New legislation, new frontiers: Indian psychiatrists' perspective of the mental healthcare act 2017 prior to implementation.

CONTEXT: The mental healthcare act 2017 represents a complete overhaul of Indian mental health legislation. AIMS: The aim of this study was to establish the opinions of Indian psychiatrists regarding the new act. SETTINGS: Mental health professionals in Bihar and Jharkhand were interviewed.
DESIGN: A focus group design was utilized.
MATERIALS AND METHODS: Key questions explored the positive and negative aspects of the act and the management of the transitional phase. All focus groups were recorded and transcribed. ANALYSIS: Data were coded and analyzed using an inductive approach.
RESULTS: Many positive aspects of the new legislation were identified especially relating to rights, autonomy, and the decriminalization of suicide. However, psychiatrists have significant concerns that the new legislation may negatively impact patients and increase stigma. Psychiatrists held varying views on the proposed licensing and inspection of general hospital psychiatric units.
CONCLUSIONS: Careful evaluation of the new legislation is needed as the concerns raised warrant ongoing monitoring.

INTRODUCTION

In 2018, India plans to implement the mental healthcare act (MHCA) 2017. This is a long-anticipated piece of legislation.[1] The major catalyst for the new act was the United Nations' convention on the rights of persons with disability (UNCRPD),[2] which India ratified in 2007. This placed a onus on India to bring its legislation in line with the UNCRPD. From a theoretical perspective, the MHCA is a highly progressive piece of legislation, concordant with a higher proportion of the world health organization human rights standards[3] than current legislation in England and Wales.[45] It remains to be seen how this legislation will work in practice.

Aims

In this study, we aim to:

Identify the perceived benefits of the MHCA

Identify concerns regarding the act's content

Identify issues relating to implementation.

Setting and design

Focus groups were held at the initial stage of a larger research project conducted by “our institution.” This project plans to examine the views of Indian psychiatrists about the new legislation. The three focus groups reported here were conducted in Bihar and Jharkhand in late 2017, before the implementation of the MHCA. A theoretical sampling method was used.[6]

MATERIALS AND METHODS

Focus groups had two moderators; the first leads the discussion, while the assistant was responsible for audio recording, note-taking, and logistics. Recordings were transcribed. The four main questions analyzed were as follows:

What is positive about the new legislation?

What are your concerns about the new legislation?

What needs to be done in the transitional phase?

What would you have done differently if you were writing the act?

Participants included 20 mental health professionals (16 psychiatrists, and the head of the department for social work, nursing, psychology, and occupational; 8 psychiatrists worked solely in the private sector) spread over the three focus groups. Focus groups lasted between 45 and 75 min. Ethical approval was granted by Trinity College Dublin School of Medicine's research ethics committee.

Analysis

After each focus group, the researchers reviewed the focus group, refined the questions, and critiqued the interview process, as part of an iterative process.[7] Recorded data were transcribed and combined with the observer's notes. Data analysis employed an inductive approach.[8] Focus group participants were not involved in data analysis.

RESULTS

The main perceived benefits and potential concerns identified by the participants are summarized in Table 1. Not only increased patient autonomy was generally seen as a positive development but also raised a number of concerns. These included the possibilities of patients refusing treatment, psychiatrists being held responsible for adverse outcomes, and underutilization of advance directives.

Table 1

Key potential benefits and concerns about the Mental Healthcare Act 2017 and the relevant sections of the Act

Some differences were noted between the varying groups of psychiatrists. Most psychiatrists who worked in public mental health hospitals tended to welcome the registration of general hospital psychiatric units (GHPUs), while others were concerned that inspection of these facilities would discourage the opening of GHPU.

Psychiatrists, who worked primarily in private settings, were troubled that this legislation placed an added onus of responsibility on them whereas those who worked primary in public or Government settings felt that the MHA placed the burden of providing healthcare on the shoulders of the Government.

Psychiatrists employed by the state were more convinced of the benefits of recognizing allied health professionals in the legislation. However, individuals in all focus groups were concerned about the place of allied health professionals and resulting underrepresentation of psychiatrists, on the central mental health authority (CMHA), the state mental health authorities (SMHAs), and the mental health review boards (MHRBs).

Probing the motivation behind the criticism revealed that concerns about patient care were the key motivating factor, even on issues that appeared to relate to reduced powers for psychiatrists. For example, concerns about the banning of unmodified electroconvulsive therapy (ECT) related to patients being deprived of life-saving interventions due to resource limitation.

Regarding implementation, all groups raised grave concerns about resource issues, in particular, how the new legislation may increase administrative work and reduce patient contact.

DISCUSSION

In general, there was a clear consensus on many topics. The two areas where there were more conflicting views related to GHPUs and individual autonomy.

GHPUs are clearly a key part of Indian psychiatry, regarding both treatment[9] and research.[10] These units have not been subject to the same level of review as stand-alone psychiatric facilities under the 1987 legislation. Sections 65–72 of the MHCA layout provisions for the registration and inspection of all mental health establishments including GHPUs (Section 2[p]). In general, psychiatrists working in stand-alone psychiatric hospitals welcomed this inclusion.

Psychiatrists working in GHPUs or predominantly working with outpatients, however, were concerned that such regulation could make hospitals less likely to open GHPUs, necessitating individuals to seek treatment in stand-alone psychiatric hospitals. This could potentially undermine many of the principals of the UNCRPD including article 19 (concerning inclusion in the community). It could also increase institutionalization, a major concern of the UNCRPD's authors.[11] Such a consequence would hamper national mental health policy[1213] and potentially undo recent progress.[14] Inspection and review processes are essential in all areas of medicine including psychiatry; hence, the impact of these new measures on stigma and institutionalization will need close monitoring.

The subject of patient autonomy provided many conflicted answers. All groups supported the addition of human right protections but were concerned that this had gone too far and that such a focus on autonomy might limit the ability to treat patients, i.e., limit the right to treatment. One psychiatrist stated, “I think it's only rights in the new Act.”

Patient autonomy is supported in many ways in the MHCA. Section 4,[3] for example, affirms patients' capacity to make treatment decisions including those perceived as inappropriate or wrong. The role of the family has been replaced in many ways with the nominated representative (giving autonomy in this area to the individuals receiving treatment),[15] and Rao et al. have highlighted how this conflicts with Indian culture.[12]

Autonomy appears to have become the unquestionable central ethical principle,[16] and paternalism has been vilified as universally negative. The general comment on article 12 of the UNCRPD has further cemented this in the international context.[17] Dogmatic and overly literal application of this position stands to harm individuals suffering from mental illness.[18]

The MHA has not, however, embraced a particularly hard-line interpretation of article 12 of the UNCRPD. Moreover, while the new legislation is a paradigm shift from the 1987 act, it still incorporates some limits to autonomy including the areas of emergency treatment (Section 94), supported admissions (Section 89), limitations on nominated representatives (Section 16), and proxy consent (Section 89[7]).

Finally, there are two key limitations to this research. First, a greater number of participants would be helpful, and hence, more focus groups are planned for after the act is implemented. In the meantime, the small sample size limits the generalizability of results (although, it is noteworthy that consistent themes emerged in our work). Second, all focus groups were held before implementation of the act, and it is possible that (a) anticipated concerns might not materialize in practice, and (b) issues which were not identified may present significant, unexpected challenges as implementation progresses.

CONCLUSIONS

The MHCA came into commenced in July 2018. Implementation will undoubtedly present many challenges. The concerns raised in this paper and elsewhere warrant careful monitoring. There is also however clear awareness that the MHCA presents unique opportunities for the development of mental healthcare in India.

Indian psychiatrists have expressed concern that individuals without clinical training will have disproportionate impact on clinical decisions under the new legislation and that psychiatrists will be underrepresented.[19] This may happen in the case of nominated representatives, MHRBs, SMHAs, and the CMHA. This however also presents an opportunity for psychiatrists as collaborators and educators, guiding and educating family members, nominated representatives, members of review boards, and mental health authorities. The guidance of psychiatrists will be needed now more than ever, and it will be important that positions are transparent, justifiable, and carefully articulated in a manner that fosters collaboration.

The MHCA places an onus on the government to provide a sufficient level of mental healthcare, bans unmodified ECT, and places allied healthcare professionals in key strategic areas in the mental health service. All these provisions will create a need to increase staffing numbers and provide additional training to existing staff to facilitate these new roles. The demand for highly trained staff, while initially challenging, could be used to draw funding for training and recruitment on the basis of these legislative requirements.

India has taken a bold step in passing the most theoretically progressive piece of mental health legislation in the world. In addition to adhering to the UNCRPD, it provides 1.3 billion people with a justiciable right to mental healthcare. This initiative might well prove too ambitious in certain respects and potentially impossible to realize in full. Whatever its outcomes, however, the new legislation has commanded international attention and may well become the mold for the next generation of rights-based mental health legislation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.