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   Table of Contents - Current issue
Coverpage
 2019
Volume 61 | Issue 10 (Supplement)
Page Nos. 633-837

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MESSAGE FROM INDIAN PSYCHIATRIC SOCIETY  

Message from President, Indian Psychiatric Society p. 633
Mrugesh Vaishnav
DOI:10.4103/psychiatry.IndianJPsychiatry_225_19  
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Message from Vice President, Indian Psychiatric Society p. 634
PK Dalal
DOI:10.4103/psychiatry.IndianJPsychiatry_217_19  
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Message from Hon. General Secretary, Indian Psychiatric Society p. 635
Vinay Kumar
DOI:10.4103/0019-5545.255582  
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EDITORIAL Top

Mental Healthcare Act (MHCA 2017)- Is a Relook Necessary for Effective Implementation? p. 636
Om Prakash Singh
DOI:10.4103/0019-5545.255592  
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GUEST EDITORIAL Top

Mental Healthcare Act 2017: Preface to the supplement p. 637
Shahul Ameen, Mahesh Gowda, GS Ramkumar
DOI:10.4103/psychiatry.IndianJPsychiatry_216_19  
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REVIEW ARTICLES Top

How right is right-based mental health law? p. 640
Bevinahalli Nanjegowda Raveesh, Guru S Gowda, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_115_19  
Human rights' frameworks are increasingly being recognized in general, and mental health in particular. Human rights can thus act as powerful catalysts for change in areas such as mental health care that has historically suffered from stigma, discrimination, and loss of dignity of patients. Mental health law in India has evolved over the past few decades, in keeping with improved delivery of care, societal changes, and increasing awareness of a person's human rights and privileges. The new Mental Healthcare Act, 2017 has shifted the focus to a rights-based approach to provide treatment, care, and protection of a person with mental illness compared to previous Mental Health Act 1987. This dynamic shift is to align, harmonize, and fulfill the requirements of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). This article reviews the existing international human rights model of disability and recovery, and the Mysore Declaration, and does a critical review of UNCRPD.
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Making the most of Mental Healthcare Act 2017: Practitioners' perspective p. 645
Vijaykumar Harbishettar, Arun Enara, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_98_19  
The Mental Healthcare Act (MHCA) 2017, after parliamentary approval in 2017, came into effect from May 29, 2018. It is rights-based and empowers the patients to make their own choices unless they become incapacitous due to mental illness. There is much emphasis on the protection of human rights of persons with mental illness. The act provides a framework and regulation on how a person with mental illness should be treated. The experts, on multiple occasions, have debated on whether the act is a boon or a bane for the practitioners in India. The MHCA 2017 brings about more impetus on documentation, unlike the previous acts. With the act in place, clear documentation with reasons for decisions made and care given are important for good practice. Although this may potentially raise the cost of care, this will ensure a safer practice of psychiatry and will prove beneficial for the patients and the psychiatrists. To comply with the provisions of the act, one will have to modify the manner in which one carries out the day-to-day practice. Regular training through workshops is required to understand the practical implications of different provisions of the act. Furthermore, regular peer group meetings may give a sense of support and an opportunity to learn from one another and help find solutions to difficult aspects. Overall, following this and adapting to the new act may bring uniformity in practice. This article aims to explore ways to leverage the MHCA 2017 from the practitioner's perspective.
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Cost estimation for the implementation of the Mental Healthcare Act 2017 p. 650
Suresh Bada Math, Guru S Gowda, Vinay Basavaraju, Narayana Manjunatha, Channaveerachari Naveen Kumar, Arun Enara, Mahesh Gowda, Jagadisha Thirthalli
DOI:10.4103/psychiatry.IndianJPsychiatry_188_19  
The Mental Healthcare Act, 2017 (MHCA) was a step that was essential, once the Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities in 2007. The MHCA looks to protect, promote, and fulfill the rights of persons with mental illness (PMI) as stated in the preamble of the Act. Further, there is an onus on the state to provide affordable mental health care to its citizens. In India, mental health has always been a lesser priority for lawmakers and citizens alike. The rights-based MHCA looks to overhaul the existing system by giving prominence to autonomy, protecting the rights of the mentally ill individuals, and making the State responsible for the care. The decision to make all this happen is commendable. The annual health expenditure of India is 1.15% of the gross domestic product, and the mental health budget is <1% of India's total health budget. This article systematically analyses and describes the cost estimation of the implementation of MHCA 2017, and it is not an estimation of mental health economics. The conservative annual estimated cost on the government to implement MHCA, 2017 would be 94,073 crore rupees. The present study estimation depicts that investing in the implementation of MHCA, 2017 by the government will yield 6.5 times the return on investment analysis benefit. If the State is not proactive in taking measures to implement the MHCA, the rights promised under this legislation will remain aspirational.
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Mental Healthcare Act 2017 – Aspiration to action p. 660
Suresh Bada Math, Vinay Basavaraju, Shashidhara Nagabhushana Harihara, Guru S Gowda, Narayana Manjunatha, Channaveerachari Naveen Kumar, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_91_19  
There is no health without mental health. Recently conducted National Mental Health Survey quoted a prevalence of 13.7% lifetime and 10.6% current mental morbidity. To address this mammoth problem, an aspirational law was enacted titled “Mental Healthcare Act, 2017” (MHCA 2017). The act is progressive and rights based in nature. The whole dedicated Chapter 5 on “Rights of the person with mental illness” is the heart and soul of this legislation. However, the act mainly focuses on the rights of the persons with mental illness (PMI), only during treatment in hospital but is not equally emphatic about continuity of treatment in the community. The act fails to acknowledge and foster the role and contribution of family members in providing care to PMI. Although there are many positive aspects to the MHCA 2017, it may impact adversely on the mental health care in India. This article focuses on the shortcomings and challenges of the act and also makes attempts to offer alternatives considering the available resources and ground reality. Concepts such as “Advance directives” and “Nominated representatives” appear to be very attractive, idealistic, and aspirational, but not evidenced based in the Indian context considering the resources. The act fails to make an impact even after 22 months to attain the goal, and will require pervasive efforts to fulfil a purpose that directs its development. This law needs to be amended as per the local resources and requirements of the society.
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Consent in current psychiatric practice and research: An Indian perspective p. 667
Furkhan Ali, Gopi Gajera, Guru S Gowda, Preeti Srinivasa, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_163_19  
Consent is a process that allows for free expression of an informed choice, by a competent individual. The consent is considered as one of the important components of health-care delivery and biomedical research today. Informed consent involves clinical, ethical, and legal dimensions and is believed to uphold an individual's autonomy and the right to choose. It is very important in Indian mental health care as the Mental Healthcare Act (MHCA) 2017 mandates informed consent in admission, treatment, discharge planning, and research intervention/procedures. In 2017, the Indian Council of Medical Research laid down the National Ethical Guidelines for BioMedical and Health Research involving Human Participant for research protocols, which the MHCA advocates. This article gives an overview on the evaluation of consent in clinical practice and also highlights the approach and challenge in psychiatric practice in India.
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Capacity for mental healthcare decisions under the Mental Healthcare Act p. 676
Vasudevan Namboodiri
DOI:10.4103/psychiatry.IndianJPsychiatry_76_19  
Mental Healthcare Act (MHCA), 2017 aims to protect and promote the rights of patients during mental health care. This Act promotes patient's autonomy and choice for those with ability to make decisions on mental health care, independent of the level of risks or complexities. Supported decision-making can vary from minimal or no support to complete support for decision-making. A decision by a nominated representative is restricted to those with incapacity for mental healthcare decisions. Capacity assessment for mental healthcare is a specific task in the clinical application of the act. This article is meant to guide clinicians on capacity assessment during the implementation of MHCA.
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Advance directives and nominated representatives: A critique p. 680
Sharad Philip, Subhashini K Rangarajan, Sydney Moirangthem, Channaveerachari Naveen Kumar, Mahesh R Gowda, Guru S Gowda, Suresh Bada Math
DOI:10.4103/psychiatry.IndianJPsychiatry_95_19  
With the ratification of the landmark United Nations Convention on Rights of Persons with Disabilities by India, it was imperative to revamp the mental health-care legislation, among other changes. Most notably, a presumption of mental capacity has been introduced, which means a paradigm shift in the client and provider relationship. The Mental Healthcare Act, 2017 empowers all persons to make advance directives (AD) and nominate representatives for shared decision-making. Psychiatric ADs (PADs) also seem to improve the information exchange between the care provider and the service user. PADs may also be used as a vehicle of consent to future treatments. While drafting the PAD, the drafter must also plan how such directed care would be financed. Insurance companies have not been mandated to comply with ADs. In the eventuality that the drafter's family refuse support for treatment specified in the PAD, the drafter would be left holding an unimplementable PAD. The AD saw its origins in the care of the terminally ill and decades later came to be utilized in mental health care. After nearly three decades of use in developed countries, evidence at best remains mixed or inconclusive. This review focuses on the AD from the Indian perspective.
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Newer documentary practices as per Mental Healthcare Act 2017 p. 686
Gopi Gajera, Preeti Srinivasa, Shahul Ameen, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_110_19  
Medical records form an integral part of patient care. Proper documentation and its maintenance are mandatory as part of the law. It is essential for a treating doctor to document the required details to avoid allegations of negligence. Proper documentation will not only help us to prove that particular services were provided but can also serve as a tool for communication with other professionals. This article draws together the standards and suggests some good clinical practices as per the Mental Healthcare Act 2017.
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Alternatives to use of restraint: A path toward humanistic care p. 693
Bevinahalli Nanjegowda Raveesh, Guru S Gowda, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_104_19  
Restraint and seclusion are measures to restrict the movement of a person. The predominant reason cited for the use of restraint in mental health settings is the safety of the staff and the patient in times of aggression and to control problem behaviors. However, there have been significant issues in terms of ethics, rights of the patient, and the harmful effects of restraint. Recently, there has been a move in Western countries to decrease its use by incorporating alternative methods and approaches. In India, the Mental Healthcare Act of 2017 advocates the use of least restrictive measures and alternatives to restraint in providing care and treatment for person with mental illness. In this context, approach to restraints is all the more relevant. This article looks to overview the types of restraints, complications of restraints, and the alternatives to restraint in diverse settings.
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Restraint guidelines for mental health services in India p. 698
Bevinahalli Nanjegowda Raveesh, Peter Lepping
DOI:10.4103/psychiatry.IndianJPsychiatry_106_19  
Restraint use in mentally ill patients are regulated by Mental Healthcare Act 2017 in India. At times, persons with mental disorders become dangerous to self, others or towards the property, warranting an emergency intervention in the form of restraint. Restraint as a matter of policy, should be implemented after attempting alternatives, only under extreme circumstances as last resort and not as a punishment. It should be an intervention focused at managing the concerned behavior for a given point of time. Restraint should always result in safety and should ensure that the human rights of mental health care users are upheld. This guideline was developed towards Indian mental health services in conjunction with international evidence-based strategies following a decade of collaborative research work between Indian and European mental health professionals.
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Discharge planning and Mental Healthcare Act 2017 p. 706
Mahesh Gowda, Gopi Gajera, Preeti Srinivasa, Shahul Ameen
DOI:10.4103/psychiatry.IndianJPsychiatry_72_19  
Mental Healthcare Act 2017 mandates that proper discharge planning should be done and documented before any discharge is done from MHEs. Discharge planning should be based on a thorough assessment of the needs of the patient. Family should be actively involved in the planning process. Necessary steps should be taken for referral to other services, especially those in the community. Discharge planning helps us to balance the goals of the treatment at admission, to reality check at the time of discharge. Adequacy of discharge planning can be ensured by using various published checklists.
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Approach to and practical challenges in certification in Psychiatry p. 710
Furkhan Ali, Guru S Gowda, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_109_19  
Psychiatrists and mental health professionals (MHPs) are often requested to provide a certificate in connection with admission, treatment, fitness, competence, administration, legal proceedings, or welfare measures and benefits for persons with mental illness. The role of Psychiatrist and MHPs in providing a certificate is an integral part of clinical practice and more so with the implementation of the Mental Healthcare Act, 2017 (MHCA 2017). While issuing a certificate, keeping patient information confidential is a challenging task for a professional as the patient care in psychiatry involves multiple stakeholders (Central and State Mental Health Authorities, Mental Health Review Board, MHPs including psychiatrist, and caregivers). There is limited training at undergraduate or postgraduate level in documentary practices and certification. This article tries to address some of the issues related to certification, professional and legal accountability, and attempts to remove some of the ambiguities associated with the certification process in psychiatry.
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Dealing with statutory bodies under the Mental Healthcare Act 2017 p. 717
NR Prashanth, Shalu Elizabeth Abraham, Chandrashekar Hongally, S Madhusudan
DOI:10.4103/psychiatry.IndianJPsychiatry_152_19  
India has an enormous burden of mental illness. In spite of the recognition of this population of people living with mental illness, the treatment gap continues to be about 83%. In order to meet this vast unmet need and in the view of aligning the mental health legislation with the international standards and the UN-Convention on the Rights of Persons with Disabilities, the Mental Healthcare Act 2017 was passed and enforced recently. The provisions in the act have been controversial from its conception. Now after the enforcement of the act, all mental health professionals (MHPs) have a legal binding to follow the provisions in the law. The MHPs are accountable to the statutory bodies – the Central Mental Health Authority, State Mental Health Authority (SMHA), Mental Health Review Board, and finally, the High Court or the Supreme Court. The Mental Healthcare Act (MHCA) and relevant articles/documents obtained pertaining to MHCA and their evaluation were reviewed, the major focus being on the role of statutory/regulatory bodies. Furthermore, an attempt was made to summarize the previous experiences in inspection of mental health establishments by SMHA of Karnataka. We concluded that the MHCA will have both positive and negative aspects. Many of the provisions in the law may appear unclear and unrealistic by many practitioners. However, it becomes precautionary for the MHPs to be well equipped with the MHCA and be acquainted with the requirements of the statutory bodies for ensuring a safe practice. The outcome of the implementation of the act will become evident only with time.
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Liabilities and penalties under Mental Healthcare Act 2017 p. 724
Chandrashekar Hongally, Madhumitha Nanditale Sripad, Raju Nadakuru, Malaiappan Meenakshisundaram, KP Jayaprakasan
DOI:10.4103/psychiatry.IndianJPsychiatry_150_19  
Introduction: Mental Healthcare Act (MHCA) 2017 is an act passed to regulate and provide mental health care and services. The act considers psychiatrists as one of the main mental health providers. Liabilities are prescribed under various chapters of MHCA 2017. It is imperative for practitioners to be completely aware of and follow the rules as per MHCA 2017, now that the rules are already framed. Materials and Methods: A thorough review of MHCA 2017, Central Mental Health Rules, and State Mental Health Rules 2018 was done. In addition, related scientific articles were accessed in PubMed and Google Scholar using keywords such as mental health legislation, law, and mental health. Relevant articles were reviewed to arrive at suggestions. Observations: Important liabilities are around the domains of registration of professionals and institutions, maintenance of records, promoting the rights of the persons with mental illness during treatment, and following the provisions of MHCA 2017 during admission and discharge. Punishment for contravention of provisions of the Act or rules or regulations made thereunder is clear and stringent and may vary from fine to imprisonment. Suggestions: Mental Health Professionals should understand the provisions of MHCA 2017 along with the rules and regulations made under this act. Please maintain basic medical records of all outpatients and inpatients and basic report of psychological assessments and release it upon request by the patient or nominated representative.
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The dawn of eMental health professional p. 730
Mohan Sunil Kumar, Sharmitha Krishnamurthy, Mahesh R Gowda, Nitya Dhruve
DOI:10.4103/psychiatry.IndianJPsychiatry_161_19  
The widespread reach and ease of use make technology a handy tool for today's practicing mental health professional (MHP), especially in light of the Mental Healthcare Act (MHCA) 2017, the essence of which safeguards the rights of patients while squarely placing the onus on MHPs. In order to keep up with the changing times, it is imperative for the MHP to be aware of the potential of technology to not only aid delivery but also ease the burden of care while being MHCA-compliant. In addition, the article calls for a more proactive role of the MHP in driving change in terms of leveraging technology in mental health settings. It looks at how certain tools can be incorporated across a range of scenarios right from wellness applications and facilitating medical adherence to aiding crisis intervention and extending quality care services in remotes areas. The article briefly outlines a framework involving various stakeholders at different levels as well as the channels in which the technology can be leveraged while keeping the patients' rights front and center. The potential barriers that an “e-ready” MHP can expect and directions for moving ahead are discussed, keeping a critical eye on the lacunae in using technology.
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Founding and managing a mental health establishment under the Mental Healthcare Act 2017 p. 735
Mahesh R Gowda, Keya Das, Guru S Gowda, KN Karthik, Preethi Srinivasa, Chandrashekhar Muthalayapapa
DOI:10.4103/psychiatry.IndianJPsychiatry_147_19  
The World Health Organization Atlas reveals lower bed and mental health professionals ratio per population in India. This may be due to a poor allocation of funding in the mental health sector by the Government. This resulted in a lack of complete and comprehensive care ranging from acute treatment to long-term rehabilitation throughout the country. The spiral of specialist care needs such as deaddiction, child psychiatric needs, and rehabilitation facility are available only to a handful of the population in metropolitan cities in India. The launching or establishment of new Mental Health Establishments (MHEs) and upgrading mental health service may provide strategies to bridge this gap from the private mental health sector. Following the inception of “Mental Healthcare Act 2017” (MHCA 2017), the process of setting up MHEs and their operations comes with new legal and healthcare aspects that remain debatable and unsettled. We put forth the basic measures that can be considered and undertaken to establish an exemplary MHE under the MHCA 2017.
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Mental Healthcare Act 2017: Impact on addiction and addiction services p. 744
Ashwin Mohan, Suresh Bada Math
DOI:10.4103/psychiatry.IndianJPsychiatry_114_19  
The Mental Healthcare Act (MHCA) 2017 has been recently enacted with the objectives of providing mental health services and securing of rights of the persons with mental illness. Mental conditions due to abuse of alcohol or drugs have been included in the definition of mental illness. However, these conditions present some unique and difficult problems due to their very nature. Despite being an integral part of psychiatry, these disorders have traditionally been dealt with separately and even treated in dedicated facilities such as deaddiction centers and rehabilitation centers. In fact, some states have separate rules for treatment delivery of these disorders. Addiction also has major legal ramifications that are dealt with other acts such as the Narcotic Drugs and Psychotropic Substances Act (NDPSA). With this background, this article focuses on the issues of capacity and informed consent specific to addiction, addresses the admission issues in addiction including the issue of coerced treatment, and the treatment facilities, and deals with the some of the discordance and inconsistency between the NDPSA and the MHCA 2017. We believe that addiction-related provisions have not been addressed adequately in the MHCA 2017, and detailed procedures specific to addiction and its treatment will be required if the MHCA 2017 has to be implemented both in letter and in spirit.
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Practical implications of Mental Healthcare Act 2017: Suicide and suicide attempt p. 750
Laxmi Naresh Vadlamani, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_116_19  
The prevalence of suicides has been increasing in recent years. The number of persons who attempt to die by suicide is 25 times that of the number of those who die by suicide every year. Indian Government passed the Mental Healthcare Act (MHCA), 2017 in the middle of 2018. Section 115 of the act decriminalized the attempt to die by suicide, thereby reducing further stress on the victim. This has legal implications with regard to abetment laws of Sections 109, 116, 306, and 309 of Indian Penal Code. Regarding mental healthcare delivery, this act enables the person who attempted to die by suicide, to access free healthcare, treatment, and rehabilitation. The cost implications for the government are enormous. Medical professionals, mental health professionals, and general and mental health establishments involved in the care of persons who attempted to die by suicide need to update their knowledge to enhance their assessment and management skills to align with the provisions of the act. Massive public awareness programs need to be conducted to enable persons who attempted to die by suicide, to access mental healthcare as per the provisions of the MHCA 2017.
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Mental Healthcare Act 2017, India: Child and adolescent perspectives p. 756
Eesha Sharma, John Vijay Sagar Kommu
DOI:10.4103/psychiatry.IndianJPsychiatry_126_19  
India has got a new mental health legislation, the Mental Healthcare Act in 2017 (MHCA). Compared to its predecessor the Mental Health Act of 1987, this act was purported to be more patient centric and rights based. Considering the significant burden of child and adolescent mental health problems in the community, it is essential to understand what this new act means for the mental healthcare of young people. This article presents sections of the act relevant to children and adolescents. We look at the provisions in the context of changes from the earlier act, concordance with other Indian legislations and with mental health legislations in other parts of the world.
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Implications of Mental Healthcare Act 2017 for geriatric mental health care delivery: A critical appraisal p. 763
Palanimuthu Thangaraju Sivakumar, Shiva Shanker Reddy Mukku, Sojan Antony, Vijaykumar Harbishettar, Channaveerachari Naveen Kumar, Suresh Bada Math
DOI:10.4103/psychiatry.IndianJPsychiatry_100_19  
The prevalence of mental health problems in older adults is increasing globally as well as in India due to population ageing. Mental Healthcare Act (MHCA) 2017 has a rights-based approach and came into force in India in May 2018. Its provisions have significant implications for promoting mental health care and protecting the rights of persons with mental illness (PMI). Older adults with mental health problems such as dementia have a high risk for loss of mental capacity, abuse, violation of their rights, and institutionalization. This act advocates the development of specialized clinical services for the older adults in mental health care institutions. It also recognizes the rights of PMI to access a range of services required, including rehabilitation services. Several provisions of the act, such as those related to mental capacity, advance directive, nominated representative, and responsibilities of other agencies, have specific challenges related to older adults with mental illness. In this article, we present a critical appraisal of the implications of MHCA 2017 in the context of the care of the older adults with mental illness.
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Mental Healthcare Act, 2017 and homeless persons with mental illness in India p. 768
Gopalrao Swaminath, Arun Enara, Ravishankar Rao, Kengeri V Kishore Kumar, Channaverachari Naveen Kumar
DOI:10.4103/psychiatry.IndianJPsychiatry_117_19  
Homeless persons with mental illness (HPMI) suffer indignities due to shirking of all obligations by the society. In addition, the HPMI is denied all rights available to citizens, such as confidentiality, privacy, safety, right to practice religion, health, and the right to not suffer from inhuman treatment. In this context, the new Mental Healthcare Act (MHCA), 2017 has brought in a list of rights for HPMI, and this is a welcome sign. The MHCA has also taken away the mandated involvement of judiciary to provide care for the HPMI. However, the ground realities in terms of the systems and the existent infrastructure are far from satisfactory to handle the issue in India. The onus of providing care for the HPMI has shifted to the state, and the public agencies are responsible for ensuring the same. The article aims to look at various sections of the MHCA relevant in regard to providing care for the HPMI.
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Hippocratic oath: Losing relevance in today's world? p. 773
Vishal Indla, MS Radhika
DOI:10.4103/psychiatry.IndianJPsychiatry_140_19  
Hippocrates oath has been considered the gold standard of ethics in medicine since long. But, the oath was formulated long before the advancements in bioethics. In this article, we try to analyse the important aspects of the oath and examine whether it holds up in the current era of medical malpractice and consumer laws or has lost its relevance.
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The enigma of doctor-patient relationship p. 776
Vijaykumar Harbishettar, KR Krishna, Preeti Srinivasa, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_96_19  
The doctor–patient relationship is crucial to the health-care delivery. In the past, the relationship was viewed as one between a healer and a sick person. However, in the modern era, it is seen as an interaction between a care provider and a service user. The Mental Healthcare Act (MHCA) 2017 gives importance to rights and provision for more autonomy to patients. We examined, in the context of the existing literature, the potential impact the implementation of MHCA 2017 can have on the doctor–patient relationship. A bond between doctor and patient that is based on trust has been an integral part of patient care and has been described to promote recovery, reduce relapse, and enhance treatment adherence. Growing mistrust among patients toward doctors leads them to change their doctors frequently, and due to this, the patients are at risk of losing the therapeutic benefit of the doctor–patient relationship. The doctor–patient relationship has been understudied in areas of health-care need, such as in rural areas, where accessibility and availability of care itself become the most important goal. Medical advancement, with several new treatment options, as well as the availability of many experts for patients to choose from, seems a boon turning into a bane. MHCA 2017 and other health-care policies so far have not given importance to this relationship that is being damaged by several factors including rising health-care costs, especially in private sector and after patients have become “consumers.” However, for now, the foremost thing is the psychiatrists have to work to comply with the law and document to justify clinical decisions.
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Violence against doctors: A viral epidemic? Highly accessed article p. 782
Indla Ramasubba Reddy, Jateen Ukrani, Vishal Indla, Varsha Ukrani
DOI:10.4103/psychiatry.IndianJPsychiatry_120_19  
Violence against doctors at their workplace is not a new phenomenon. However, in recent times, reports of doctors getting thrashed by patients and their relatives are making headlines around the world and are shared extensively on social media. Almost every doctor is worried about violence at his/her workplace, and very few doctors are trained to avoid or deal with such situations. This article aims to discuss the risk factors associated with violence against doctors and the possible steps at a personal, institutional, or policy level that are needed to mitigate such incidents.
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Sale of medicines by Registered Medical Practitioners at their clinics: Legal and ethical issues p. 786
Suresh Bada Math, Narayana Manjunatha, Channaveerachari Naveen Kumar, Guru S Gowda, Sharad Philip, Arun Enara, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_89_19  
In India, manufacturing, storing, transportation, distribution, and dispensing of drugs are licensed and regulated under the drugs and cosmetic act, 1940; Indian Medical Council Act, 1956; the Pharmacy Act, 1948; and the Narcotic Drugs and Psychotropic Substances Act, 1985. Prescribing and dispensing medicines at the same time to their patients by registered medical practitioners (RMPs) is a well-known practice in all systems of medicine across the country. Further, the kind of branded medicines a patient gets from the clinics will come wrapped in a huge profit margin for RMPs, and this has been an alternative source of income to them. Dispensing and selling of medicines by RMPs at their clinics to their patients may represent a significant potential conflict of interest with the medical ethical principles, namely autonomy, beneficence, and non-maleficence and it raises various ethical and legal challenges. This article focuses on the ethical and legal issues of this practice and emphasizes the need for a proactive and dynamic approach to meet the rising demand for quality healthcare in India.
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Health insurance and mental illness p. 791
A Sangoi Bijal, C Naveen Kumar, N Manjunatha, Mahesh Gowda, Vinay Basavaraju, Suresh Bada Math
DOI:10.4103/psychiatry.IndianJPsychiatry_158_19  
One of the important provisions of the Mental Healthcare Act, 2017, in section 21 (4), is the inclusion of “mental illnesses” for health insurance coverage. This is a progressive step toward considering mental illness at par with physical illness, which will, in turn, ensure better access to mental health care. In this context, the article summarizes the concept of “health insurance” and then goes on to talk about various provisions for persons with mental illnesses in India. We also discuss some of the relevant concerns that may arise in this context. Whereas insurance for mental illness is a welcome step toward achieving universal health coverage, there is a need to deliberate on various issues before we can achieve that.
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The need for “code of practice” as a supplement to Mental Healthcare Act 2017 p. 798
Divya Ganesh Nallur
DOI:10.4103/psychiatry.IndianJPsychiatry_113_19  
Mental Healthcare Act (MHCA) 2017 is the current legislation overseeing and protecting the mental healthcare of patients with mental illness. All professionals working with this vulnerable patient population must abide by this legislation. This article is an attempt to make a case for the need for a “Code of Practice” (CoP) as a statutory guidance document to help all stakeholders in implementing the legislation. It is argued that the CoP is essential to effectively safeguard the rights and autonomy of the patients and to safeguard professionals from uneasy repercussions from unintended mistakes in implementing the legislation.
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Reorientation of postgraduate training in the background of the Mental Healthcare Act 2017 p. 804
Vijaykumar Harbishettar, Pratima Murthy
DOI:10.4103/psychiatry.IndianJPsychiatry_148_19  
In India, postgraduate (PG) training in Psychiatry began in 1941 and came under the regulation of the Medical Council of India in 1956. Since then, it has evolved into a more structured objective system. Most PG courses require compulsory submission of a dissertation work to provide experience in planning, executing, and disseminating research, in addition to clinical work, thus preparing the students to be future teachers or trainers and clinical practitioners. The training regulatory board needs to revisit the curriculum with regard to the provisions under the Mental Healthcare Act (MHCA) 2017, to incorporate the necessary knowledge, skills, and competence of trainees. The Act gives directions to the psychiatrists to act in certain ways in certain situations and makes documentation and completing forms more important. There are provisions for doing research in patients with severe mental illness with certain safeguards. The article discusses the aspects of the MHCA that necessitate modifications to the training, to equip the trainee psychiatrists to work within the framework of the act and also to familiarize them with the aspects of patient safeguards while conducting research. The trainees should take the initiative and put in efforts to understand the practical implications. Mentored learning of practical scenarios in their clinical postings is the best way to learn. Finally, one has to understand that there may be varying interpretations of the provisions of the act. Any interpretation of the provision can still be challenged in court.
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The rights of persons with disability act, 2016: Challenges and opportunities p. 809
Suresh Bada Math, Guru S Gowda, Vinay Basavaraju, Narayana Manjunatha, Channaveerachari Naveen Kumar, Sharad Philip, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_105_19  
India signed the United Nations Convention on the Rights of Person with Disabilities (UNCRPD) and subsequently ratified the same on October 1, 2007. The UNCRPD proclaims that disability results from an interaction of impairments with attitudinal and environmental barriers which hinders full and active participation in society on an equal basis. Further, the convention also mandates the signatories to change their national laws, to identify and eliminate obstacles and barriers, and to comply with the terms of the UNCRPD. In this regard, the Government of India initially undertook the amendment of laws such as Persons with Disability Act, 1995 (PWD Act 1995). The Rights of PWD Act, 2016 (RPWD Act 2016) replaced the PWD Act 1995 to comply with the UNCRPD. The new act was fine-tuned considering the socio-cultural and local needs of the society, and the available resources. Persons with Mental Illness (PMI) are often stigmatized and discriminated, which hinders their full and active participation in society. This is a much larger issue, especially in women, gender minorities, backward communities, and the poor and the migrated populations. Adding to the complexities, PMIs are often not aware of their illness, refuse the much-needed treatment and often are not in a place to exercise their rights. There is an urgent need to address this issue of attitudinal barrier so that the rights of PMI are upheld. Hence, this article discusses challenges and opportunities in the RPWD Act 2016 from the perspective of PMI.
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Is it the right time to implement Community Treatment Order in India? p. 816
Guru S Gowda, Arun Enara, Bevinahalli Nanjegowda Raveesh, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_88_19  
India enacted the Mental Healthcare Act, 2017 (MHCA 2017) on April 7, 2017 to align and harmonize with United Nations Convention on Persons with Disabilities and the principles of prioritizing human rights protection. While MHCA 2017 is oriented toward the rights of the patients, the rights of the family members and professionals delivering treatment, care, and support to persons with severe mental disorder (SMD) often suffer. MHCA 2017 mandates discharge planning in consultation with the patients for admitted patients and makes the service providers responsible for ensuring continuity of care in the community. The concerns surrounding the chances of relapse and recurrence when a person with a SMD stops medications continue to remain largely unaddressed. The rights-based MHCA 2017 makes it difficult for the prevailing practices of surreptitious treatment by the family/caregiver and proxy consultations on behalf of the patients. This will, in turn, lead to increased chances of relapse, risk of violence, homelessness, stigma, and suicide in persons with SMDs in the community, largely due to noncompliance to treatment. This will also result in increased caregiver burden and burnouts and may also cause disruptions in the family and the community. To strike a balance over the current MHCA 2017, there is a need to amend or bring-forth a new law rooted in the principles of community treatment order.
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Civil commitment of persons with mental illness: Comparison of the Mental Healthcare Act 2017 with corresponding legislations of the USA p. 821
Srinagesh Mannekote, Ajayan Pillai, Vijaykumar Harbishettar
DOI:10.4103/psychiatry.IndianJPsychiatry_81_19  
The policies and procedures for the treatment of psychiatric patients are within the boundaries of ethical and legal principles of medical practice, with equal importance to human rights and values. Both in India and the USA, the Mental Health Legislation/Act guides psychiatrists in performing their duty toward the patients within this framework. The objective of this review was to compare the Indian Mental Healthcare Act (MHCA) of 2017 with mental health legislations currently existing in the USA, taking New York State Mental Hygiene Law as an example. The evolution of the American mental health legislation over the years was reviewed, including the aspects of involuntary admissions and segregating the psychiatric patients from the community. Over the years, the assessment and treatment approaches inclined toward patient's “rights and liberty” such as assessment of competency to make decisions, the involvement of family members and mandatory requirement of procedure to be followed during admission, inpatient care, and discharge. The current American mental health system is compared and contrasted with MHCA 2017. In the context of existing American mental health legislation and practical issues, this review tried to anticipate possible shortcomings or difficulties that can occur during the implementation of MHCA 2017. Several differences and similarities exist between the two legislations. Added to this, in America itself, there are smaller variations in mental health legislation in each state, albeit the general principles remain the same. Whether this is going to be the case in India once the individual states form the rules is worth a consideration.
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How to make rules and regulations for the states in accordance with the Mental Healthcare Act 2017 p. 827
Chandrashekar Hongally, V Sneha, G Archana
DOI:10.4103/psychiatry.IndianJPsychiatry_156_19  
Mental Healthcare Act (MHCA) 2017 was gazetted on April 7, 2017. It repeals the Mental Health Act, 1987, and it can be implemented only after the state rules are formed. The central government has already published three sets of rules. This article was written with an objective to review how to make rules and regulations for the state as per MHCA, 2017. All sections of MHCA 2017 and the mental health rules previously made by different states according to the Mental Health Act 1987 were reviewed. Google and PubMed searches were done to review the implementation of their respective mental health acts by different countries and states in the past. Go through Central/State Mental Health Rules, 2018, framed by the central government. Try to adapt it for the state. A meeting on MHCA 2017 should be conducted, including all stakeholders who will give their suggestions about changes to be made. Frame an initial draft and discuss it with the stakeholders and finalize the draft. Discuss the draft in state mental health authority meetings and submit the draft to the government. The Department of Legislation and Parliamentary Affairs can be consulted. The draft should be sent to the central government's Ministry of Health and Family Welfare for approval. According to MHCA 2017, state rules can be formed in relation to the aspects mentioned under Sections 121 and 123. The state government should make notification of the rules and then implement them.
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Family matters! – The caregivers' perspective of Mental Healthcare Act 2017 p. 832
KS Pavitra, Shubrata Kalmane, Akilesh Kumar, Mahesh Gowda
DOI:10.4103/psychiatry.IndianJPsychiatry_141_19  
Mental health continues to fight for acceptance in health care all over the world. The need for a separate act for mental illnesses proves this fact even more. The very nature of the mental illness has necessitated legislation to aid the service providers and service users. The Mental Healthcare Act 2017 has taken great initiatives in terms of protection of human rights for people with mental illness such as the inclusion of mental illness in health insurance, stress on informed consent, decriminalization of suicide, and introduction of advance directives (ADs) and punishment to those who violate the law. However, in a country like India where the family as a unit has more significance than personal autonomy, the new act emphasizes the patient's rights and, in doing so, may make the doctors more defensive and fearful in making clinical decisions, thus shifting the burden to the shoulders of the family members. There is a need for suitable amendments to include the family's concerns as well; otherwise, the present act would stand as an alien Western law enforced on Indian cohesive family dynamics. Qualitative studies are required from the family's perspective to illustrate the hindrances that the patients' families are facing. In the context of Indian family structure and dynamics and working in the Indian community, we feel that without suitable amendments to include the family's concerns, the present act would stand as an alien Western law enforced on Indian cohesive family dynamics.
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