The mental health care bill 2013: a critical appraisal

A Focus Group Study of Indian Psychiatrists' Views on Electroconvulsive Therapy under India's Mental Healthcare Act 2017: 'The Ground Reality is Different'

BACKGROUND

India's Mental Healthcare Act, 2017 (MHCA) greatly restricts the use of electroconvulsive therapy (ECT) in minors and bans unmodified ECT. Indian psychiatrists have raised concerns that these measures may deprive certain patients of life-saving treatment. This study describes the perspectives of Indian psychiatrists on how ECT is dealt with in the legislation.

METHODS

We conducted nine focus groups in three Indian states. We explored the positive and negative implications of the MHCA and discussed its implementation, especially in relation to ECT.

RESULTS

Many of the themes and concerns commonly discussed in relation to ECT in other jurisdictions are readily apparent among Indian psychiatrists, although perspectives on specific issues remain heterogeneous. The one area of near-universal agreement is Indian psychiatrists' affirmation of the effectiveness of ECT. We identified three main areas of current concern: the MHCA's ban on unmodified ECT, ECT in minors, and ECT in the acute phase. Two broad additional themes also emerged: resource limitations and the impact of nonmedical models of mental health. We identified a need for greater education about the MHCA among all stakeholders.

CONCLUSION

Core concerns about ECT in India's new legislation relate, in part, to medical decisions apparently being taken out of the hands of psychiatrists and change being driven by theoretical perspectives that do not reflect "ground realities." Although the MHCA offers significant opportunities, failure to resource its ambitious changes will greatly limit the use of ECT in India.

EAT-PAD: Educating about psychiatric advance directives in India

BACKGROUND

With India enacting the Mental Health Care Act (MHCA; No. 10 of 2017a), Psychiatric Advance Directives (PADs) have been legalised and have become binding orders for psychiatrists treating patients. There is a paucity of research into acceptability of PADs in Indian mental health care, likely due to a lack of awareness. There are no educational measures about PADs provided for in this Act. Facilitators and facilitation methods have not been elaborated upon as well.

AIM

The aim of this study is (a) to develop/evaluate the effectiveness of a structured Education-cum-Assessment Tool (EAT) in providing information regarding PADs and (b) to evaluate modes of facilitation required by patients to complete PADs.

METHODS

A tool was developed as per provisions regarding PADs in the Mental Health Care Bill of 2013. This tool was administered to patients ( n = 100), purposively sampled from the adult psychiatry review out-patient department (OPD). Patients were evaluated on retention of information, completion of PADs, modes of facilitation and time taken to write one.

RESULTS

Mean years of education was 8.28 (±5.74) years and mean duration of illness was 8.30 (±7.04) years. In all, 65% had Below-Poverty Line (BPL) status. All participants completed valid PADs in an average of 15 minutes. About 93% required facilitation via assistance in writing and reminding. The mean EAT scores implied above 70% retention but did not relate to types of facilitation.

CONCLUSIONS

EAT scores can be used as an approximate measure of the patient's ability to understand and retain information which is a part of decisional capacity. Types of facilitation can help in understanding patient's ability to communicate their choices. Service providers may find EAT a time-effective tool for uniformly educating service users regarding PADs and indirectly assessing competence.

Dealing with statutory bodies under the Mental Healthcare Act 2017

India has an enormous burden of mental illness. In spite of the recognition of this population of people living with mental illness, the treatment gap continues to be about 83%. In order to meet this vast unmet need and in the view of aligning the mental health legislation with the international standards and the UN-Convention on the Rights of Persons with Disabilities, the Mental Healthcare Act 2017 was passed and enforced recently. The provisions in the act have been controversial from its conception. Now after the enforcement of the act, all mental health professionals (MHPs) have a legal binding to follow the provisions in the law. The MHPs are accountable to the statutory bodies - the Central Mental Health Authority, State Mental Health Authority (SMHA), Mental Health Review Board, and finally, the High Court or the Supreme Court. The Mental Healthcare Act (MHCA) and relevant articles/documents obtained pertaining to MHCA and their evaluation were reviewed, the major focus being on the role of statutory/regulatory bodies. Furthermore, an attempt was made to summarize the previous experiences in inspection of mental health establishments by SMHA of Karnataka. We concluded that the MHCA will have both positive and negative aspects. Many of the provisions in the law may appear unclear and unrealistic by many practitioners. However, it becomes precautionary for the MHPs to be well equipped with the MHCA and be acquainted with the requirements of the statutory bodies for ensuring a safe practice. The outcome of the implementation of the act will become evident only with time.

How right is right-based mental health law?

Human rights' frameworks are increasingly being recognized in general, and mental health in particular. Human rights can thus act as powerful catalysts for change in areas such as mental health care that has historically suffered from stigma, discrimination, and loss of dignity of patients. Mental health law in India has evolved over the past few decades, in keeping with improved delivery of care, societal changes, and increasing awareness of a person's human rights and privileges. The new Mental Healthcare Act, 2017 has shifted the focus to a rights-based approach to provide treatment, care, and protection of a person with mental illness compared to previous Mental Health Act 1987. This dynamic shift is to align, harmonize, and fulfill the requirements of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). This article reviews the existing international human rights model of disability and recovery, and the Mysore Declaration, and does a critical review of UNCRPD.

Is it the right time to implement Community Treatment Order in India?

India enacted the Mental Healthcare Act, 2017 (MHCA 2017) on April 7, 2017 to align and harmonize with United Nations Convention on Persons with Disabilities and the principles of prioritizing human rights protection. While MHCA 2017 is oriented toward the rights of the patients, the rights of the family members and professionals delivering treatment, care, and support to persons with severe mental disorder (SMD) often suffer. MHCA 2017 mandates discharge planning in consultation with the patients for admitted patients and makes the service providers responsible for ensuring continuity of care in the community. The concerns surrounding the chances of relapse and recurrence when a person with a SMD stops medications continue to remain largely unaddressed. The rights-based MHCA 2017 makes it difficult for the prevailing practices of surreptitious treatment by the family/caregiver and proxy consultations on behalf of the patients. This will, in turn, lead to increased chances of relapse, risk of violence, homelessness, stigma, and suicide in persons with SMDs in the community, largely due to noncompliance to treatment. This will also result in increased caregiver burden and burnouts and may also cause disruptions in the family and the community. To strike a balance over the current MHCA 2017, there is a need to amend or bring-forth a new law rooted in the principles of community treatment order.

Liabilities and penalties under Mental Healthcare Act 2017

INTRODUCTION

Mental Healthcare Act (MHCA) 2017 is an act passed to regulate and provide mental health care and services. The act considers psychiatrists as one of the main mental health providers. Liabilities are prescribed under various chapters of MHCA 2017. It is imperative for practitioners to be completely aware of and follow the rules as per MHCA 2017, now that the rules are already framed.

MATERIALS AND METHODS

A thorough review of MHCA 2017, Central Mental Health Rules, and State Mental Health Rules 2018 was done. In addition, related scientific articles were accessed in PubMed and Google Scholar using keywords such as mental health legislation, law, and mental health. Relevant articles were reviewed to arrive at suggestions.

OBSERVATIONS

Important liabilities are around the domains of registration of professionals and institutions, maintenance of records, promoting the rights of the persons with mental illness during treatment, and following the provisions of MHCA 2017 during admission and discharge. Punishment for contravention of provisions of the Act or rules or regulations made thereunder is clear and stringent and may vary from fine to imprisonment.

SUGGESTIONS

Mental Health Professionals should understand the provisions of MHCA 2017 along with the rules and regulations made under this act. Please maintain basic medical records of all outpatients and inpatients and basic report of psychological assessments and release it upon request by the patient or nominated representative.

Mental Healthcare Act, 2017, and addiction treatment: Potential pitfalls and trepidations

The Mental Healthcare Act (MHCA), 2017, is enacted with an aim to promote and protect the rights of and improve the care and treatment for people affected by mental illness in India. The Act purportedly includes substance use disorder (SUD) specifically in the definition of mental illness itself. However, some of the phrases used in the definition such as "abuse" are not clear, as the current classificatory systems of mental illnesses do not have any diagnostic category termed "abuse." Another important issue is the lack of clarity on which categories of SUD would be covered under MHCA. Simple reading of the text of the Act seems to suggest that SUD is a single entity for the purpose of this law. In such case, many provisions of the act such as supported admission that are meant for the treatment of people with severe mental illnesses with gross impairment may become applicable to all types of SUD. This can create potential problems for addiction treatment providers. On the other hand, certain other provisions of the Act are good news for patients suffering from SUD. The Act lays down various rights that include, among others, protection from cruel, inhuman, or degrading treatment in any mental health establishment. This is very important from the perspective of treatment of SUD in the context of India, where human rights violations in the name of addiction treatment are often reported. The inclusion of SUD in MHCA, 2017, slots SUD as a health issue, rather than a law-and-order issue alone. This displays the intent of policymakers toward SUD, which, in itself, is laudable. There are certain ways in which the potential pitfalls mentioned earlier can be addressed, which is discussed in the article.

The right to mental healthcare: India moves forward

In 2018, India's Mental Healthcare Act 2017 granted a legally binding right to mental healthcare to 1.3 billion people, in compliance with the Convention on the Rights of Persons with Disabilities. Many countries, including the UK, ratified the Convention but only India has stepped up to the mark so dramatically.Declaration of interestNone.

India's Mental Healthcare Act, 2017: Content, context, controversy

India's new mental health legislation, the Mental Healthcare Act, 2017, was commenced on 29 May 2018 and seeks explicitly to comply with the United Nations Convention on the Rights of Persons with Disabilities. It grants a legally binding right to mental healthcare to over 1.3 billion people, one sixth of the planet's population. Key measures include (a) new definitions of 'mental illness' and 'mental health establishment'; (b) revised consideration of 'capacity' in relation to mental healthcare (c) 'advance directives' to permit persons with mental illness to direct future care; (d) 'nominated representatives', who need not be family members; (e) the right to mental healthcare and broad social rights for the mentally ill; (f) establishment of governmental authorities to oversee services; (g) Mental Health Review Boards to review admissions and other matters; (h) revised procedures for 'independent admission' (voluntary admission), 'supported admission' (admission and treatment without patient consent), and 'admission of minor'; (i) revised rules governing treatment, restraint and research; and (j) de facto decriminalization of suicide. Key challenges relate to resourcing both mental health services and the new structures proposed in the legislation, the appropriateness of apparently increasingly legalized approaches to care (especially the implications of potentially lengthy judicial proceedings), and possible paradoxical effects resulting in barriers to care (e.g. revised licensing requirements for general hospital psychiatry units). There is ongoing controversy about specific measures (e.g. the ban on electro-convulsive therapy without muscle relaxants and anaesthesia), reflecting a need for continued engagement with stakeholders including patients, families, the Indian Psychiatric Society and non-governmental organisations. Despite these challenges, the new legislation offers substantial potential benefits not only to India but, by example, to other countries that seek to align their laws with the United Nations' Convention on the Rights of Persons with Disabilities and improve the position of the mentally ill.

How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India

BACKGROUND

Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce.

AIMS

To determine the possible treatment options our clients make as a part of psychiatric advance directives.

MATERIALS AND METHODS

Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices.

RESULTS

About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future.

CONCLUSION

The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.

New legislation, new frontiers: Indian psychiatrists' perspective of the mental healthcare act 2017 prior to implementation

CONTEXT

The mental healthcare act 2017 represents a complete overhaul of Indian mental health legislation.

AIMS

The aim of this study was to establish the opinions of Indian psychiatrists regarding the new act.

SETTINGS

Mental health professionals in Bihar and Jharkhand were interviewed.

DESIGN

A focus group design was utilized.

MATERIALS AND METHODS

Key questions explored the positive and negative aspects of the act and the management of the transitional phase. All focus groups were recorded and transcribed.

ANALYSIS

Data were coded and analyzed using an inductive approach.

RESULTS

Many positive aspects of the new legislation were identified especially relating to rights, autonomy, and the decriminalization of suicide. However, psychiatrists have significant concerns that the new legislation may negatively impact patients and increase stigma. Psychiatrists held varying views on the proposed licensing and inspection of general hospital psychiatric units.

CONCLUSIONS

Careful evaluation of the new legislation is needed as the concerns raised warrant ongoing monitoring.

History of psychiatry: An Indian perspective

A knowledge of history becomes important in learning the way concepts have evolved and how they are understood in different and conflicting traditions in psychiatry. Modern psychiatry and its history has always been observed through the prism of western science which has its own evolutionary line in which the eastern sciences can't fit and are always at a disadvantage. Especially the colonial bid to prove its legitimacy as a civilizing mission led to representation of European medicine as morally superior to the eastern practices resulting in a biased history. Though in reality, the history of psychiatry is heterogeneous and consists of many different scientific and cultural traditions which vary between populations. hence the Indian concept of "unmada" can't be compared or conformed to "schizophrenia" without addressing its cultural and historical contexts. Many suggest that in case of Indian patients, an understanding of illness through a Vedantic model of psych seems more appealing in comparison to the western constructs, as such an attitude has been transferred over generations. Therefore, a knowledge of history of psychiatry, especially from an Indian perspective becomes important.

Factors influencing advance directives among psychiatric inpatients in India

OBJECTIVES

Advance directives are documents stating treatment preferences in case of future lack of decision making capacity. In India, as in many other countries, legislators advocate Psychiatric Advance Directives (PADs), while evidence on its use is limited. This study examined factors influencing PADs by gathering inpatients perspectives on PADs at discharge and investigating patient characteristics associated with the expression of treatment wishes in PADs.

METHODS

We conducted a hospital based descriptive study in Bangalore. 200 patients were included. The Mini International Neuropsychiatric Interview, CGI-S and CGI-I (Clinical Global Impression scales), the Insight Scale-2, and an Illness insight assessment were completed within 3days of admission. We used the Bangalore Advance Directive Interview (BADI) to assess attitudes towards PADs. 182 subjects were reassessed within 3days of discharge, along with an interview on their perspectives on PADs.

RESULTS

67% welcomed the need for PADs in India. 95.6% made their own PADs. 80% followed their doctors' advice in their PAD. Subjects lacking insight or remaining symptomatic at discharge opted significantly more often against ECT, antipsychotics, and inpatient care. Linear regression showed that low socio-economic status, unwillingness to stay in hospital, and having received ECT before were inversely associated with the expression of treatment wishes in PADs.

CONCLUSIONS

This study's findings are relevant for India and Western countries alike while generating legislation including patients' perspectives. A majority of patients favoured PADs. Absent insight, severe psychopathology and incomplete recovery may negatively influence the way PADs are completed. Therefore, clinicians must assess patient's capacity to formulate PADs carefully, as capacity may significantly influence patients' views. The timing of when to formulate one's PAD within the illness process may be essential.

Being a Forensic Psychiatrist in India: Responsibilities, Difficulties, and Criticalities

Forensic psychiatry is in its infancy in India. There is a clear module or a well-structured training in the country except for recently opened few courses. Lack of trainer in the field might lead to compromised state when one has to take decision between the well-being of a person versus society. Starting from social contexts, such as marriage and mental illness, to the interpretation of criminal mind, there is a multitude of situations where forensic psychiatrist has a handful of jobs which suffer due to lack of infrastructure. In this article, we delineate the importance of a forensic psychiatrist in different civil as well as legal scenarios and difficulties often faced while handling it.

Involuntary admission and treatment experiences of persons with schizophrenia: Implication for the Mental Health Care Bill 2016

BACKGROUND

Involuntary admission and treatment experiences may affect the attitude of patients toward subsequent treatment and further outcomes. This issue has received relatively less research attention in persons with schizophrenia from developing countries.

METHODOLOGY

In this hospital based prospective observational study, involuntary admission, treatment and coercion experiences among 76 persons with schizophrenia, admitted under special circumstances of Mental Health Act -1987 were studied. Demographic, clinical and assessments related to coercion experiences were completed within 3days of admission. In 67 subjects, a reassessment was done just before discharge.

RESULTS

Mean (SD) age was 33.1 (±11.5) years, 47.8% (n=32) were males and 32.8% (n=22) were married. 92.5% (n=62) had absent insight at admission. Mean CGI Severity score at admission was 6.27 (±0.53). Mean (SD) score on MacArthur Perceived Coercion Scale at admission was 4.04 (±1.61). This reduced to 2.43(±1.91) [p<0.001]. This reduction correlated significantly with improvements in global functioning (r=-0.40, p <0.001), insight level(r=0.26, p<0.001) and as well as symptom severity(r=0.36, p<0.001). At discharge, 70% (n=47) patients reported that their involuntary admission was justified.

CONCLUSION

Perceived coercion in schizophrenia though common clinical phenomena, it is a dynamic state which reduces over course of treatment. At Discharge, majority reported that their admission was justified, even though they were admitted involuntarily. The study underlines the need for a standardized rule of conduct based coercive practice in psychiatry.

Mental health, mental illness, and human rights in India and elsewhere: What are we aiming for?

The Mental Health Care Bill 2013 was introduced to the Rajya Sabha (India's upper house of parliament) in August 2013 and following 134 official amendments, passed in August 2016. Properly implemented, mental health legislation such as this plays a key role in protecting the rights of the mentally ill, ensuring access to care, and promoting social justice for the mentally ill, their families and carers. In this context, the 2006 United Nations' Convention on the Rights of Persons with Disabilities (CRPD) presents a real opportunity to improve the position of people with disabilities and those disabled by long-term mental illness. The CRPD also presents many challenges to mental health legislators and service-providers, especially in relation to involuntary care, mental capacity, and substitute decision-making. Nevertheless, the CRPD has still generated strong incentive for reform and is an opportunity that should not be missed. Legislation along the lines of India's 2013 Bill offers much that is positive and progressive in terms of standards of care, revised processes for involuntary admission, and enhanced governance throughout mental health services. In this way, this kind of legislation, although imperfect in certain respects, promotes the principles of the CRPD (as outlined in the preamble to India's 2013 Bill). It is important that such initiatives focus not only on the right to liberty but also on rights to treatment, social care, social inclusion, and political empowerment of the mentally ill. Globally, the mentally ill have been neglected for far, far too long. It is time to fix this.