Forensic Psychiatry : Mental Health Care Act

Mental Health Care Act: MHCA 2017

A new legislation that deals with treatment and rights of patients with mental illness, replacing the older act MHCA-1987.

Mental Health Establishments

Hospitals where patients with mental illness are treated.

Capacity

• Capacity to make mental health care or treatment-related decisions.
• Ability to understand the information relevant to making decisions related to treatment.
• Understand the consequences of decisions or lack of decisions.
• Ability to communicate decisions—verbally or through writing.

Advance Directive

Every person who is not a minor can make an advance directive. He can mention:

• The way he wishes to be treated for a mental illness.
• The way he wishes not to be treated for a mental illness.
• Can also mention whom he wants to appoint as a nominated representative.

Applicable only when he/she loses the capacity to take decisions.

Duty of the Psychiatrist

• To ensure that treatment is being given according to the advance directive made by the patient.

Responsibility of Patient/Caregiver/Nominated Representative

• Give access to advance directives.
• If unforeseen consequences arise due to following a valid advance directive, the doctor cannot be held liable for the same. Not applicable in emergency treatment.

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Nominated Representative

Any person can appoint a nominated representative.

• Should not be a minor.
• Competent in discharging the duties as a nominated representative.
• Can be removed if he wishes to.
  • If a person lose capacity to make mental health care or treatment-related decisions, his nominated representative will help (or will take) in taking decisions related to treatment of the person
  • For minors: Legal guardians shall be the nominated representative

Admission of Person with Mental Illness

Independent Admissions

• If he wishes to get admitted when he has capacity to make mental health care or treatment-related decisions.
• Section 86: Deals with Independent Admission and Treatment.
• Section 87: Admission of minors.

Supported Admission

For those who need admission due to threatened/attempted bodily harm to himself or others, or are unable to take care of themselves or lose capacity to make mental health care or treatment decisions. Nominated repre Ji sentatives can give consent for admission.

• Section 89: Admission and treatment of person with mental illness with high support needs up to 30 days.
• Section 90: Admission and treatment of persons with mental illness with high support needs beyond 30 days.

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Prohibited Procedures

• ECT (Electroconvulsive Therapy) without the use of anesthesia and muscle relaxants: Direct ECT is banned.

APA recommends that:

• ECT can be considered for clozapine-resistant schizophrenia or in combination with other antipsychotics.
• Especially for those who have catatonia, significant suicide risk, or require rapid response due to the severity of their psychiatric or medical condition.
• For patients who show a response to ECT, maintenance treatment with ECT could be considered as an adjunct to clozapine or other antipsychotics.

Indications for ECT:

1. Catatonia
2. Affective symptoms
3. Rapid control of symptoms
4. Suicidality
5. Past response to ECT
6. Augmentation, etc.

Non-pharmacological:

1. Psychoeducation
2. Psychosocial intervention

ECT for Minors: If the psychiatrist considers the need:

• Take informed consent from the guardian.
• Permission from the mental health review board.
• Sterilization of men and women: If intended as treatment for mental illness.
• Chaining in any manner: No chaining whatsoever.
• Restriction of psychosurgery for persons with mental illness: If considers the need, take informed consent from the patient and approval from the mental health review board.

Restraints and Seclusions

Physical restraint may only be used:

• If it is the only means to prevent harm to the patient or others.
• Authorized by the psychiatrist in charge of the patient and mental health establishment.

Decriminalization of Suicide

Any person who attempts to commit suicide shall be presumed to have severe stress and shall not be tried or punished under Section 309 IPC.

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Protection of Children from Sexual Offenses Act (POCSO 2012)

Legal framework for the protection of children against sexual offenses for both male and female children. Protects children from offenses of:

• Sexual harassment
• Sexual assault
• Penetrative sexual harassment (vaginal, anal, oral)
• Child pornography

Aggravated (Penetrative) Sexual Assault

If sexual assault on a child is done by a person in a position of authority (armed forces, police, public servant, management of remand room, hospital), when:

• Gang is involved.
• Deadly weapons are used.
• Caused grievous hurt.
• Inflicted life-threatening disease like HIV.
• Attempted murder.
• Caused the child to become mentally ill.
• Made the female child pregnant.
• Done repeatedly.
• Child < 12 years.
• Done during communal or sectarian violence.

Reporting of Cases

Any person who has knowledge that an offense under the POCSO Act is committed or likely to be committed shall inform the special juvenile police unit/local police.

Criminal Responsibility

A socially harmful act is not the sole criterion for whether a crime is committed. There are 2 components of the crime:

• Voluntary conduct (Actus reus)
• Evil intent (Mens rea): Cannot exist if the offender's mental status is so deficient or diseased that he lacks capacity for rational intent.

Section 84 IPC

Embodies McNaughton's rule: Nothing is an offense which is done by a person who, at the time of doing it:

• By reason of unsoundness of mind, he is incapable of knowing the nature of the act or that he is doing what is either wrong or contrary to the law.

Example: If a patient has the delusion of persecution that his neighbor is trying to kill him, if he kills the neighbor before being killed, he may not be held responsible for the act.

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Durham Rule

An accused person is not criminally responsible if his or her unlawful act was a product of mental illness or mental defect. This rule was later discarded in the USA.

Curren's Rule

An accused person will not be criminally responsible for his act if, at the time of committing the act:

• He did not have the capacity to regulate his conduct to the requirements of law.
• Or, as a result of a mental disease or defect.

Section 85 IPC

Criminal responsibility of an intoxicated person: If a person is so intoxicated at the time of committing the act that he is incapable of judging the nature of the act or that he is doing wrong or contrary to the law, then he has not committed an offense, provided that he was administered the substance against his will or without his knowledge.

Section 86 IPC

An intoxicated person with voluntary drunkenness is criminally responsible if he had the intention or knowledge of committing a crime.

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