra, 2020;Fovet et al., 2020). Though there is no study among the prison population to assess the prevalence of mental disorders in Bangladesh, the high prevalence among the referred patients (Mullick et al., 1998) warrants the assessment of prisoners in scale. Moreover, the increasing number of prisoners in Bangladesh since 2014, which currently reached more than 80 thousand with an occupancy rate of 195.8% (World Prison Brief, 2021), makes them more vulnerable to mental illness (Bhugra, 2020) and validates the need to strengthen forensic mental health in the country.

Conclusion:
This study is the first of its kind, providing an overview of forensic mental health in Bangladesh. With the findings and feedback from both health and judicial systems, this will be useful to policymakers to revisit the existing policies and make necessary changes. Our findings will also help the planning departments of different ministries to understand the importance of capacity building and training programs. This paper should also encourage researchers and academicians to explore further the challenges and opportunities to improve forensic mental healthcare services in Bangladesh.