Judicial involuntary admission under the Mental Health Act in Goa, India: profile, outcome and implications.

Reception order (RO) by a magistrate is a mode of involuntary admission provided under the Indian Mental Health Act of 1987. To the best of our knowledge there has been no evaluation of this provision in clinical practice. The present paper is a descriptive study through retrospective case-note review of patients admitted by way of RO to a tertiary care hospital in Goa. Compared with those admitted voluntarily, those admitted by RO tended to be single, middle aged (40-60 years old) and non-Goan; on average they had a significantly longer hospital stay than voluntarily admitted patients. Non-affective psychosis and substance use disorders were the more common diagnoses. While admissions by RO serve a useful role in bringing patients who are not under proper care into the mental healthcare system, they do not address the issue of aftercare.

At times, people who are mentally unwell need to be admitted to a psychiatric hospital against their will for reasons of their own safety and/or that of others. In India, all admissions, both voluntary and involuntary, come under purview of the Indian Mental Health Act of 1987 (MHA). Under the Act there are two modes of involuntary admission: special circumstances (SC) and magisterial reception order (RO). For SC, family members or friends can request an admission if this is supported by two medical certificates. This provision is valid for a maximum of 90 days, beyond which an RO has to be obtained to continue the admission. For the RO, family members or the police may apply to a magistrate requesting the admission of a person to a psychiatric hospital. The magistrate has to be satisfied that the person is suffering from a mental disorder that needs admission for treatment or for the safety of others. The magistrate has to take into consideration the evidence of mental illness as certified by a government doctor. The RO is valid for 30 days. Within this period, the treating doctor has to certify the presence of mental illness, failing which the order lapses. If certified, the patient can be detained indefinitely until the treating doctor deems the patient fit for discharge. The patient can appeal against the order or for discharge to the magistrate or higher appellate (Gazette of India, 1987).

The objective of the present case-note review is to describe:

the sociodemographic and clinical profile of people admitted by way of RO (comparisons are drawn with patients admitted voluntarily)

their clinical outcomes

the procedural details of the RO process.

Methods

Goa, with a population of 1.5 million, is one of the smallest states in India. It has some of the best socioeconomic and health parameters in the country. Psychiatric services are provided by the public as well as the private sector. There is no active community-based psychiatric care. The onus is on the patient and family to access healthcare and for the latter to provide adequate support in the community.

In this study we retrospectively assessed the case-notes of all patients admitted by RO to a tertiary care psychiatric teaching hospital in Goa in the year 2006. Data were obtained from case-notes and RO documentation, from various magistrates’ offices, which accompanied the patients. Select data were also obtained from 100 randomly selected voluntarily admitted patients in the same period. Data were collected using a structured questionnaire recording the following:

sociodemographic details – age, gender, ethnicity, religion, marital status and education for both RO and voluntarily admitted patients

RO procedural details – who the complainant was, the nature of the complaint, whether the RO was supported by a medical report, duration of the RO, whether the patient was eventually certified as mentally unwell and the time taken to certify

clinical profile and discharge outcomes – clinical diagnosis and time to discharge, for both RO and voluntary patients.

Diagnoses based on ICD-10 (World Health Organization, 1992) were made during the course of the admission by the treating team, headed by a consultant.

Analysis

The counts and frequency of all the variables were recorded. Chi-square and t-tests were used to compare the sociodemographic profiles and clinical diagnoses of RO admissions with those of patients who were voluntarily admitted.

Results

Admissions to the hospital in 2006 totalled 1640, of which 109 (7%) were by way of RO. Case-notes could be traced for 100 of these patients, while RO documentation was available for all 109.

The sociodemographic profile of RO patients is compared with that of voluntary patients in Table 1. Of Goan patients on RO, 62% were Christians and 50% came from a single taluka (administrative unit of the state), namely Salcete. Compared with voluntary admissions, patients on RO were significantly more likely to be middle aged (i.e. 40–60 years old), non-Goan, Christian and unmarried.

Table 1

Sociodemographic details of patients admitted under reception order (RO) (n = 100) compared with voluntarily admitted patients (VP) (n = 100)

Variable		RO	VP	P
Age	<18	3	0	< 0.001
	18–40	50	75
	40–60	45	21
	>60	2	4
Gender	Male	73	64	0.06
	Female	27	36
Ethnicity	Goan	51	89	< 0.001
	Non-Goan (Indian)	36	11
	Foreign national	13	0
Religion	Hindu	43	59	0.003
	Christian	48	36
	Muslim	9	5
Marital status	Married	39	64	< 0.001
	Single	42	35
	Other	6	1
	Not known	13	0
Education	Elementary	9	6	< 0.001
	Pre-university	40	68
	University	12	6
	Nil	11	20
	Not known	28	0

Table 2 gives the procedural details of the RO admissions. The predominant reason for taking the patient into custody was ‘nuisance’, which was described as interfering with others without causing harm to person or property. Violence was reported for 18 patients, described as harm to property or person. For all but two patients, mental illness could be certified. One of these patients was diagnosed with an intellectual disability, which does not fall in the ambit of the MHA. The other was an elderly man with no family who was admitted to the medical college hospital, from where he was referred to the study site by RO on certification of a casualty medical officer.

Table 2

Reception order procedural details

Variable		n (%)
Complaint made by (n = 109)	Police	65 (59.2)
	Public	27 (24.7)
	Relative	6 (5.5)
	Social worker	6 (5.5)
	Doctor	4 (3.6)
	Employer	1 (0.9)
Nature of complaint (n = 109)	Nuisance	70 (64.3)
	Wandering	18 (16.5)
	Violence	18 (16.5)
	Other	3 (2.7)
Medical report accompanied (n = 109)	Yes	102 (93.6)
	No	7 (6.4)
Mental illness certified (n = 100)	Yes	98 (98)
	No	2 (2)
Time (days) needed to certify (n = 98)	< 5	94 (96)
	> 5	4 (4)

Table 3 describes the clinical profile and outcomes of the RO patients. While all the non-Goan RO patients and foreign nationals were admitted for the first time, 47 of the Goan RO patients had had prior admissions. The RO patients had a significantly longer hospital stay than the voluntary patients. However, no significant differences were noted in the diagnosis for which the patient was admitted.

Table 3

Clinical profile and outcomes of patients admitted under reception order (RO) (n = 100) compared with voluntarily admitted patients (VP) (n = 100)

Variable	RO	VP	P
Diagnosis			0.02
Acute psychosis	4	3
Schizophrenia	29	35
Schizoaffective disorder	2	2
Mania	16	22
Substance use disorder	27	31
Unspecified non-organic psychosis	15	0
Personality disorder	4	1
Dementia	1	0
Intellectual disability	1	0
No psychiatric diagnosis	1	0
Depression	0	5
Other	0	1
Discharge			< 0.01
Time to discharge, days: mean (s.d.)	55.5 (97.9)	16.4 (17.9)
Time to discharge, days: median	25.5	10.5
Range, days	4–515	1–97

Discussion

To our knowledge this is the first Indian descriptive study of involuntary admissions by way of RO. Significantly more middle-aged, unmarried and non-Goan people were admitted by RO compared with voluntarily admitted patients. A trend towards more male admissions was noted. Involuntary admission in other parts of the world has been similarly reported to disproportionately involve young, single people (Malla et al, 1987; Bauer et al, 2007) as well as middle-aged men (Brissos et al, 2007). In India, where caring for the patient in the community is largely the responsibility of the family, being unmarried may be an added disadvantage. It is not uncommon for people who are mentally ill to wander far away from home, sometimes even out of state. These individuals, on account of their abnormal behaviour, are then picked up by the police under the provisions of the MHA, resulting in an overrepresentation of people from out of state.

There was also a significant overrepresentation of Christians, probably because 50% of the Goan patients on RO came from a single taluka, one which has a high Christian representation. However, the reason for the overrepresentation of patients from this taluka is not clear.

In 94% of cases the magistrate relied upon medical certificates before issuing the RO. Such safeguards can assuage concerns raised by the psychiatric community about whether the judiciary can properly be assigned the role of determining presence of mental illness (Antony, 2000). Interestingly, the time taken to certify the presence of mental illness was less than 5 days in 96% of cases. This suggests that these patients had overt signs and symptoms to indicate mental abnormality, which in turn aided the judicial system to channel them towards the mental hospital. Therefore the RO system appears reliably to serve the purpose of getting persons with overt mental illness who are not in receipt of proper care into the mental healthcare system. However, the absence of any provision for periodic review after admission is a serious shortcoming in the MHA. In the absence of rehabilitation services, patients can languish in mental hospitals for years on end, itself a grave violation of their human rights.

Of those from our study who had previously been admitted, 75% had been brought back via a repeat RO admission. This raises important issues about the efficiency of aftercare and lack of social support, which need further evaluation. A community-based mental healthcare approach (which is largely missing in most parts of the country) might address such issues.

Lastly, those on RO spent significantly more time in the hospital than those voluntarily admitted. Longer stays for involuntarily admitted patients have also been reported in other studies (Malla et al, 1987). In our study it could be partly explained by the large number of patients from other states, for whom arranging travel back home was difficult, for a host of logistical and administrative reasons. This should be a matter of concern for policy-makers and resolving it would go a long way towards the timely and appropriate relocation of such patients back to the care of their loved ones.

Our paper provides some important information to fill the literature gap and at the same time raises some important issues related to legislation and policy. The MHA is an upgrade of the Indian Lunacy Act of 1912. While many changes were made, it still draws considerable criticism from practitioners of psychiatry and the public at large (Kala & Kala, 2007). The government of India is currently drafting a new Mental Health Care Act (MHCA; Pathare & Jagade, 2010). A provision for those with intellectual disability needs to be considered for the new MHCA, as it is excluded from the purview of the current MHA. The new MHCA will have to stipulate more safeguards to prevent the misuse of involuntary admission. It should safeguard poor and homeless people from being admitted to mental hospital in the absence of appropriate alternative resources, as was evident in one of the present series of RO admissions. While there is scope to reduce the role of the judiciary to a minimum, a system to monitor the admissions should be considered, in order to safeguard the rights of those who are mentally ill.

We can conclude that the RO is a useful provision in the MHA, allowing for the treatment of patients with mental illness who would otherwise have been neglected, but it does little to address the issue of continuity of care and the ‘revolving door’ phenomenon. We hope that the new MHCA will address these issues.