Hegde, Prakyath Ravindranath; Gautham, Manaswi1; Kumar, Channaveerachari Naveen; Manjunatha, Narayana; Math, Suresh Bada
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Indian Journal of Psychiatry 67(1):p 168-180, January 2025. | DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_688_24
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INTRODUCTION

The World Health Organization (WHO)’s Comprehensive Mental Health Action Plan 2013–2030 recommends systematically shifting the locus of care from long-stay psychiatric hospitals to nonspecialized health settings.[1] This includes expanding the coverage of evidence-based interventions through a network of linked community-based mental health services, which encompass short-stay inpatient and outpatient care in general hospitals, primary care, comprehensive mental health centers, day care centers, support for persons with mental illness (PWMIs) with mental disorders living with their families, and supported housing. This shift allows PWMIs to regain independence and engage in social and vocational activities, significantly improving their overall wellbeing.

The WHO, in its document on transitioning mental health care from institutions to community settings in the South-East Asia Region, provides statistics and recommendations related to residential facilities for PWMIs in India. In 2020, India had 136 psychiatric institutions, of which 46 were operated by the government, and the country had a total of 1.43 psychiatric beds per 100,000 people. India also recorded the highest number of involuntary admissions in the region, with 15,890 cases, accounting for 28% of all admissions. Additionally, 68% of inpatients stayed for less than a year, yet over 2000 individuals continued to reside in institutions despite having recovered, representing 12% of all admissions. Regarding community-based care, India has 223 residential facilities, and recent initiatives have increased this number to 330 across various states.[2]

The Mental Healthcare Act (MHCA) 2017, a landmark legislation, emphasizes a rights-based approach and mandates the provision of high-quality, humane, and patient-centered care within the community, aligning with international standards.[3] In comparison to the Mental Health Act 1987, the revised MHCA 2017 has taken adequate care of the human rights and privileges of mentally ill people.[4]

Purpose and scope

The clinical practice guidelines aim to provide comprehensive and practical guidance for healthcare professionals, mental health establishments (MHEs), and stakeholders involved in the care of PWMIs in MHE, particularly focused on admissions, covert medication, proxy consultation, and proxy prescription. The guidelines address key aspects of long-stay care, aligning with the principles and provisions of the MHCA 2017, which are admissions to an MHE, management of PWMIs in MHE, and discharge from an MHE. For this paper, the MHE has been classified as hospital-based (H-MHE) and community-based MHE (C-MHE) based on the existing literature,[5] MHCA 2017,[3] and Mental Health Atlas of WHO.[6] The operations definition of these MHEs is provided in Figure 1.

Figure 1: Operational definitions for various residential facilities for persons with mental illness. §Mental Health Establishment as defined in Section 2(p) of the Mental Healthcare Act 2017 of India, which includes residential facilities for persons with substance use disorder, but excludes residential facilities for persons with intellectual developmental disorder without concurrent mental illness. *Acute care services (ACS) are specialized medical interventions provided at H-MHEs to address immediate and significant risks of self-harm, harm to others, or self-neglect in PWMI in the acute phase of treatment
However, this CPG does not address the stay of persons with intellectual disabilities without a concurrent mental illness diagnosis. By adhering to these guidelines, mental health professionals and institutions can ensure that PWMIs in long-stay care receive optimal treatment and support, while upholding their rights, dignity, and autonomy. These guidelines are designed to be a practical and adaptable resource, evolving with new evidence and best practices to continuously improve the quality of care for this vulnerable population.

In this paper, ‘lacks capacity’ refers to a PWMI needing 100% support from their nominated representative (NR) to make mental healthcare and treatment decisions (MHTDs), including admission. Conversely, ‘has capacity’ means the PWMI can make treatment decisions. Both determinations are made based on the capacity guidance document, prepared by the expert committee as per Section 81 of the MHCA 2017.[7]

Section refers to sections of the MHCA 2017 of India in this paper.

Guiding principles

The MHCA 2017 strives to ensure access to mental healthcare services for PWMIs while simultaneously protecting, promoting, and fulfilling their rights during treatment and recovery, recognizing that these two objectives are intrinsically linked in the journey toward wellbeing (Preamble of MHCA 2017)
The MHCA 2017 presumes all PWMI have the capacity to make decisions about their mental healthcare, including admission and continued stay at an MHE unless there are reasonable reasons to doubt the presumption [Section 4(1)]
This principle of “least restrictive alternative” or “least restrictive environment” mandates that PWMIs should be offered treatment options and settings that meet their treatment needs while imposing the least possible restriction on their rights and freedoms. In alignment with this principle, admission to a mental health establishment should only be considered when it is deemed the least restrictive care option available, after considering any existing advance directives [Section 89(1)(b), and Section 90(2)(b)]
All admissions to an MHE should be independent admissions as much as possible, including long stay, unless supported admission is unavoidable [Section 85(2)]
Supported admission should be provided only to those who lack capacity. No one deemed to have the capacity should be forced to remain in an MHE against their will or without providing ongoing consent [(Section 89(1)(c), Section 90(2)(c)]
All treatment decisions related to the care of PWMIs in a supported admission who lack capacity should be made in discussion with and consent of the NR; then a ‘best interests’ decision needs to be made with the consent of the NR for the treatment plan [Section 89(7), Section 90(13)]
Long-stay MHE should only be considered in exceptional circumstances for the shortest possible duration and as a last resort after appropriate community-based treatment options have been exhausted [Section 18(5)(c)]
Every PWMI has the right to community living, and PWMIs who no longer require treatment at a restrictive long-stay psychiatric hospital should be supported through community-based establishments such as halfway homes by the appropriate government [Section 19(3)]
The MHCA 2017 explicitly prohibits the continued confinement of PWMIs in MHE solely due to factors such as lack of family support, rejection by family, homelessness, or the absence of community-based facilities [Section 19(2)]
This Clinical Practice Guideline (CPG) for Long Stay in psychiatric settings will adopt a comprehensive approach encompassing admission and treatment processes, aligning with relevant sections of the MHCA 2017. Each phase will be discussed in detail, outlining the types of admissions, criteria or requirements for each, and the resources and facility types necessary for providing care. The CPG will also address critical issues such as covert medication and proxy consultation, given the prevalent practices in India and the lack of explicit provisions in the MHCA 2017, along with the ambiguity surrounding these areas.

METHODOLOGY

The first draft of the clinical recommendations was prepared based on a systematic review and analysis of the existing guidelines elsewhere, grounded in the provisions of the MHCA 2017 of India. A systematic literature search was conducted across websites, guidelines from other countries, and journal articles to gather policies on covert medication, proxy prescription, and refill strategies, including their ethical and legal considerations. The purpose of this search was to create guidelines within the purview of the MHCA 2017.

The search strategies involved two components: one focusing on gray literature (using Google) and the other on scientific and clinical literature (using PubMed). The gray literature search used terms like ‘covert medication’, ‘proxy consultation’, ‘proxy access’, ‘repeat prescriptions’, and ‘refill management’, conducted in June 2024, reviewing the first 50 websites listed on Google for relevant guidelines. Policy guidelines were identified for review and development.

The scientific and clinical literature search was conducted on June 20, 2024 using PubMed, specifically to review concerns relevant to India. The search terms used were (“proxy consultation” OR “proxy prescription” OR “proxy consultations” OR “covert medication” OR “covert administration”) AND (“India”), with no date limits. The abstracts of the resulting 12 articles were reviewed to assess their relevance, and applicable findings were incorporated into the guideline development.

Development process

The first draft, developed as outlined in the earlier section of the methodology, was submitted on June 30, 2024, with extensive correspondence continuing throughout July 2024. The development process included a face-to-face workshop with leading practitioners from psychiatry on August 10 and 11, 2024. Recommendations were shaped through in-depth discussions, facilitating open debate to reach a consensus. To avoid bias and ensure diverse perspectives, the working group in the workshop included psychiatrists from various backgrounds, including those affiliated with standalone psychiatric institutions, both public and private, and psychiatric units within general hospitals. All members contributed to discussions, and decisions were informed by prevailing practices and peer-reviewed clinical literature. The draft guidelines were iteratively reviewed, with feedback collected and areas of disagreement resolved. The revised draft was submitted on August 25, 2024. Subsequently, the draft was made available on the Indian Psychiatric Society (IPS) website for a period of 10 days, from November 23, 2024 to December 2, 2024, inviting feedback from IPS members for further refinement.

ADMISSION OF PERSONS WITH MENTAL ILLNESS IN LONG-STAY MENTAL HEALTH ESTABLISHMENTS

Persons with mental illness consenting for admission and treatment at mental health establishment

A PWMI can be admitted as an independent patient and continue as an inpatient for an extended period. However, they have to meet the criteria for admission to an MHE, which has to be periodically reviewed.

Criteria for admission under Section 86:
To be admitted under Section 86, a PMWI should have a mental illness of sufficient severity that necessitates admission to the MHE. This determination should be made the medical officer or mental health professional in charge of the MHE, in accordance with the established policies of the MHE. In addition to the severity requiring admission, there must be a reasonable likelihood that the admission will benefit the PWMI.
Continued stay in an MHE requires the written consent of the PWMI. Furthermore, no treatment should be initiated or continued without the informed consent of the PWMI, as mandated by the MHCA 2017.
Capacity requirement: While capacity is presumed to be present, before admission, irrespective of the type or setting of the admission, it is required to do a capacity assessment as per capacity guidance. It is important because a PWMI who lacks the capacity should not be admitted under Section 86. As a routine, capacity assessment is not required to be repeated for independent admission during a long stay at any MHE as a periodic legal need, unlike supported admission. But it is important to note that capacity is a dynamic ability, specific to time and task. Therefore, at any time during the inpatient care as an independent admission, if the PWMI is found to be unable to understand the nature or purpose of their treatment decision, capacity assessment has to be repeated as per the guidance document. If deemed not to have the capacity, the admission under Section 86 should be terminated.
Resources required: While the MHCA does not explicitly mandate specific resources required for independent admissions under Section 86, it emphasizes the principle of the least restrictive environment. Therefore, if a hospital-based MHE admits a PWMI under this section, it is preferable to have less restrictive facilities within the MHE. The minimum standards for the MHE will be as prescribed by respective state/central MHCA regulations.
The MHE can establish its own policies regarding the admission and treatment of PWMI as long as these policies do not violate the provisions of the MHCA. A lack of less restrictive facilities should not be a reason to keep the PWMI in a more restrictive environment than necessary for the treatment of the PWMI.

If a PWMI admitted under Section 86 finds the facility too restrictive and requests discharge, they should be discharged within 24 hours as their admission is considered independent and voluntary. Since these patients are not deemed to pose a significant risk of harm to themselves, or others, or of self-neglect, acute care services focused on crisis management are not a necessity.

Therefore, even low-resource facilities can cater to the needs of PWMIs admitted under Section 86. However, a comprehensive community treatment plan is essential at all levels of facilities, especially if the PWMI is in a long stay. This plan should focus on reintegrating the PWMI into the community and providing ongoing support to ensure their wellbeing.

All long-stay PWMIs should have access to rehabilitation services. So, MHE should develop a model of care for transitioning patients of long-term psychiatric facilities to the community. The focus of these models should be to reduce the length of hospital stay and reduce readmission.

d. Type of Mental Health Establishment: Independent admission under Section 86 of the MHCA can occur at any registered MHE, whether it is a community-based MHE (C-MHE) or a hospital-based MHE (H-MHE). The essential requirement is that the PWMI provides informed consent for their stay and meets the admission criteria outlined.
The major differences between the H-MHE and C-MHE concerning provisions, level of resources needed, and type of admissions allowed as per MHCA 2017 are summarized in Table 1.

Table 1: Classification of MHE based on residential care provision
Admission of minor

Guidelines for inpatient care and use of ECT in children and adolescents as per MHCA 2017 have been discussed comprehensively in the earlier IPS (Indian Psychiatric Society) guidelines.[8]

Person with mental illness not consenting for admission and treatment at mental health establishment

All supported admissions fall under section 89 for 30 days, and stay beyond 30 days comes under section 90. The detailed process for supported admission under both these sections is summarized in Table 2.

Table 2: Process for admission of nonconsenting patients at MHE
e. Criteria for admission under sections 89 and 90: We can divide the admission criteria into severity criteria, least restrictive criteria, and capacity criteria. The detailed admission criteria for these are provided in Table 3. Continuation of admission beyond 30 days in MHE necessitates a reassessment by two psychiatrists and periodic review by the MHRB. The behavioral criteria for continuation are stricter, requiring the behaviors mentioned above to have occurred “consistently over time.”

Table 3: Relevant sections and criteria for admission of nonconsenting patients§
f. Capacity requirement:
At the time of admission: Capacity assessment done as per the capacity guidance document by the professions should ascertain that the PWMI lacks capacity. No PWMI who has capacity should be admitted as supported admission.
Periodic reassessment under Section 89: There should be a reassessment of capacity every week under Section 89(8). If the PWMI regains capacity during these weekly assessments, their admission under this section must be immediately terminated. At the end of 30 days, there should be a review by Section 90(1) to assess for continued admission under Section 90. This review should also involve capacity assessment.
Before continuation of admission beyond 30 days under Section 90: Only those who lack capacity should be considered for continuous admission at the MHE under Section 90.
Periodic reassessment under Section 90: Capacity assessments should occur every fortnight for those admitted under Section 90(13). Those who regain capacity will be discharged, while those who lack capacity under Section 90(13) support can continue as supported admissions under Section 90 with treatment decision by the nominated representative temporarily for 14 days.
c. Resources required: Supported admission typically will require a high resource setting. There should be provision of acute care services as defined. These settings being restrictive should have additional human resources to adhere to the MHCA 2017 rules. For example, there should be monthly reporting of the restraining orders and documentation related to the stay including steps taken to discharge from the restrictive environment.
d. Type of Mental Health Establishment: Admission of nonconsenting PWMIs under section 89 and section 90 should only occur at hospital-based MHE. As the PWMIs meeting the criteria for admission include risk of harm to self and others or severe neglect, they will be restrictive and inclusive of medical intervention. The decision pathway for supported admission under Section 89 and Section 90 is depicted in Figures 2 and 3, respectively.

Figure 2: Decision pathway for nonconsenting patients until 30 days. §Section of Mental Healthcare Act, 2017. ‡Capacity assessment to be done as per capacity guidance. *Board refers to respective Mental Health Review Boar

Figure 3: Decision pathway for nonconsenting patients beyond 30 days. §Section of Mental Healthcare Act, 2017. ‡Capacity assessment to be done as per capacity guidance. †The admission shall initially be limited to 90 days. Beyond this period, the admission may be extended for an additional 120 days initially, and thereafter for periods of 180 days each. *Board refers to respective Mental Health Review Board
MANAGEMENT OF PERSONS WITH MENTAL ILLNESS IN LONG STAY

Oral medication in consenting persons with mental illness

Medications for the PWMI admitted as independent admission should be done with the informed consent of the PWMI after providing reasons for the medication. If a PWMI is refusing treatment, they should be provided with information about the consequence of not taking medication, and refusal should be documented. No PWMI who has the capacity should be forced or given medication covertly.

Covert medication

Covert medication refers to the practice of administration of oral medication in a disguised form (e.g., in food or drink) to a patient.[9] This does not include the administration of medication in food or drink to aid swallowing or through medical tubes as long as the PWMI is aware of the medication. The practice of administering medication covertly presents significant ethical, legal, and clinical challenges.

International perspective and ethical consideration
Internationally, the ethical aspects of covert medication emphasize the importance of patient autonomy and the potential risks to identity and trust.[10] While covert medication may be justified in certain situations, it must be carefully weighed against its long-term impact on the patient’s sense of identity and trust in the healthcare provider. There is a significant dearth of professional guidance regarding this form of deception, with exceptions primarily found in the National Health Service (NHS) Trust, where covert medication is used for patients with mental incapacity.[11] In these cases, it is implemented with strict adherence to ethical standards and legal frameworks. However, authors have argued that in resource-limited settings like India, where family and community play a crucial role, the ethical considerations may differ, necessitating a tailored approach.[12]

b. Indian perspective on covert medication
The practice of covert medication in India was examined in a special theme of an earlier edition of the Indian Journal of Psychiatry published in 2012.[13] This issue included seven key articles that examined various aspects of covert medication, including ethical and legal issues, practical challenges, and perspectives from both patients and caregivers.

These articles provided important insights into the practice of covert medication in the Indian context. They addressed the ethical dilemmas faced by healthcare providers and caregivers, as well as the need for clear guidelines, particularly in light of the MHCA 2017. For a summary of the key points from these articles, refer to Table 4.

Table 4: List of articles published in the 2012 edition of the Indian Journal of Psychiatry with a special theme on covert medication
c. Current practice and legal framework
The MHCA 2017 emphasizes patient autonomy, informed consent, and the rights of PWMI, thereby placing greater scrutiny on practices like covert medication. Under the MHCA 2017, covert medication is particularly contentious when administered to patients who have the capacity to make informed decisions.

Despite these challenges and legal advancements, covert medication remains prevalent. Recent studies from India have shown that a significant proportion of caregivers and healthcare providers still resort to covert medication to manage nonadherent patients with severe mental illnesses like schizophrenia and bipolar disorder.[21,22]

d. Guidelines for covert medication at Mental Health Establishment in Indian settings
Based on these insights, the following guidelines are recommended for the use of covert medication in hospital settings. The decision to administer covert medication can be considered for a PWMI who lacks the capacity when admitted to the MHE. This decision should be made by the care team, with the consent of the nominated representative (NR). Covert medication should be avoided if the PWMI is willing to take oral medication and only used in exceptional circumstances after all attempts to persuasion have failed. The decision pathway for administering covert medication, when the PWMI refuses essential medication, is illustrated in Figure 4. The prerequisites and considerations are outlined in Table 5.

Figure 4: Decision pathway for covert medication at a hospital-based MHE. Covert medication refers to the practice of administration of oral medication in a disguised form; §All efforts to give medication openly, including attempts to convince, have failed or been rejected

Table 5: Guidelines for the administration of covert medications during Hospital Stay
e. Covert medication in the community by the caregiver
In developing the guidelines on covert medication, it is acknowledged that while the primary focus has been on its application within hospital settings, there is a recognized prevalence of covert medication practices in community settings by the caregiver. Given the current lack of robust community-based services in India, these practices often arise out of necessity when adequate support systems are not in place.

Although a healthcare professional’s direct involvement may end at the point of prescribing and advising on adherence, it is important to consider the ethical and practical implications when covert medication is used outside institutional oversight. Covert medication in the community poses significant ethical challenges, particularly concerning the autonomy and rights of the PWMI. There is a substantial risk of losing trust if covert medication is discovered, which can have long-lasting negative effects on the therapeutic relationship and the patient’s engagement with future treatment. Therefore, it is essential to ensure that covert medication is employed only in the patient’s best interests and when no other viable alternatives exist.

This framework provides a structured approach to addressing covert medication in community settings, emphasizing the following principles:

Capacity Assessment: Before prescribing, there should be an assessment of the patient’s capacity to consent to their treatment. In patients who are assessed as having the capacity to make informed decisions, families should be informed of this capacity and advised to refrain from using covert medication. Covert medication should only be considered if the patient lacks capacity and it is absolutely necessary for their wellbeing, and in the interest of the PMWI.
Education and Advocacy: Healthcare providers should engage in discussions with caregivers and families, emphasizing the ethical implications of covert medication and the importance of transparency. Education should focus on the potential risks, including the risk of losing trust, and the legal boundaries within which they must operate.
Documentation: Any disclosure of covert medication practices by caregivers should be documented in the patient’s records, along with the rationale for its use and any alternative strategies discussed.
Parenteral medication

Parenteral depot and rapid tranquillization are considered restrictive practices. As a general rule, the benefits of using chemical restraints or parenteral depot for the PWMI must outweigh the potential negative effects and risks associated with not using the restrictive practice.

Rapid tranquillization: The chemical restrain can be fixed doses or symptoms triggered. In both scenarios, the use of chemical restraints (intramuscular or intravenous) as a restrictive practice may be considered under the following conditions at an MHE, with consent from the NR, in a PWMI who lacks capacity:

When it is the least restrictive option to prevent the PWMI’s behavior from causing harm to themselves or others taking into account the severity of the illness, and the history of multiple tranquilizations in the last 24 hours.
As a temporary measure when there is a need to protect the PWMI and others from significant harm.
As part of a treatment strategy that aims to create a safer environment for the PWMI and others, ultimately leading to reduced or eliminated need for restrictive interventions. The strategy can be fixed-dose chemical restrain but has to be reviewed every day.
Additional considerations:

Less restrictive options have been evaluated and deemed unsuitable or ineffective.
Mechanisms are established at the MHE to enable continuous monitoring and evaluation of the practice’s use.
Chemical restraints should not be used as a form of punishment or to make up for logistic difficulties such as a shortage of staff at the MHE.
Parenteral depot: The decision to start a parenteral depot should be made with the consent of the PWMI. In rare cases where the PWMI lacks capacity and requires a parenteral depot, the decision should be made with written consent from the NR. For those refusing, each dose should be preceded by a capacity assessment conducted within the preceding 7 days. If the assessment determines a lack of capacity, the parenteral depot should continue with the consent of the NR. Once the PWMI regains capacity, the decision to continue the parenteral depot should be agreed upon and consented to by the PWMI.

Use of restraints and seclusion in long stay

Restraint guidelines for mental health services in India have been discussed comprehensively in the earlier IPS guidelines on restraint.[23]

Communicating with the nominated representative or family

For independent admission, the presence of a caregiver is not required unless mandated by the policies of the MHE.
For PWMI admitted under supported admissions, periodic capacity assessments occur periodically, contingent upon the PWMI not regaining capacity. These interactions provide an opportunity to update the NR on the PWMI’s health status, treatment progress, and any modifications to the treatment plan, ensuring that the NR is informed and involved in the ongoing care process. Decisions such as covert medication and ECT (electroconvulsive therapy) should be administered only after obtaining written consent from the NR. For ECT, consent must be obtained before the initiation of the course, and there is no need to take consent before each session unless clinically indicated. Once the PWMI regains capacity, the ECT can only continue with the consent of the PWMI.
When the NR is not available, the steps to be followed have been mentioned as described in Section 14(4) of the MHCA 2017. The details of these steps are depicted in Figure 5.

Figure 5: Stepwise procedure when Nominated Representative (NR) is not available. In accordance with Section 14(4) of Mental Healthcare Act, 2017
In the event of emergencies or significant changes in the PWMI’s condition, the NR must be promptly informed. All communications with the NR or family should be thoroughly documented, including the date, time, content of discussions, and any decisions made. This documentation ensures transparency and accountability while safeguarding the PWMI’s confidentiality and privacy as per legal requirements.
Additionally, MHEs should make attempts to provide support and educational resources to NRs and families to help them understand the PWMI’s condition, treatment options, and the role they play in the recovery process. This can include informational brochures, workshops, support groups, and individual counseling, fostering a supportive and collaborative environment for all stakeholders involved.
DISCHARGE PROCEDURES FROM MENTAL HEALTH ESTABLISHMENT

The MHCA 2017 outlines specific procedures for the discharge of patients admitted to MHEs. These procedures vary depending on the type of admission and the patient’s condition. However, a discharge plan is a mandatory requirement for all discharge from any MHE, irrespective of the type and setting of admission as per Section 98 of the MHCA. It is important to note that discharge planning is an ongoing process, and it should start from the time a PWMI is admitted to MHE. A community treatment plan is required to be presented to MHRB, when PWMI is admitted under section 90, when applying for review to the MHRB, for continued supported admission.

Collaborative Planning: Before a patient is discharged, the psychiatrist responsible for their care must consult with the patient, their nominated representative, family members, caregivers, and other relevant parties to develop a discharge plan. The community treatment plan should be made with available resources leveraging the District Mental Health Program, which mandates the presence of at least one psychiatrist in each district across the country. The postdischarge plan should outline the treatment and services that will be provided to the PWMI, including emergency contact information for crises and details of follow-up appointments.

Role of proxy consultation and refill management

Given the challenges of consistent access to in-person consultations in many parts of India, there is a strong case for implementing structured guidelines for proxy prescriptions and refill management. Table 6 provides a comprehensive framework tailored to the Indian context. These recommendations are essential for safeguarding the health and wellbeing of PWMI, particularly in situations where traditional, in-person consultations are not feasible. Research indicates that proxy consultations are relatively common in India, driven by socioeconomic factors, patient-related issues such as unwillingness to visit clinics, and logistical challenges like mobility issues among elderly patients.[24] Studies also highlight the legal and ethical complexities involved in proxy practices, especially under the MHCA 2017, which emphasizes patient rights and informed consent.[25] By learning from countries like the UK and Australia, which have advanced systems for managing refill prescriptions through e-filing and proxy access,[26,27] India can adapt these best practices to fit its healthcare environment. Implementing these guidelines will enhance the safety and effectiveness of postdischarge care for PWMI, ensuring that their treatment continues uninterrupted while maintaining compliance with the MHCA 2017.

Table 6: Guidelines for proxy prescription and refill management
SPECIAL CONSIDERATIONS

Managing the demise of persons with mental illness

The demise of the PWMI in the MHE needs to be informed to the police at the earliest. The NR and family must be promptly informed if not present at the premises. A certified copy of the medical record has to be preserved by the head of the MHE. A qualified medical professional should certify the death, adhering to legal requirements. Thorough documentation of the cause of death, care provided, and communications with the NR/family are important. Postdemise, grief counseling, and bereavement support should be offered to the NR and family.

Research in long stay

The MHCA 2017 sets forth specific provisions in Section 99 for conducting research involving PWMI, ensuring that ethical standards are rigorously upheld. Researchers are required to obtain free and informed consent from participants before engaging them in studies that involve interviews or any psychological, physical, chemical, or medicinal interventions. In cases where a participant is unable to provide such consent but does not object to participation, permission must be sought from the relevant State Mental Health Authority. This permission is contingent upon the State Mental Health Authority’s determination that the research cannot be conducted on individuals capable of giving informed consent, is essential for advancing the mental health of the population represented by the participant, and aims to generate knowledge relevant to the specific mental health needs of persons with mental illness. Researchers must also disclose their interests fully, avoid conflicts of interest, and adhere to both national and international ethical guidelines, including registration with the Clinical Trials Registry-India (CTRI) and compliance with the ethical guidelines established by the Indian Council of Medical Research (ICMR), securing approval from an institutional ethics committee.

However, this provision does not restrict research studies involving the review of case notes or file review of PWMIs who are unable to provide informed consent as long as the anonymity of these individuals is maintained.

CONCLUSION

These guidelines provide a structured and tailored framework for managing PWMIs in a long stay in the Indian context, aligned with the MHCA 2017. They emphasize the appropriate admission of PWMIs who lack capacity and require high support, the ethical use of covert medication and proxy consultation, and the importance of ongoing capacity assessments. The guidelines are designed to reflect current legal requirements and cultural considerations, ensuring that care practices are grounded in reality while being both ethically sound and legally compliant. Additionally, it advocates for transitioning PWMIs to community-based care whenever possible, reinforcing the MHCA’s commitment to deinstitutionalization.
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