XII: ADMISSION, TREATMENT AND DISCHARGE

85. (1) For the purposes of this Act, “independent patient or an independent admission” refers to the admission of person with mental illness, to a mental health establishment, who has the capacity to make mental healthcare and treatment decisions or requires minimal support in making decisions.

(2) All admissions in the mental health establishment shall, as far as possible, be independent admissions except when such conditions exist as make supported admission unavoidable.

Independent admission and treatment

86. (1) Any person, who is not a minor and who considers himself to have a mental illness and desires to be admitted to any mental health establishment for treatment may request the medical officer or mental health professional in charge of the establishment to be admitted as an independent patient.

(2) On receipt of such request under sub-section (1), the medical officer or mental health professional in charge of the establishment shall admit the person to the establishment if the medical officer or mental health professional is satisfied that––
(a) the person has a mental illness of a severity requiring admission to a mental health establishment;
(b) the person with mental illness is likely to benefit from admission and treatment to the mental health establishment;
(c) the person has understood the nature and purpose of admission to the mental health establishment, and has made the request for admission of his own free will, without any duress or undue influence and has the capacity to make mental healthcare and treatment decisions without support or requires minimal support from others in making such decisions.

(3) If a person is unable to understand the purpose, nature, likely effects of proposed treatment and of the probable result of not accepting the treatment or requires a very high level of support approaching hundred per cent. support in making decisions, he or she shall be deemed unable to understand the purpose of the admission and therefore shall not be admitted as independent patient under this section.

(4) A person admitted as an independent patient to a mental health establishment shall be bound to abide by order and instructions or bye-laws of the mental health establishment.

(5) An independent patient shall not be given treatment without his informed consent.

(6) The mental health establishment shall admit an independent patient on his own request, and shall not require the consent or presence of a nominated representative or a relative or care-giver for admitting the person to the mental health establishment.

(7) Subject to the provisions contained in section 88 an independent patient may get himself discharged from the mental health establishment without the consent of the medical officer or mental health professional in charge of such establishment.

Admission of minor

87. (1) A minor may be admitted to a mental health establishment only after following the procedure laid down in this section.

(2) The nominated representative of the minor shall apply to the medical officer in charge of a mental health establishment for admission of the minor to the establishment.

(3) Upon receipt of such an application, the medical officer or mental health professional in charge of the mental health establishment may admit such a minor to the establishment, if two psychiatrists, or one psychiatrist and one mental health professional or one psychiatrist and one medical practitioner, have independently examined the minor on the day of admission or in the preceding seven days and both independently conclude based on the examination and, if appropriate, on information provided by others, that,—
(a) the minor has a mental illness of a severity requiring admission to a mental health establishment;
(b) admission shall be in the best interests of the minor, with regard to his health, well-being or safety, taking into account the wishes of the minor if ascertainable and the reasons for reaching this decision;
(c) the mental healthcare needs of the minor cannot be fulfilled unless he is admitted; and
(d) all community based alternatives to admission have been shown to have failed or are demonstrably unsuitable for the needs of the minor.

(4) A minor so admitted shall be accommodated separately from adults, in an environment that takes into account his age and developmental needs and is at least of the same quality as is provided to other minors admitted to hospitals for other medical treatments.

(5) The nominated representative or an attendant appointed by the nominated representative shall under all circumstances stay with the minor in the mental health establishment for the entire duration of the admission of the minor to the mental health establishment.

(6) In the case of minor girls, where the nominated representative is male, a female attendant shall be appointed by the nominated representative and under all circumstances shall stay with the minor girl in the mental health establishment for the entire duration of her admission.

(7) A minor shall be given treatment with the informed consent of his nominated representative.

(8) If the nominated representative no longer supports admission of the minor under this section or requests discharge of the minor from the mental health establishment, the minor shall be discharged by the mental health establishment.

(9) Any admission of a minor to a mental health establishment shall be informed by the medical officer or mental health professional in charge of the mental health establishment to the concerned Board within a period of seventy-two hours.

(10) The concerned Board shall have the right to visit and interview the minor or review the medical records if the Board desires to do so.

(11) Any admission of a minor which continues for a period of thirty days shall be immediately informed to the concerned Board.

(12) The concerned Board shall carry out a mandatory review within a period of seven days of being informed, of all admissions of minors continuing beyond thirty days and every subsequent thirty days.

(13) The concerned Board shall at minimum, review the clinical records of the minor and may interview the minor if necessary.

Discharge of independent patients

88. (1) The medical officer or mental health professional in charge of a mental health establishment shall discharge from the mental health establishment any person admitted under section 86 as an independent patient immediately on request made by such person or if the person disagrees with his admission under section 86 subject to the provisions of sub-section (3).

(2) Where a minor has been admitted to a mental health establishment under section 87 and attains the age of eighteen years during his stay in the mental health establishment, the medical officer in charge of the mental health establishment shall classify him as an independent patient under section 86 and all provisions of this Act as applicable to independent patient who is not minor, shall apply to such person.

(3) Notwithstanding anything contained in this Act, a mental health professional may prevent discharge of a person admitted as an independent person under section 86 for a period of twenty-four hours so as to allow his assessment necessary for admission under section 89 if the mental health professional is of the opinion that––
(a) such person is unable to understand the nature and purpose of his decisions and requires substantial or very high support from his nominated representative; or
(b) has recently threatened or attempted or is threatening or attempting to cause bodily harm to himself; or
(c) has recently behaved or is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him; or
(d) has recently shown or is showing an inability to care for himself to a degree that places the individual at risk of harm to himself.

(4) The person referred to in sub-section (3) shall be either admitted as a supported patient under section 89, or discharged from the establishment within a period of twenty-four hours or on completion of assessments for admission for a supported patient under section 89, whichever is earlier.

Admission and treatment of persons with mental illness, with high support needs, in mental health establishment, up to thirty days (supported admission)

89. (1) The medical officer or mental health professional in charge of a mental health establishment shall admit every such person to the establishment, upon application by the nominated representative of the person, under this section, if––
(a) the person has been independently examined on the day of admission or in the preceding seven days, by one psychiatrist and the other being a mental health professional or a medical practitioner, and both independently conclude based on the examination and, if appropriate, on information provided by others, that the person has a mental illness of such severity that the person,––
(i) has recently threatened or attempted or is threatening or attempting to cause bodily harm to himself; or
(ii) has recently behaved or is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him; or (iii) has recently shown or is showing an inability to care for himself to a degree that places the individual at risk of harm to himself; (b) the psychiatrist or the mental health professionals or the medical practitioner, as the case may be, certify, after taking into account an advance directive, if any, that admission to the mental health establishment is the least restrictive care option possible in the circumstances; and (c) the person is ineligible to receive care and treatment as an independent patient because the person is unable to make mental healthcare and treatment decisions independently and needs very high support from his nominated representative in
making decisions.

(2) The admission of a person with mental illness to a mental health establishment under this section shall be limited to a period of thirty days.

(3) At the end of the period mentioned under sub-section (2), or earlier, if the person no longer meets the criteria for admission as stated in sub-section (1), the patient shall no longer remain in the establishment under this section.

(4) On the expiry of the period of thirty days referred to in sub-section (2), the person may continue to remain admitted in the mental health establishment in accordance with the provisions of section 90.

(5) If the conditions under section 90 are not met, the person may continue to remain in the mental health establishment as an independent patient under section 86 and the medical officer or mental health professional in charge of the mental health establishment shall inform the person of his admission status under this Act, including his right to leave the mental health establishment.

(6) Every person with mental illness admitted under this section shall be provided treatment after taking into account,––
(a) an advance directive if any; or
(b) informed consent of the patient with the support of his nominated representative subject to the provisions of sub-section (7).

(7) If a person with the mental illness admitted under this section requires nearly hundred per cent support from his nominated representative in making a decision in respect of his treatment, the nominated representative may temporarily consent to the treatment plan of such person on his behalf.

(8) In case where consent has been given under sub-section (7), the medical officer or mental health professional in charge of the mental health establishment shall record such consent in the medical records and review the capacity of the patient to give consent every seven days.

(9) The medical officer or mental health professional in charge of the mental health establishment shall report the concerned Board,––
(a) within three days the admissions of a woman or a minor;
(b) within seven days the admission of any person not being a woman or minor.

(10) A person admitted under this section or his nominated representative or a representative of a registered non-governmental organisation with the consent of the person, may apply to the concerned Board for review of the decision of the medical officer or mental health professional in charge of the mental health establishment to admit the person to the mental health establishment under this section.

(11) The concerned Board shall review the decision of the medical officer or mental health professional in charge of the mental health establishment and give its findings thereon within seven days of receipt of request for such review which shall be binding on all the concerned parties.

(12) Notwithstanding anything contained in this Act, it shall be the duty of the medical officer or mental health professional in charge of the mental health establishment to keep the condition of the person with mental illness admitted under this section on going review.

(13) If the medical officer or mental health professional in charge of the mental health establishment is of the opinion that the conditions specified under sub-section (1) are no longer applicable, he shall terminate the admission under this section, and inform the person and his nominated representative accordingly.

(14) Non applicability of conditions referred to in sub-section (13) shall not preclude the person with mental illness remaining as an independent patient.

(15) In a case, a person with the mental illness admitted under this section has been discharged, such person shall not be readmitted under this section within a period of seven days from the date of his discharge.

(16) In case a person referred to in sub-section (15) requires readmission within a period of seven days referred to in that sub-section, such person shall be considered for readmission in accordance with the provisions of section 90.

(17) If the medical officer or mental health professional in charge of the mental health establishment is of the opinion that the person with mental illness admitted under this section in the mental health establishment requires or is likely to require further treatment beyond the period of thirty days, then such medical officer or mental health professional shall be duty bound to refer the matter to be examined by two psychiatrists for his admission beyond thirty days.

Admission and treatment of persons with mental illness, with high support needs, in mental health establishment, beyond thirty days (supported admission beyond thirty days)

90. (1) If a person with mental illness admitted under section 89 requires continuous admission and treatment beyond thirty days or a person with mental illness discharged under sub-section (15) of that section requires readmission within seven days of such discharge, he shall be admitted in accordance with the provisions of this section.

(2) The medical officer or mental health professional in charge of a mental health establishment, upon application by the nominated representative of a person with mental illness, shall continue admission of such person with mental illness, if—
(a) two psychiatrists have independently examined the person with mental illness in the preceding seven days and both independently conclude based on the examination and, on information provided by others that the person has a mental illness of a severity that the person––
(i) has consistently over time threatened or attempted to cause bodily harm to himself; or
(ii) has consistently over time behaved violently towards another person or has consistently over time caused another person to fear bodily harm from him; or
(iii) has consistently over time shown an inability to care for himself to a degree that places the individual at risk of harm to himself;
(b) both psychiatrists, after taking into account an advance directive, if any, certify that admission to a mental health establishment is the least restrictive care option possible under the circumstances; and
(c) the person continues to remain ineligible to receive care and treatment as a independent patient as the person cannot make mental healthcare and treatment decisions independently and needs very high support from his nominated representative, in making decisions.

(3) The medical officer or mental health professional in charge of the mental health establishment shall report all admissions or readmission under this section, within a period of seven days of such admission or readmission, to the concerned Board.

(4) The Board shall, within a period of twenty-one days from the date of last admission or readmission of person with mental illness under this section, permit such admission or readmission or order discharge of such person.

(5) While permitting admission or readmission or ordering discharge of such person under sub-section (4), the Board shall examine––
(a) the need for institutional care to such person;
(b) whether such care cannot be provided in less restrictive settings based in the community.

(6) In all cases of application for readmission or continuance of admission of a person with mental illness in the mental health establishment under this section, the Board may require the medical officer or psychiatrist in charge of treatment of such person with mental illness to submit a plan for community based treatment and the progress made, or likely to be made, towards realising this plan.

(7) The person referred to in sub-section (4) shall not be permitted to continue in the mental health establishment in which he had been admitted or his readmission in such establishment merely on the ground of non-existence of community based services at the place where such person ordinarily resides.

(8) The admission of a person with mental illness to a mental health establishment under this section shall be limited to a period up to ninety days in the first instance.

(9) The admission of a person with mental illness to a mental health establishment under this section beyond the period of ninety days may be extended for a period of one hundred and twenty days at the first instance and thereafter for a period of one hundred and eighty days each time after complying with the provisions of sub-sections (1) to (7).

(10) If the Board refuses to permit admission or continuation thereof or readmission under sub-section (9), or on the expiry of the periods referred to in sub-section (9) or earlier if such person no longer falls within the criteria for admission under sub-section (1), such person shall be discharged from such mental health establishment.

(11) Every person with mental illness admitted under this section shall be provided treatment, after taking into account—
(a) an advance directive; or
(b) informed consent of the person with the support from his nominated representative subject to the provision of sub-section (12).

(12) If a person with mental illness admitted under this section, requires nearly hundred per cent. support from his nominated representative, in making decision in respect of his treatment, the nominated representative may temporarily consent to the treatment plan of such person on his behalf.

(13) In a case where consent has been given under sub-section (12), the medical officer or mental health professional in charge of the mental health establishment shall record such consent in the medical records of such person with mental illness and review on the expiry of every fortnight, the capacity of such person to give consent.

(14) A person with mental illness admitted under this section, or his nominated representative or a representative of a registered non-governmental organisation with the consent of the person, may apply to the concerned Board for review of the decision of the medical officer or mental health professional in charge of medical health establishment to admit such person in such establishment and the decision of the Board thereon shall be binding on all parties.

(15) Notwithstanding anything contained in this Act, if the medical officer or mental health professional in charge of the mental health establishment is of the opinion that the conditions under sub-section (1) are no longer applicable, such medical officer or mental health professional shall discharge such person from such establishment and inform such person and his nominated representative accordingly.

(16) The person with mental illness referred to in sub-section (15) may continue to remain in the mental health establishment as an independent patient.

Leave of absence

91. The medical officer or mental health professional in charge of the mental health establishment may grant leave to any person with mental illness admitted under section 87 or section 89 or section 90, to be absent from the establishment subject to such conditions, if any, and for such duration as such medical officer or psychiatrist may consider necessary.

Absence without leave or discharge

92. If any person to whom section 103 applies absents himself without leave or without discharge from the mental health establishment, he shall be taken into protection by any Police Officer at the request of the medical officer or mental health professional in-charge of the mental health establishment and shall be sent back to the mental health establishment immediately.

Transfer of persons with mental illness from one mental health establishment to another mental health establishment

93. (1) A person with mental illness admitted to a mental health establishment under section 87 or section 89 or section 90 or section 103, as the case may be, may subject to any general or special order of the Board be removed from such mental health establishment and admitted to another mental health establishment within the State or with the consent of the Central Authority to any mental health establishment in any other State:
Provided that no person with mental illness admitted to a mental health establishment under an order made in pursuance of an application made under this Act shall be so removed unless intimation and reasons for the transfer have been given to the person with mental illness and his nominated representative.

(2) The State Government may make such general or special order as it thinks fit directing the removal of any prisoner with mental illness from the place where he is for the time being detained, to any mental health establishment or other place of safe custody in the State or to any mental health establishment or other place of safe custody in any other State with the consent of the Government of that other State.

Emergency treatment

94. (1) Notwithstanding anything contained in this Act, 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, subject to the informed consent of the nominated representative, where the nominated representative is available, and where it is immediately necessary to prevent—
(a) death or irreversible harm to the health of the person; or
(b) the person inflicting serious harm to himself or to others; or
(c) the person causing serious damage to property belonging to himself or to others where such behaviour is believed to flow directly from the person’s mental illness.
Explanation.—For the purposes of this section, “emergency treatment” includes transportation of the person with mental illness to a nearest mental health establishment for assessment.

(2) Nothing in this section shall allow any medical officer or psychiatrist to give to the person with mental illness medical treatment which is not directly related to the emergency treatment specified under sub-section (1).

(3) Nothing in this section shall allow any medical officer or psychiatrist to use electroconvulsive therapy as a form of treatment.

(4) The emergency treatment referred to in this section shall be limited to seventy-two hours or till the person with mental illness has been assessed at a mental health establishment, whichever is earlier:
Provided that during a disaster or emergency declared by the appropriate Government, the period of emergency treatment referred to in this sub-section may extend up to seven days.

Prohibited procedures

95. (1) Notwithstanding anything contained in this Act, the following treatments shall not be performed on any person with mental illness—
(a) electro-convulsive therapy without the use of muscle relaxants and anaesthesia;
(b) electro-convulsive therapy for minors;
(c) sterilisation of men or women, when such sterilisation is intended as a treatment for mental illness;
(d) chained in any manner or form whatsoever.

(2) Notwithstanding anything contained in sub-section (1), if, in the opinion of psychiatrist in charge of a minor’s treatment, electro-convulsive therapy is required, then, such treatment shall be done with the informed consent of the guardian and prior permission of the concerned Board.

Restriction on psychosurgery for persons with mental illness

96. (1) Notwithstanding anything contained in this Act, psychosurgery shall not be performed as a treatment for mental illness unless—
(a) the informed consent of the person on whom the surgery is being performed; and (b) approval from the concerned Board to perform the surgery, has been obtained.

(2) The Central Authority may make regulations for the purpose of carrying out the provisions of this section.

Restraints and seclusion

97. (1) A person with mental illness shall not be subjected to seclusion or solitary
confinement, and, where necessary, physical restraint may only be used when,—
(a) it is the only means available to prevent imminent and immediate harm to person concerned or to others;
(b) it is authorised by the psychiatrist in charge of the person’s treatment at the mental health establishment.

(2) Physical restraint shall not be used for a period longer than it is absolutely necessary to prevent the immediate risk of significant harm.

(3) The medical officer or mental health professional in charge of the mental health establishment shall be responsible for ensuring that the method, nature of restraint justification for its imposition and the duration of the restraint are immediately recorded in the person’s medical notes.

(4) The restraint shall not be used as a form of punishment or deterrent in any circumstance and the mental health establishment shall not use restraint merely on the ground of shortage of staff in such establishment.

(5) The nominated representative of the person with mental illness shall be informed about every instance of restraint within a period of twenty-four hours.

(6) A person who is placed under restraint shall be kept in a place where he can cause no harm to himself or others and under regular ongoing supervision of the medical personnel at the mental health establishment.

(7) The mental health establishment shall include all instances of restraint in the report to be sent to the concerned Board on a monthly basis.

(8) The Central Authority may make regulations for the purpose of carrying out the provisions of this section.

(9) The Board may order a mental health establishment to desist from applying restraint if the Board is of the opinion that the mental health establishment is persistently and wilfully ignoring the provisions of this section.

Discharge planning

98. (1) Whenever a person undergoing treatment for mental illness in a mental health establishment is to be discharged into the community or to a different mental health establishment or where a new psychiatrist is to take responsibility of the person’s care and treatment, the psychiatrist who has been responsible for the person’s care and treatment shall consult with the person with mental illness, the nominated representative, the family member or care-giver with whom the person with mental illness shall reside on discharge from the hospital, the psychiatrist expected to be responsible for the person’s care and treatment in the future, and such other persons as may be appropriate, as to what treatment or services would be appropriate for the person.

(2) The psychiatrist responsible for the person’s care shall in consultation with the persons referred to in sub-section (1) ensure that a plan is developed as to how treatment or services shall be provided to the person with mental illness.

(3) The discharge planning under this section shall apply to all discharges from a mental health establishment.

Research

99. (1) The professionals conducting research shall obtain free and informed consent from all persons with mental illness for participation in any research involving interviewing the person or psychological, physical, chemical or medicinal interventions.

(2) In case of research involving any psychological, physical, chemical or medicinal interventions to be conducted on person who is unable to give free and informed consent but does not resist participation in such research, permission to conduct such research shall be obtained from concerned State Authority.

(3) The State Authority may allow the research to proceed based on informed consent being obtained from the nominated representative of persons with mental illness, if the State
Authority is satisfied that––
(a) the proposed research cannot be performed on persons who are capable of giving free and informed consent;
(b) the proposed research is necessary to promote the mental health of the population represented by the person;
(c) the purpose of the proposed research is to obtain knowledge relevant to the particular mental health needs of persons with mental illness;
(d) a full disclosure of the interests of persons and organisations conducting the proposed research is made and there is no conflict of interest involved; and
(e) the proposed research follows all the national and international guidelines and regulations concerning the conduct of such research and ethical approval has been obtained from the institutional ethics committee where such research is to be conducted.

(4) The provisions of this section shall not restrict research based study of the case notes of a person who is unable to give informed consent, so long as the anonymity of the persons is secured.

(5) The person with mental illness or the nominated representative who gives informed consent for participation in any research under this Act may withdraw the consent at any time during the period of research.

Practice implications

  1. Voluntary admissions must meet the criteria described under Section 86. Patients who do not meet the “substantial disorder with gross impairments” criteria for mental illness cannot be admitted even if they are keen and their doctor is willing to provide treatment. This may be viewed as a violation of the right of individuals to seek treatment in the most appropriate setting as agreed between them and their doctor or clinical service provider. Though the criteria for admission are described, the MHRB does not have the power to review such admissions.
  2. If a voluntary patient requests discharge and the MO intends to hold the patient for 24 hours, then assessment under Section 89 should also be done within the 24 hours. NR’s consent is essential for an admission under Section 89. However, an NR is not required for a voluntary patient and admission under Section 89 cannot materialize without NR consent. A patient seeking discharge in contravention of the judgement of the MO is likely to conceal NR-related information. Revealing such information may result in the patient being retained in the MHE against his/her wish.
  3. A patient with a serious mental illness, who lacks capacity but does not meet severity criteria for supported admission (i.e., risk to self/ risk to others/ self neglect), cannot be admitted. For example, a patient who suffers from severe depression and impaired capacity but is not recently engaging / engaged in any acts that threaten self or others and is also capable of looking after own self cannot be admitted for treatment.
  4. Risk definition is restrictive. Risk to another ‘person’ only is considered in making decisions. Risk to ‘public’ or ‘cause fear’ in a category of people are not considered. For example, an individual with prior military experience has paranoid delusions about the police and is known to harbour vengeful ideas towards the police. However, he has not committed any vengeful or violent acts in the preceding 30 days. Furthermore, he has not caused any fear in any particular person. Due the individual’s military experience, the psychiatrist considers him to be a serious risk to any police station. The restricted definition of risk does not accommodate clinical judgements; therefore, if such a patient is admitted under Section 90 and he appeals to the MHRB for discharge, the MHRB would have to approve the request.
  5. Although the Act stresses equality between physical and mental illnesses, the criteria of admission for minors can be considered as discriminatory. Minors with mental illness have to meet severity criteria to get inpatient care. Thus, they cannot be admitted as part of an assessment/or as a more effective way of conducting a
    comprehensive work up and undertaking intense psychological or behavioural interventions.
  6. Section 89 (10) provides patients/NR/ NGO with the power to appeal to the MHRB to review an admission decision. This implies that the MHRB can conclude that an individual was wrongly admitted. This is in stark contradiction with the appeals process in other countries. Boards/tribunals in many countries s are not entitled to review the decision made by professionals. Their role is only to verify if, at the point of appeal, the individual meets the criteria for continued admission and whether such continued admission is justified. However, if the MHRB concludes that an admission under Section 89 was not appropriate, the hospital stay would then become ‘unlawful detention’. Similarly, all admissions under Section 90 are to be reviewed by the MHRB. Thus, the MHRB has the authority to’ permit’ or ‘reject’ an admission that has already happened. If the MHRB views an admission as unwarranted, the period during which the person was kept in hospital would be considered as ‘illegal confinement’. In contrast, if like the boards in other countries, the MHRB only verifies if an individual meets criterion for continued admission, it would then be able to discharge a patient without turning the hospital stay up to that point in time into ‘illegal confinement’.
  7. The act does not specify the number of times a person can appeal during one period of admission.
  8. Since all Section 90 admissions are automatically reviewed by the MHRB, the MO would need to send a report to the MHRB justifying each Section 90 admission.
  9. During admission, psychiatrists need to consider ADs made by the patient. A valid AD could also stipulate the care or treatment a person does not wish to receive for a mental illness. If a valid AD includes the wish to not be admitted to a MHE, or to not be treated with a class of medication like antipsychotics, admission and treatment can become difficult if not impossible. The act does not provide professionals with temporary options to override such an AD. The professional can only appeal to the MHRB under section 11. A decision may take up to 90 days (section 80(4). In the interim, there may be serious difficulties in providing appropriate care to the patient. The NR cannot override a valid AD.
  10. The requirement of general or special order to transfer patients is a limitation. The MHRB/ SMHA would need to issue general orders for a transfer, regardless of the reasons underlying the transfer. A transfer can arise because the patient would like to be closer to home or be in a different MHE (e.g., a private MHE rather than public MHE). Patients may also need to be transferred for better physical care or for accessing facilities like intensive care that are not available in the current MHE. The requirement for approval from the MHRB can delay the treatment.
  11. Section 92 states that if a patient is absent without leave, the MO can request the police to bring the patient back to the MHE. However, this is applicable only to mentally ill prisoners (section 103). No mention is made about patients under section 89, 90 who are also eligible to be brought back.
  12. Emergency interventions can be given in any Health Establishment or in the community. Section 94(4) states that the provision for emergency treatment lasts 72 hours or till the person is assessed at the MHE, whichever is earliest. It is not clear whether the emergency provision is applicable to patients already in a MHE. Patients in a MHE are likely to require life-saving emergency interventions (for physical and mental disorders); in many such instances, the consent of the NR may not be available immediately the act says the provision for emergency treatment is available only till the person is assessed at a MHE. Thus, patients who are already admitted may not be covered under this provision. A patient who is brought to a MHE, from a community setting, for assessment, could require emergency interventions before assessment can be arranged and completed. The act says, ‘until a person is assessed at a MHE’. This could be interpreted to mean that the MHE can arrange for the assessment by the psychiatrist/MO/MHP and in the meantime, administer emergency treatment until the assessment is completed.
  13. ECT can be administered to a minor only with the consent of the guardian and the prior approval of the MHRB. ECT is not included in the definition of life- saving emergency treatment. ECT cannot be given if a patient with capacity refuses it. The consent of the NR is required only if the patient has no capacity. Patients can refuse ECT in a valid advance refusal. CT cannot be administered to such patients when they lose capacity even if the NR consents to it. The MO would need to approach the MHRB to review the AD.
  14. Seclusion is prohibited. Seclusion for short periods could be useful in de-escalating a potentially aggressive situation. Low stimulus areas could be particularly useful. However, this could also be interpreted as seclusion.
  15. Voluntary patients who take discharge against medical advice may not require a discharge plan. Additionally, voluntary patients who are unwilling to engage in the discharge process may also not need a discharge plan. Unplanned discharge could result in inadequate and chaotic care in the community.

(Practice implications section written by Dr Manoj Kumar Therayil.)