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   Introduction
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    Use of Electroco...
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 Table of Contents    
CLINICAL PRACTICE GUIDELINES  
Year : 2019  |  Volume : 61  |  Issue : 8  |  Page : 155-157
Inpatient care and use of electroconvulsive therapy in children and adolescents: Aligning with mental health care act, 2017


1 Department of Psychiatry, PGIMER, Chandigarh, India
2 Department of Psychiatry, Gautam Hospital, Jaipur, Rajasthan, India

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Date of Web Publication14-Jan-2019
 

How to cite this article:
Grover S, Avasthi A, Gautam S. Inpatient care and use of electroconvulsive therapy in children and adolescents: Aligning with mental health care act, 2017. Indian J Psychiatry 2019;61, Suppl S2:155-7

How to cite this URL:
Grover S, Avasthi A, Gautam S. Inpatient care and use of electroconvulsive therapy in children and adolescents: Aligning with mental health care act, 2017. Indian J Psychiatry [serial online] 2019 [cited 2020 Aug 14];61, Suppl S2:155-7. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/8/155/250044





   Introduction Top


The Government of India passed the Mental Health Care Act (MHCA) in the year 2017 and the rules of the same were circulated on May 29, 2018, for immediate effect. Accordingly, it can be said that the MHCA has come into effect, and there is a need to reorganize the services to meet the requirement of MHCA. The MHCA has implication for all kinds of psychiatric practice and services, but in relation to child and adolescent psychiatry services, it has specific implications about inpatient care and administration of electroconvulsive therapy (ECT).

As few children and adolescents with various psychiatric disorders, especially those with severe mental disorders, may require inpatient care, hence, it is important for the mental health professionals to be aware of the specific regulations laid down by MHCA for inpatient care and administration of ECT in minors. This document provides an overview for inpatient care, administration of ECT in minors, advance directives, and nominated representative as per the MHCA and the regulations need to be complied with for inpatient care and administration of ECT for any of the disorders covered in this volume of clinical practice guidelines for children and adolescent psychiatric disorders.


   Definition of Minor Top


MHCA identifies a person as minor if she/he is aged below 18 years of age. In such a situation, she/he is not considered capable of giving consent for the treatment and the consent for admission and various interventions must be obtained from nominated representative.


   Inpatient Care Of Minors Top


MHCA, 2017, has laid down specific provisions for admission of minors to a mental health establishment (MHE) [Table 1]. According to Section 87 of MHCA, “minor is defined as a person who has not completed the age of 18 years.” According to MHCA, “a minor can be admitted to an MHE which has provision to accommodate them 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.”
Table 1: Inpatient care procedures for minors as per the Mental Health Care Act, 2017

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It further states that if a minor requires inpatient care, “the nominated representative of the minor will have to apply to the medical officer in charge of an MHE for admission of the minor to the establishment. On receipt of such an application, the medical officer or mental health professional in charge of the MHE 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 7 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 an MHE; (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 MHC 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.

If a minor is admitted to the MHE, then the information about the same must be sent to the Mental Health Review Board (MHRB) within 3 days of admission or readmission. According to MHA, The “nominated representative or an attendant appointed by the nominated representative shall under all circumstances stay with the minor in the MHE for the entire duration of the admission of the minor to the MHE. 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 MHE for the entire duration of her admission. If the nominated representative no longer supports admission of the minor under this section or requests discharge of the minor from the MHE, the minor shall be discharged by the MHE.”

A minor can be kept admitted for a maximum duration of 30 days. If inpatient care is required for duration >30 days, then on completion of 30 days, the nominated representative can request for continued admission in the prescribed format. On receipt of such applications, “the medical officer or mental health professional in charge of a MHE shall continue admission of such person with mental illness, if (a) two psychiatrists have independently examined the person with mental illness in the preceding 7 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 toward 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 MHE is the least restrictive care option possible under the circumstances; and (c) the person continues to remain ineligible to receive care and treatment as an independent patient as the person cannot make MHC and treatment decisions independently and needs very high support from his nominated representative, in making decisions.” All such decisions must be communicated to the MHRB within a period of 3 days. The MHRB may extend the admission or readmission within 7 days of discharge for a period of 90 days. Further requests for continuing admissions could be made, following similar procedures and extensions will be granted by the MHRB for a period of 120 days and subsequently for a maximum duration of 190 days.

Further, the MHCA states that informed consent for all sorts of treatment of minors must be obtained from the nominated representative. However, it is important to remember that if during the hospital stay, the minor attains the age of 18, he/she should be classified as independent patient, and the same should be communicated to her/him and further treatment needs to continue as either independent patient or patient requiring high support need.


   Use of Electroconvulsive Therapy in Minors Top


Till now, there was no prohibition in the administration of unmodified ECT in patients of different age group for various psychiatric conditions as per the clinical indication.

As per the Section 95 (1) (a) of MHCA, “use of ECT without the use of muscle relaxants and anesthesia” is a prohibited procedure. According to the MHCA, unmodified ECT cannot be administered in patients of any age group.

Section 95 (1) (b) of MHCA states that “ECT for minors” is a prohibited procedure, except in situations, when the treating psychiatrist feels the need to use ECT. Section 95 (2) states that “notwithstanding anything contained in subsection (1) if in the opinion of psychiatrist in charge of a minor's treatment, ECT is required, then such treatment shall be done with the informed consent of the guardian and prior permission of the concerned board.” Accordingly, if the treating psychiatrist feels the need to used ECT, then such treatment shall be done with the informed consent of the guardian and prior permission of the MHRB.

It is also important to remember that, as per the Section 94 of MHCA, ECT cannot be given as part of the emergency treatment. The Section 94 (3) of MHCA states that “nothing in this section shall allow any medical officer or psychiatrist to use ECT as a form of treatment[Table 2].
Table 2: Regulations for the use of electroconvulsive therapy as per the Mental Health Care Act, 2017

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   Advance Directives Top


As per the MHCA, minors cannot make advance directives. However, the legal guardian can make an advance directive for the patient. The Section 11 (4) states that “the legal guardian shall have right to make an advance directive in writing in respect of a minor and all the provisions relating to advance directive, mutatis mutandis, shall apply to such minor till such time he attains majority.”


   Nominated Representative Top


As per MHCA, for minors, the parents shall act as their nominated representative, with few exceptions. As per the Section 15 of MHCA, subsection (2), “if the mental health professional or any other person acting in the best interest of the minor represents on behalf of the minor. For stating that the legal guardian cannot act as nominated representative, the person making the request has to provide evidence that the legal guardian is not acting in the best interest of the minor or the legal guardian is otherwise not fit himself/herself to act as the nominated representative of the minor.” In such a scenario, the MHRB may appoint any suitable individual as the nominated representative provided the individual is willing for the same. However, if no one is available to become a nominated representative of the minor, then the MHRB can appoint the “director in the department of social welfare of the state in which such board is located, or his nominee, as the nominated representative of the minor with mental illness” (Section 15, MHCA).[1]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
The Gazette of India. The Mental Health Care Act, 2017. No. 10. New Delhi: The Gazette of India; 2017.  Back to cited text no. 1
    

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Correspondence Address:
Prof. Sandeep Grover
Department of Psychiatry, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_557_18

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    Tables

  [Table 1], [Table 2]



 

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