Theme: Mental Health

Admission and Discharge in Mental Health Establishments

Admission and discharge in a mental health establishment can be in the following ways:

In the independent mode of admission and discharge, the person has the capacity to make mental health care and treatment decisions, or requires very less support in making such decisions. Therefore, as an independent patient, one consents to every treatment decision. The person is also free to discharge themselves from the establishment.

In the supported mode of admission and discharge,  the person with mental illness does not have the capacity to make mental health care and treatment decisions, or requires very high support in making such decisions.

In addition, separate rules exist for admission as a minor.

  1. The Mental Healthcare Act, 2017 [↩]

Independent Admission and Discharge

Independent admission means the admission of a person who has the capacity to make mental health care decisions, or requires very less support in making them. An independent patient is given treatment only after informed consent((Section 86(5),  the Mental Healthcare Act, 2017. )) (i.e. permission given after complete knowledge of the treatment and its consequences). Additionally, an independent patient must follow the rules of the establishment, if admitted((Section 86(4),  the Mental Healthcare Act, 2017 )).

Criteria for Admission

The mental health professional in charge of the establishment must ensure that((Section 86(2),  the Mental Healthcare Act, 2017 )) :

  • The person has a mental illness severe enough to require admission,
  • They will benefit from the admission
  • They have understood the nature and purpose of admission
  • The person has made the request for admission of their own free will and have the capacity to take mental health care and treatment decisions.

Procedure for Admission

A person can admit themselves in an establishment if they want to and are above the age of 18 years. To do this, they must request the professional in charge of the establishment((Section 86(2),  the Mental Healthcare Act, 2017 )). The professional does not require permission from anyone to admit an independent patient. For example, the nominated representative or the caregiver((Section 86(6),  the Mental Healthcare Act, 2017 )).

Discharge

A person does not need the permission of the professional for discharge((Section 86(7),  the Mental Healthcare Act, 2017 )). Additionally, they should be discharged immediately((Section 88(1),  the Mental Healthcare Act, 2017 )). However, the person may be retained for 24 hours to assess whether they need to be admitted as a supported patient.  However, this happens only if the professional believes that((Section 88(3),  the Mental Healthcare Act, 2017 )):

  • The person is unable to understand the nature and purpose of their decisions and requires substantial support from their nominated representative
  • They have recently threatened/attempted to cause physical harm to themselves
  • The person has recently behaved violently towards someone else or has caused someone else to fear physical harm from them
  • They have recently shown an inability to care for themselves to the extent that they pose a danger to themselves.

 

Supported Admission and Discharge

The supported mode of admission and discharge means that the person being admitted does not have the capacity to make mental health care decisions, or requires very high support. All admissions in a mental health care establishment should be independent, except when supported admission is necessary((Section 85(2),  the Mental Healthcare Act, 2017 )).

Supported Admission for 1 month

Criteria and Procedure for Admission

The nominated representative must make an application to the mental health professional in-charge of the establishment. The criteria is as follows:((Section 89(1),  the Mental Healthcare Act, 2017 )).

  • A psychiatrist and a mental health professional/medical practitioner have examined the person within the last 7 days. Additionally, both must conclude that the mental illness is severe enough that they have recently:
    • Attempted/threatened to cause physical harm to themselves
    • Behaved violently towards someone else or have caused someone else to fear physical harm
    • Shown an inability to care for themselves to the extent that they pose a harm to themselves
  • The professional certifies (after considering the advance directive) that admission to the establishment is the least restrictive care option possible
  • The person is ineligible to be an independent patient due to inability to make treatment decisions independently and requirement of a very high support from their nominated representative.

Treatment

Before treatment, the following is considered:((Section 89(6),  the Mental Healthcare Act, 2017 ))

  • An advance directive, if any
  • Informed consent (i.e. permission given after complete knowledge of the treatment and its consequences). If the person is not able to give informed consent, the nominated representative may do so on their behalf((Section 89(7),  the Mental Healthcare Act, 2017 )). In such a case, the consent must be recorded in the medical records by the professional in-charge. Additionally, the professional must review the person’s capacity to give consent every 7 days((Section 89(8),  the Mental Healthcare Act, 2017 )).

Discharge 

Once the person stops meeting the criteria mentioned above, they may be discharged from the establishment. The professional must inform them/their nominated representative((Section 89(5),  the Mental Healthcare Act, 2017 )).

For the next 7 days after discharge, they cannot be readmitted((Section 89(15),  the Mental Healthcare Act, 2017 )). If these conditions are not met, they may remain in the establishment as a patient((Section 89(5),  the Mental Healthcare Act, 2017 )).

Supported Admission for more than 1 month

Criteria and Procedure for Admission

If the person requires continuous treatment beyond 30 days or has to be readmitted within 7 days of discharge, the nominated representative must make an application to the professional in-charge. The professional will continue admission of the person if((Section 90(2),  the Mental Healthcare Act, 2017 )):

  • Two psychiatrists have examined them independently within the last 7 days. Additionally, both conclude that the mental illness is severe enough that the person has consistently over time:
    • Attempted/threatened to cause physical harm to themselves
    • Behaved violently towards someone else or caused  someone else to fear physical harm
    • Shown an inability to care for themselves to the extent that they poses a harm to themselves
  • Both the psychiatrists certify (after considering the advance directive) that admission to the establishment is the least restrictive care option possible.
  • The person is ineligible to be an independent patient due to inability to make treatment decisions independently and requirement of a very high support from their nominated representative.

The Mental Health Review Board must review and permit such an admission((Section 90(4),  the Mental Healthcare Act, 2017 )). The admission is for 90 days((Section 90(8),  the Mental Healthcare Act, 2017. )). It can be extended to 120 days at the first instance, and after that, to 180 days at every instance, as required, with the Mental Health Review Board’s permission((Section 90(9),  the Mental Healthcare Act, 2017 )).

Treatment 

Before treatment, the following is considered:((Section 90(11),  the Mental Healthcare Act, 2017 ))

  • The advance directive, if any
  • Informed consent (i.e. permission given after complete knowledge of the treatment and its consequences). If the person is not able to give informed consent, their nominated representative may do so on their behalf((Section 90(12),  the Mental Healthcare Act, 2017 )), and in such a case, the consent must be recorded in the medical records by the professional, who must also review the person’s capacity to give consent every 15 days((Section 90(13),  the Mental Healthcare Act, 2017 )).

Discharge 

Once the professional believes that the person has stopped meeting the criteria mentioned above, they will be discharged from the establishment, and the person and their nominated representative must be informed((Section 90(15),  the Mental Healthcare Act, 2017 )). However, they may remain in the establishment as an independent patient((Section 90(16),  the Mental Healthcare Act, 2017 )).

Rights of Persons with Mental Illness

Persons with mental illness have certain rights((Mental Healthcare Act, 2017 )) so as to safeguard them from discrimination and harm. These rights are:

Right to make an Advance Directive

An advance directive is a legal document. In other words, it specifies healthcare decisions that should be taken for a person in the event they are not capable of making such decisions. Persons with mental illness can take the help of a service provider, NGO or lawyer to make this document.

Right to appoint a Nominated Representative 

A nominated representative is a person who is appointed by a person with mental illness to discharge certain duties. This includes provision of support to the person while making treatment decisions, helping such a person get admitted to a mental health establishment if required, etc.

Right to Access Mental Healthcare

A person with mental illness has the right to access mental health care from government-funded mental healthcare services, such as inpatient and outpatient services, half-way homes, sheltered accommodation etc. They can also get services to support the family of the person with mental illness.

Right to Community Living 

A person with mental illness has the right to community living. They can live with and be a part of society and not be forced to live in isolation, etc. For example, someone with mental illness need not live in an abandoned. They can live in a residential area and be a part of society.

Right to Live with Dignity

Every person with a mental illness has a right to live with dignity. In other words, protection from cruel, inhuman or degrading treatment in any mental health establishment.

Right to Equality and Non-discrimination

Every person with mental illness has a right to equality and non-discrimination. For example, persons with physical illness have the same rights as those with physical illnesses.

Right to Information

A person with mental illness and their  nominated representative have the right to ask for information. For instance, information about the person’s mental illness, treatment plan, any side effects, about the criteria for admission in a mental health establishment, about the law governing provision of care to people with mental illness, etc. 

Right to Confidentiality

A person with mental illness has the right to confidentiality. This includes information on their mental health, mental healthcare and physical healthcare. However, there are certain exceptions to this. 

Right to Legal aid

A person with mental illness has a right to free legal aid. Legal aid means providing free of cost legal services including Representation by a lawyer in legal proceedings, payment of all costs including process fees, expenses of witnesses etc.

Right to Complain

In case of deficiency of care treatment and related services in a mental health establishment, a person with mental illness or their nominated representative have the right to complain. 

Right to Communication

A person with a mental illness who is admitted to a mental health establishment has the right to communicate with their personal contacts. This includes the right to receive or refuse visitors, to send and receive electronic mail, etc. 

The law punishes mental health establishment or any other person who violate these rights. The punishment is  jail time of up to 6 months and/or a fine up to Rs. 10,000 for the first offence. For any subsequent offence, the jail time is up to 2  years and/or with a fine between Rs. 50,000 to 2 lakhs((Section 108,  the Mental Healthcare Act, 2017 )). You should complain against such a person, or approach the Court with the help of a lawyer.

Making an Advance Directive

An advance directive is a legal document that specifies the healthcare decisions that should be taken for a person in case they are not capable of making such decisions. It comes into force when someone no longer has the capacity to make healthcare-related decisions. Once the person regains the ability to make mental healthcare decisions, then the advance directive ceases to be operational.

The document has to include((Section 5(1),  the Mental Healthcare Act, 2017 )):

Only major persons  (those who have completed 18 years of age) can make this document. Please note that any decision taken by a person (when they have the ability to make such decisions) will override the advance directive((Section 5(4),  the Mental Healthcare Act, 2017 )). However, if a person requires emergency treatment((Section 9,  the Mental Healthcare Act, 2017. )) then the directions in the advance directive need not be followed. For example, the advance directive does not apply in suicide cases.

To make the document, you should approach an NGO which works in this field or a lawyer, who will be able to help you out.

Appointing Someone on your Behalf

A nominated representative is a person who is appointed by a person with mental illness to discharge the following duties((Section 17,  the Mental Healthcare Act, 2017 )):

  • Consider the wishes, life history, values, cultural background and the best interests of the person with mental illness, and give importance to their views regarding such decisions.
  • Provide support to the person with mental illness in making treatment decisions.
  • Seek information on diagnosis and treatment to provide adequate support to the person with mental illness.
  • Have access to the family/home-based rehabilitation services with respect to the person with mental illness.
  • Be involved in discharge planning. This includes, discharge back into the community or transfer of their care to a new psychiatrist/mental health establishment.
  • Apply to the mental health establishment for admission of the person with mental illness.
  • Apply to the concerned Mental Health Review Board on behalf of the person with mental illness for discharge or to complain regarding any violation of rights.
  • In case of the admission of a minor in the mental health establishment, appoint a suitable attendant who will stay with the minor.
  • Have the right to give/withhold consent for research that can be conducted on the person with mental illness.

Criteria for Appointment of a Nominated Representative

To appoint a nominated representative, a person should be((Section 14(3),  the Mental Healthcare Act, 2017. )):

  • Major (above 18 years of age)
  • Competent to discharge their duties
  • Able to give written consent to being the nominated representative. However, the respective mental health professional should get this in writing.

Order of Appointment of a Nominated Representative

If you are a person with mental illness, you can yourself appoint a nominated representative. However, if you do not appoint  a nominated representative, then the following people shall be considered as your nominated representative (in  this order from first to last)((Section 14(4),  the Mental Healthcare Act, 2017 )):

  • The individual appointed as a nominated representative in the advance directive
  • A relative
  • A caregiver
  • A person appointed by the Mental Health Review Board
  • The Director of the Department of Social Welfare, or their designated representative

Additionally, to appoint a nominated representative, you should approach an NGO which works in this field or a lawyer, who will be able to help you out.

Confidentiality of Health Related Information

The right to confidentiality of a person with mental illness about their mental health, mental healthcare and physical healthcare((Section 23(1),  the Mental Healthcare Act, 2017 )) means that the mental health professional who is providing care/treatment must keep all such health related information private, and not reveal it without the person’s consent .

This also includes the release of information to the media, such as the release of photographs or any other information without consent((Section 24(1),  the Mental Healthcare Act, 2017 )).

For instance, information is released by the relevant medical professional in the following cases((Section 23(2),  the Mental Healthcare Act, 2017 )):

  • To the nominated representative to enable them to fulfil their duties
  • To other health professionals to enable them to provide care and treatment
  • If it is necessary to protect any person from harm or violence or threat to life
  • On an order by an authority, such as the Mental Health Review Board, High Court, Supreme Court, etc.
  • In the interests of public safety and security.

The right to confidentiality of the person with mental illness applies to all information stored in electronic or digital format.((Section 24(2),  the Mental Healthcare Act, 2017 )).

Living in Society

Every person with a mental illness has a right to((Section 19(1),  the Mental Healthcare Act, 2017 )) live with and be a part of the society or community. In other words, just because a person with mental illness has no family or is homeless does not mean that they will be institutionalized in a mental health establishment.

Sometimes the family may abandon the person with mental illness. In such situations, it is the duty of the government to provide appropriate support, such as:

  • Legal aid
  • Community-based establishments, such as half-way homes, group homes, etc.,
  • Facilitate them living with their family/in the family home((Section 19(2)(3),  the Mental Healthcare Act, 2017 ))

For example, it is the duty of the government to find accommodation for beggars. The government cannot force them to stay in a mental health establishment.

Right to Access Mental Healthcare

Every person has the right to access mental health care from government-funded mental healthcare services. These services include((Section 18(4),  the Mental Healthcare Act, 2017 )):

  • Acute mental healthcare services like outpatient and inpatient services
  • Half-way homes, sheltered accommodation, supported accommodation
  • Mental health services to support the family of a person with mental illness or home-based rehabilitation
  • Hospital, community-based rehabilitation establishments and services
  • Child mental health services and old age mental health services.

Cost of Mental Health Services 

The government must make the medicines, as mentioned on the Essential Drug List, free of charge for all persons with mental illness at mental health establishments run/funded by the government((Section 18(10),  the Mental Healthcare Act, 2017 )). Persons with mental illness who are destitute, homeless, or living below poverty line, are entitled to free mental healthcare services. They can approach mental health establishments run/funded by the government((Section 18(7),  the Mental Healthcare Act, 2017. ))

Right to Equality and Non-Discrimination

Every person with mental illness has a right to equality and non-discrimination including((Section 21(1),  the Mental Healthcare Act, 2017 )):

  • No discrimination against a person with mental illness on any basis. This includes reasons such as gender, sex, sexual orientation, religion, culture, caste, social or political beliefs, class or disability
  • Emergency facilities and services  of good quality, and  of the same quality and availability as those provided to persons with physical illness
  • Ambulance services  of the same manner, extent and quality as provided to persons with physical illness
  • Good living conditions in health establishments , of the same manner, extent and quality as provided to persons with physical illness
  • Any other health services provided to persons with physical illness, of the same manner, extent and quality as provided to persons with physical illness

The law punishes mental health establishment or any other person who violate these rights. The punishment is jail time of up to 6 months and/or a fine up to Rs. 10,000 for the first offence. For any subsequent offence, the jail time is up to 2  years and/or with a fine between Rs. 50,000 to 2 lakhs((Section 108,  the Mental Healthcare Act, 2017 )). You should complain against such a person, or approach the Court with the help of a lawyer.