MHCA 2017 FINAL.pptx

Psychiatry

1. Mental Health Care Act 2017 Presenter- Dr. Shanu Soni Junior Resident-II Moderator- Dr. Astha Singh Assistant Professor

2. I ND I A N LUNACY A C T ( 1912 ) : T h e n a m e “ lun a t i c a sy lu m ” i s c h a n g ed t o “ m e nt al hospitals”. This act first defined the procedure of admission and certification. P u r po s e o f th i s act w as t o e n s u re c u s tod i al care a n d t o prevent harm to society. In 1920, the administration of a Mental hospital is given to m e d i cal p er s onn el f r o m p r i s o n a utho r i t i e s . Indian lunacy act,1912 prevailed for more than 75 years

3. Demerits of ILA ACT,1912 Bhore committee report (1946) highlighted the inadequacy of Mental health services and criticized outdated ILA No provision of treatment N o p r ot ec t i o n o f r i g ht s Provision of welfare schemes No time limit is specified for involuntary admissions.

4. ROLE OF INDIAN PSYCHIATRIC SOCIETY(IPS) Later in 1948 , Indian Psychiatric Society was officially established after Independence. Indian Psychiatric Society suggested various changes in Indian Lunacy Act and proposed Mental health bill in 1949. After a long gap of 40 years, Mental Health Act was passed in Parliament in 1987 and came into effect in all states in April 1993. Such a long gap is due to delay in the formation of rules by various state governments.

5. M E N T A L HEALTH ACT, 1987 It contains 10 chapters with 98 sections. MERITS of MHA,1987 Replacement of offensive terminologies of ILA, 1912 Establishment of licensing authorities Provision of admission in special circumstances and outpatient care To be treated without violation of human rights. Appointment of guardians for maintaining property Provision for bearing the expenses of treatment by Government in certain cases.

6. DEMERITS OF MHA,1987 It does not address the fundamental right “right to life and liberty” enshrined in Constitution under Article 21. This act only covered psychiatric hospitals/nursing homes and excluded other places like places where persons will mental illness are kept on the name of de-addiction, rehabilitation, or religious healing, leaving them to follow unstandardized practices. Focussed on hospital-based custodial care, ignoring community care Failure to provide provision for emergency care for helping families of mentally ill Failed to give prominence to choices of persons with mental illness as individual or regarding the range of the treatment

7. India ratified the united nations convention on the Rights of Persons with Disabilities (UNCRPD 2006) in October 2007. Mental health act 1987 was not adequate to protect the rights of persons with mental illness. To fulfil this obligation of the UNCRPD, the new Mental Health care Bill was set in process.

8. PARADIGM SHIFT

9. MENTAL HEALTH CARE ACT 2017 The Convention on Rights of Persons with Disabilities and its Optional Protocol was adopted on the 13th December 2006 at United Nations Headquarters in New York and came into force on the 3rd May, 2008. India has signed and approved the Convention on the 1st October, 2007 Enacted by -Lok Sabha and Passed on -27th March 2017 . Enacted by -Rajya Sabha and Passed on -30th March 2017 The MHCA 2017 on 7th April 2017 got assent of hon’president of India. Came into effect on 29 th May 2018

10. And On the same day i.e. 29 th May 2018 - 3 important laws/rules were also planned, drafted, and notified 1. Mental Health Care Rules 2018 [Rights of Person with Mental Illness under section 121(1) and (3)] 2. Mental Health Care Rules 2018 for Central Mental Health Authority(CMHA) and Mental Health Review Board (MHRB) under section 121 (1) and (3) 3. Mental Health Care Rules 2018 for State Mental Health Authority under section 121 (1) and (4)

11. ON 16 TH AUGUST 2019- 1. Guidance document for assessment of Mental Capacity under [MHCA,2017-Section 81(1)] 2. List of essential drugs under mhca 2017- sec. 8(10) 18 th DECEMBER. 2020- 1. Central Mental Health Regulation was also notified under MHCA 2017- Section 122

12. IT HAS 16 CHAPTERS WITH 126 SECTIONS(CLAUSES) 2 MAIN OBJECTIVES OF MHCA 2017- A. an act to provide for mental health care and services for persons with mental illness B. to protect, promote and fulfill the rights of such persons during delivery of mental health care and services. Mental Health Care Act,2017 for the first time clearly articulated 1 . Mental capacity under section 4 2. Advanced director under section 5 to 13 3. Nominated representative section 14 to 17 4. Right of person with mental illness from under section 18 to 28

13. CHAPTER TITLE SECTION I PRELIMINARY AND DEFINITIONS 1-2 II MENTAL ILLNESS AND CAPACITY TO MAKE MENTAL HEALTH CARE AND TREATMENT DECISIONS 3-4 III ADVANCE DIRECTIVES 5-13 IV NOMINATED REPRESENTATIVE 14-17 V RIGHTS OF PERSONS WITH MENTAL ILLNESS 18-28 VI DUTIES OF THE APPROPRIATE GOVERNMENT 29-32 VII CENTRAL MENTAL HEALTH AUTHORITY 33-44 VIII STATE MENTAL HEALTH AUTHORITY 45-56 IX FINANCE AND AUDIT 57-64 X MENTAL HEALTH ESTABLISHMENT REGISTRATION 65-72 XI MENTAL HEALTH REVIEW BOARD 73-84 XII ADMISSION, TREATMENT AND DISCHARGE 85-99 XIII RESPONSIBILITIES OF OTHER AGENCIES 100-105 XIV RESTRICTION OF DISCHARGE OF FUNCTIONS BY PROFESSIONALS NOT COVERED 106 XV OFFENCES AND PENALTIES 107-109 XVI MISCELLANEOUS 110-126

14. C H A P T E R - I It contains only basic definitions (Section 2) Mental health care (MHC): includes analysis and diagnosis of a person’s mental condition and treatment as well as care and rehabilitation of such person for his mental illness or suspected mental illness. “Informed Consent” means consent given for a specific intervention, without any force, undue influence, fraud, threat, mistake or misrepresentation, and obtained after disclosing to a person adequate information including risks and benefits of, and alternatives to, the specific intervention in a language and manner understood by the person.

15. “Mental Illness” means a disorder of thinking, mood, perception, orientation or memory that grossly impairs j u d g m e n t , behavior , ca p ac it y t o r ec ogn i z e r ea lit y o r a b ilit y t o meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, specially characterized by sub-normality of intelligence.

16. Mental Health Establishment(MHE) : Any health establishment including Ayurveda, Yoga, Naturopathy, Unani, Sidha and Homeopathy (AYUSH) establishment. Where persons with mental illness are admitted and reside at or kept in for care, treatment, convalescence and rehabilitation either temporarily or otherwise includes any general hospital or general nursing home whether private or public. But does not include a family residential place where a person with mental illness resides with his relatives or friends

17. CHAPTER-II (MENTAL CAPACITY) Determination of mental illness (section 3) Capacity to make decisions regarding his/her mental health care or treatment decisions refers to ability to (section 4): Understand the information that is relevant to take a decision on the t r e a t m e n t o r ad m i ss i o n o r p e r s o na l a ss i s t an ce . Appreciate any reasonably foreseen consequence of a decision or lack of decision on the treatment or admission or personal assistance Communicate the decision by means of speech, expression, gesture or any other means

18. CHAPTER-III AD V A NCE DI R E C T I V E ( 5 - 12) A document expressing the way one wishes to receive or not receive mental health care or treatment. Every person, who is not a minor, have a right to make an advance directive in writing, specifying any or all of the following, namely:–– the way the person wishes to be cared for and treated for a mental illness the way the person wishes not to be cared for and treated for a mental illness the individual or individuals, in order of precedence, he wants to appoint as his nominated representative.

19. I n c as e o f m i n o r - T h e l e g al g u ar d i an (Pare nt s o r Care G i v er) Process- Patient/NR’s responsibility to provide the AD copy to the t rea t i n g P s y c h i a t r i s t . Then the psychiatrist has to assess the Mental Capacity of the patient . If patient has lost his/her MC then only AD will be applicable. Every board shall maintain online register of all advance directives registered with it and make them available to c on cer n ed M H P as re qu i re d .

20. POWER TO REVIEW, ALTER, MODIFY OR CANCEL ADVANCE DIRECTIVE (SECTION 11) A mental health professional or a relative or a caregiver of a person desires not to follow an advance directive while treating a person with mental illness, such person shall make an application to the concerned Board to review, alter, modify or cancel the advance directive. It can be override if he has inadequate information or if made contrary to any existing law. It remain effective till the person regains capacity and can be changed any number of times according to the decision of person with mental illness. It can only be amended by two- the person or MHRB . Advance directive doesn’t apply to emergency treatment.

21. LIABILITY OF MEDICAL HEALTH PROFESSIONAL IN RELATION TO ADVANCE DIRECTIVE(SECTION-13) Liability of MHP/MHE in relation to advance directive : A medical practitioner or a mental health professional shall not be held liable for not following a valid advance directive, if he has not been given a copy of the valid advance directive by the family member. A medical practitioner or a mental health professional shall not be held liable for any unforeseen consequences on following a valid advance directive.

22. Chapter-IV Nominated Representative(SECTION 14-17) ❖Any major person can be appointed as per wish of patient making nominated representative. ❖Nomination shall be made in writing on plain paper with the person’s signature or thumb impression of the person referred and is to be registered by MHRB. ❖NR should follow the Supported/shared decision making. ❖Guardians are Nominated Representative for minors unless the Board decides otherwise. ❖Any appointed Nominated Representative or the patient himself/herself or the Family member, treating psychiatrist can apply for revoking NR list. ❖MHRB has the power to amend.

23. WHEN NO NOMINATED REPRESENTATIVE HAS BEEN APPOINTED If no NR is appointed or available or NR refuses to do their duties following people can be appointed by MHRD (Order of precedence ) 1. A relative 2. A caregiver 3. A suitable person appointed as such by the concerned board 4. If no such person is available, the Board shall appoint the Director, Department of Social Welfare or his designated representative as Nominated Representative. Temporary NR- By Psychiatrist.

24. Role and responsibilities of Nominated Representative consider patient’s current and past wishes, the life history, values, cultural background and the best interests of the person with mental illness. Providing support to PWMI for taking decisions on mental health care related such as admission, treatment, discharge and rehabilitation. Apply to the mental health establishment for admission. Be involved in discharge planning Appoint a suitable attendant. Have the right to give or withhold consent for research

25. CHAPTER V-RIGHTS OF PWMI(SEC. 18-28) 18. Right to access mental healthcare. 19. Right to community living. 20. Right to protection from cruel, inhuman and degrading treatment. 21. Right to equality and non-discrimination. 22. Right to information. 23. Right to confidentiality. 24. Restriction on release of information in respect of mental illness. 25. Right to access medical records. 26. Right to personal contacts and communication. 27. Right to legal aid. 28. Right to make complaints about deficiencies in provision of services.

26. SEC.18- RIGHT TO ACCESS MENTAL HEALTH CARE Means state has responsibility for providing all types of services (In-Patient/Out-Patient/Rehabilitation) Should be affordable cost, quality and quantity. Compensatory( if right to access mental health care is not available then central health care and upwards i.e. taluka and district level the compensation has to be provided for seeking treatment form somewhere else) Free treatment for BPL/Destitute Long term treatment care also included like rehabilitation services, shelter accommodation.

27. RIGHT TO PROTECTION FROM CRUEL, INHUMAN AND DEGRADING TREATMENT TREATMENT(SEC. 20) Safe and hygiene environment. Adequate sanitary condition Education and religious practices, within the mental hospitals. Privacy, clothing Not to be forced to undertake any work in mental health establishment and to receive appropriate renumeration for work when undertaken Adequate provision preparing for living in the community.

28. g) Wholesome food, articles of personal hygiene in particular, women personal hygiene(like sanitary napkins) h) No compulsory tonsuring(shaving of head hair) i )To wear own personal clothes if so wished and to not be forced to wear uniforms provided by the establishment, and j)To be protected from all forms of physical, verbal, emotional and sexual abuse.

29. RIGHT TO EQUALITY AND NON-DISCRIMINATION(SEC. 21) Equality to person with physical illness in the provision of all health care. Obligation of the state to provide emergency services for mental illness such as ambulance, adequate and appropriate living conditions similar to physical illness. Health insurance for those with mental illness- insurers make provisions for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness.

30. RIGHT TO INFORMATION(SEC.22) As per the act, PWMI and his NR shall have the rights to the following information- Reason for admission Review of admission procedure What trearment procedure is done and information provided should be in patients language.

31. RIGHT TO CONFIDENTIALITY(SEC.23) Duty to keep information confidential Exceptions are- NR Other mental health professionals(MHP) and other health professionals to enable them to provide care and treatment. Dangerous to self or others Medical emergencies In the interest of public safety and security. Judicial proceedings.

32. RIGHT TO ACCESS MEDICAL RECORDS(SEC. 25) All PWMI shall have the rights to access their basic medical records as may be prescribed May withhold specific information in the medical records. Shall inform the PWMI of his right to apply to the concerned board.

33. RIGHT TO COMMUNITY LIVING(SEC.19) RIGHT TO RESTRICTION ON RELEASE OF INFORMATION IN RESPECT OF MENTAL ILLNESS(SEC.24) RIGHT TO PERSONAL CONTACTS AND COMMUNICATION(SEC. 26) RIGHT TO LEGAL AID(SEC.27) RIGHT TO MAKE COMPLAINTS ABOUT DEFICIENCIES IN PROVISION OF SERVICES(SEC. 28)

34. CHAPTER- X MENTAL HEALTH ESTABLISHMENTS (65-72) • Every person or organization who proposes to establish or run a MHE shall register with CMHA or SMHA. • All Central Government Mental Health Establishment to apply to Central Mental Health Authority in form B of CMHA rules with demand draft of 20,000 rupees drawn in favor of Chairperson, CMHA. Registration process is made simple and easy. • Provisional Registration is issued within 10 days and is valid for 12 months. Permanent registration(within 30 days)

35. CHAPTER-XI MENTAL HEALTH REVIEW BOARDS (MHRB)(SEC. 73-84) A judicial body which periodically review the use of and the procedure for making an advance directive, advise the Govt. on protection of rights of the PWMI. Composition of a MHRB : 1. District judge or Retired District Judge- as chaireperson of the board 2. Representative of District Collector or District Magistrate or Deputy Commissioner of the districts 3. 2 members -1 psychiatrist & 1 medical practitioner 4. 2 members - 1 PWMI or a Caregiver of PWMI & 1 person representing organizations of PWMI or NGOs working in the field of mental health.

36. CHAPTER – XII Ad m i ss i o n , T r e a t m ent a nd Di s ch a r g e ( S 8 5 - 90) Form C Form E Form D Form F

37. INDEPENDENT DISCHARGE S-88 • On request by the patient admitted under S 86 - Application via Form G In case of minor S 87- Application via Form H by NR • MHP can prevent the discharge for 24 hours to assess the Mental Capacity. • Discharge Planning (S 98) -Very essential, applicable for all type of admission. • Leave of absence(S-91)- The medical officer or mental health professional may grant leave to any person with mental illness admitted under section 87,89 or 90, to be absent from the establishment. Application via Form I

38. EMERGENCY TREATMENT (SEC.94) Any medical treatment, including treatment for mental illness, may be provided by any registered medical practitioner to a person with mental illness either at a health establishment or in the community, and where it is immediately necessary to prevent- (a) death or irreversible harm to the health of the person (b) the person inflicting serious harm to himself or to others (c) the person causing serious damage to property belonging to himself or to others where such behavior is believed to flow directly from the person’s mental illness. • Where the nominated representative is available, Informed Consent is to be taken. • Limited to first 72 hours or till the person with mental illness has been assessed at a mental health establishment, whichever is earlier and may extend up to seven days during disaster or emergency declared by government.

39. PROHIBITED TREATMENT ( S-95 S-96) Electro-convulsive therapy without the use of muscle relaxants and anesthesia. (b) Electro-convulsive therapy for minors. (c) Sterilization of men or women, when such sterilization is intended as a treatment for mental illness (d) Chained in any manner or form Restriction of psychosurgery for patients with mental illness (Chapter XII, Section 96). Should Apply and permission should be taken from the concerned MHRB before performing psychosurgery.

40. USE OF RESTRAINTS AND SECLUSION( S- 97) Seclusion or Solitary Confinement is prohibited. Physical Restraints- It is the only means available to prevent imminent and immediate harm to person concerned or to others. It is authorized by the psychiatrist. During the period of restraints every vitals, symptoms progression is to be measured minutely. Physical restraint shall not be used for a period longer than it is absolutely necessary to prevent the immediate risk of significant harm The Nominated Representative shall be informed about every instance of restraint within a period of twenty four hours . The mental health professional in charge shall be responsible for ensuring that the method, nature, justification, and duration of restraint shall be recorded in medical notes.

41. CHAPTER-XIII RESPONSIBILITIES OF OTHER AGENCIES (S-100-105) Duties of police officers in respect of persons with mental illness (S-100) 1. To take under protection any person found wandering and believed to have mental illness or to be a risk to himself or others. 2. Police officer within 24 hours will take the person to a Public Health Establishment for assessment. 3. If medical assessment does not reveal mental illness, the person shall be taken to his residence or to a Government establishment if he is homeless.

42. In MHA 1987, it was not possible to discharge an homeless person with mental illness( HPMI ) without a certificate from the District Court. In the MHCA 2017, the medical officer “informs” the police officer, who later, in accordance with the act, reintegrates him/her to the family or a government establishment for homeless persons (Section 100, Subsection 6). There is no involvement of the judiciary in either admission or discharge of HPMI

43. SEC. 101 REPORT TO MAGISTRATE Any person, who has reason to believe that a person has mental illness and is being ill treated or neglected shall report to police Every officer in-charge of a police station, who has reason to believe that any person residing within the limits of the police station has a mental illness and is being ill treated or neglected, will report to the magistrate. Sec.101(3)- report to magistrate of PWMI in private residence who is ill treated or neglected The magistrate may cause the PWMI to be produced before him and pass an order in accordance with the provisions of sec.102

44. SEC. 102- ADMITTING PWMI SEC. 102 conveying or admitting PWMI to mental health establishment by magistrate. Public health establishment. Not exceeding 10 days. After the psychiatrist /MO needs to deal with such person in accordance with the provision of act( admit under sec. 86,89,90 depending on the situation).

45. HALFWAY HOMES • A halfway home is a less restrictive transitional living facility for persons with mental illness who are discharged as inpatient from a mental health establishment but are not fully ready to live independently on their own or with the family. • Persons with mental illness on discharge from a mental health establishment may seek admission in a Government run or Government funded halfway home. • A person with mental illness who has not been admitted as an inpatient but is advised by a mental health professional for admission in a Halfway Home may also be admitted. • Admission and discharge in Half-way home as per the Mental Healthcare Act, 2017 • It shall provide social, medical, psychiatric, educational, and other related services to inmates.

46. CHAPTER - XV OFFENCES AND PENALTIES (107-109) Penalties for establishing or maintaining mental health establishment in contravention of provisions of this Act (S 107)- Whoever carries on a mental health establishment without registration: First contravention :5000/- to 50,000/- Second contravention :50,000 – 2,00000/- Subsequent contravention: 2 lakh to 5 lakh Whoever knowingly serves as a mental health professional in a mental health establishment without registration, shall be liable to a penalty of 25,000/- rupees. State Authority will adjudicate this section, not by MHRB.

47. Any person who contravenes any of the provisions of this Act (S108)- First contravention – imprisonment for six months or fine of ten thousand rupees or with both. Subsequent contravention – imprisonment for two years or with a fine of fifty thousand to five lakh rupees or with both. Offences by companies(S-109): – Where an offence is committed by a company, every person who at the time the offence was in-charge of the company shall be deemed to be guilty.

48. CHAPTER - XVI MISCELLANEOUS (110 -126) S-110:Power to call for information S-111: Power of Central Government to issue directions S-112: Power of Central Government to supersede Central Authority. S-113: Power of State Government to supersede State Authority. S-114: Special provisions for States in Northeast and Hill states. S-115 :Presumption of severe stress in case of attempt to commit suicide

49. PROVISION FOR DECRIMINALIZATION OF SUICIDE IN CHAPTER-XVI Section 115 of the act provides for de-criminalizing suicide attempts (section 309 IPC). A person who attempts suicide shall be presumed to be suffering from severe stress at that time and will not be punished under Indian Penal Code.

50. MERITS OF MHCA, 2017 The act provides a framework and regulation on how a person with mental illness should be treated. There is much emphasis on the protection of the human rights of persons with mental illness. The MHCA 2017 brings about more impetus on documentation, with reasons for decisions made and care given are important for good practice The Act includes substance use disorder (SUD) specifically in the definition of mental illness. This displays the intent of policymakers toward SUD. The new Mental Healthcare Act (MHCA), 2017 has brought in a list of rights for HPMI-right to community living and all other rights of PWMI

51. CRITICISM:MHCA 2017 ❖Admission procedure has become more tedious. ❖Availability and approachability of MHRB. ❖The act undermines the role of family members. Even when admission is involuntary, Psychiatrists need to take into account advance directive (AD)/ consent of the nominated representative (NR)/ assess capacity periodically and treat. This is time-consuming, resource-consuming, and a hindrance in patient care and discharge of duties by the psychiatrist.

52. THANK YOU