Mental Healthcare Act,2017 (MHCA),from Paper to Clinical Practice in the Mental Health Settings

Sir,

The Mental Health Care Act, 2017, ¹ was implemented in the country for ensuring the rights of persons with mental illness (PwMI). ² Since its launch, it has been critiqued by the scientific community, highlighting its shortcomings and issues with implementation.^3–5 However, such critiques did not explicitly highlight the issues with the implementation of the MHCA in routine clinical discourse. Hence, we intend to highlight the practical challenges in implementing MHCA in the routine clinical practice, based on our experience of following MHCA over the last few years, particularly those related to the nonavailability of Mental Health Review Boards (MHRBs) and community-based mental health (CB-MH) services, and potential ways out.

The MHRB is the main quasi- judiciary body for the enforcement of the law. ⁶ The foundation of mental health care and rights of PwMI under MHCA involves and requires the active participation of the MHRB. However, because of the lack of the MHRBs, mental health professionals (MHPs) often struggle in balancing between providing quality care to the PwMI and being legally and ethically correct.^7,8 Some of the contentious issues are highlighted as follows:

A PwMI admitted to a mental health establishment (MHE) with high support needs (Section 89) should be treated as per one’s advanced directives (ADs), if made earlier, and it is the responsibility of the MHRBs to make it available for the MHPs (Sections 5, ss 7). Moreover, revocation, cancellation, or amendment in the ADs must be channeled through the MHRB upon request of the nominated representatives [Section 11(1)]. However, ADs are currently not available for the MHPs in most cases because of the absence of a functional MHRB; furthermore, in the absence of the MHRB, any amendment in ADs concerning the treatment (e.g., in case of conflicting opinions of the PwMI, their nominated representatives, and/or MHPs about the treatment) cannot be made, thus posing challenges for the MHPs in providing treatment.

All admissions of a minor (independent or with high support needs), admission of PwMI with high support needs (female and male), prolonged admission (beyond 30 days; Section 90, ss 1), readmissions within seven days of discharge of a person previously admitted with high support needs (Section 90, ss 3) say for maintenance modified electroconvulsive therapy, drug-related adverse events, worsening of symptoms, etc. are to be conveyed to the MHRBs within the stipulated time. However, the nonavailability of the MHRBs creates an undue fear or dilemma among the MHPs as to how to balance one’s clinical decisions with the duty to inform the MHRBs about such admissions, which may discourage them from admitting such individuals or discharging them prematurely (depicted in case vignette, online-only supplementary file 1).

Similarly, for prohibited procedures (modified electroconvulsive therapy for minors, psychosurgery) and interventional research conducted on a person who is unable to give free and informed consent, approval of the MHRB (Section 95) and state mental health authority (SMHA; Section 99, ss 2), respectively, are required.1 The lack of MHRBs, also SMHAs in a few states, or the formalities involved therein may adversely affect the clinical decisions (being contemplated or taken for the PwMI) of the MHPs for fear of being scrutinized or facing inadvertent legal consequences.

MHCA rules that the MHPs should not prolong the admission of PwMI for the lack of CB-MH services and to prepare the continuity of care for those requiring repeated admissions (Sections 18, 19, 90, and 98). Because of the nonavailability of the CB-MH services, ⁹ there is a possibility that a proportion of the PwMI who are symptomatic, yet do not fulfil the criteria for supported admission, ends up becoming long-stay patients in mental health institutions; however, MHCA does not allow this, raising dilemmas on where these patients should be sent? Alternatively, the symptomatic person or those at high risk of relapse postdischarge because of the lack of CB-MH services may require a hospitalization beyond 30 days. However, because of the nonavailability of the MHRB, the MHPs may become apprehensive in continuing the hospitalization for not being able to fulfil the formalities.

MHCA mandates monthly reporting to the MHRBs of restraints imposed on the PwMI in the MHEs (Section 97). Similarly, MHRBs are the appellate bodies for the PwMI to register complaints against the MHE for any deficiency in care. However, the absence of MHRBs limits the much-needed supervision on the MHEs and undermines the rights of PwMI (and their caregivers/nominated representatives) to seek redressal for their concerns.

Lastly, MHCA entrusts states to implement the Act (including setting up SMHAs, MHRBs, CBMH services, etc.; Sections -55, 61, 62, 115[2]). Poor mental health budget and human resources ¹⁰ in most of the states may impact their political will to implement the Act, thus can act as an impediment in the setting up of MHRBs.

Way Ahead

The following steps can be useful to overcome the aforementioned challenges:

For issues related to treatment (including ensuring best possible supported treatment decisions in case of difference in opinions among the stakeholders), research, or rights of PwMI, an institute-level medical board (involving an MHP, legal expert, community members, preferably persons with lived experience, from outside the institute) should be constituted for adjudication till the MHRBs are formed.

The center should support the states, maybe on a one-time basis, in line with the national/district mental health program (NMHP/DMHP) so that SMHAs/MHRBs get established expeditiously.

There is a need to establish MHRBs at the earliest. Untill then, some interim arrangements should be made for ensuring the rights of PwMI and to bring about clarity in clinical practice.

CB-MH services must be strengthened by effectively implementing DMHP and CB-MH services for ensuring the rights of PwMI to receive treatment in the least restrictive environment.

Till CB-MH services are established, there should be a provision, on an interim basis, if it is deemed necessary by the psychiatrist and the psychological social worker of the MHEs that CB-MH services are unavailable/unaffordable, or prolongation of admission is required for sustained improvement, a prolonged hospitalization may be encouraged with the consent of caregivers (and/or of PwMI).

Supplementary Material

The supplementary material for this article is available online.