Under which sections of the Mental Healthcare Act 2017 do we admit patients lacking capacity due to mental health issues?

Admission Sections Under Mental Healthcare Act 2017

Patients lacking capacity due to mental health issues in India are admitted under "Supported Admission" provisions of the Mental Healthcare Act 2017, which replaces the previous concept of involuntary admission. 1

Key Admission Categories

Independent Admission

• Capacitous patients cannot be coerced into receiving treatment and must provide their own consent for admission, regardless of the severity or complexity of their mental illness 1
• This upholds patient autonomy and choice for those with decision-making ability 2

Supported Admission

• This is the primary mechanism for admitting patients who lack capacity for mental healthcare decisions 1
• Supported admission replaces the "involuntary admission" terminology from the Mental Health Act 1987 1
• A nominated representative makes the admission decision when the patient lacks capacity 2
• The treating psychiatrist and family/caregiver consent should suffice for supported admission according to practicing psychiatrists 3

Capacity Assessment Requirements

Capacity must be assumed present initially until proven otherwise through specific assessment 4

The assessment must evaluate four key domains:

• Ability to understand relevant information about the mental healthcare decision 4
• Ability to retain that information long enough to make the decision 4
• Ability to use or weigh that information as part of decision-making 4
• Ability to communicate their decision by any means 4

Critical Pitfalls to Avoid

• Mental illness alone does not automatically mean lack of capacity 5
• Capacity is decision-specific, not a global assessment—patients may have capacity for some decisions but not others 4, 5
• Do not assess capacity based solely on diagnosis, age, or appearance 4

Documentation Requirements for Supported Admission

Document specific evidence of impairment in the functioning of mind or brain affecting decision-making 4:

• Include specific examples of the patient's confusion and its impact on the particular decision 4
• Record the clinical reasoning that led to the determination of incapacity 4
• Identify and document the authorized surrogate decision-maker (nominated representative) 4

Consultation documentation should include:

• Discussions with family members about the patient's baseline cognitive function 4
• The patient's previously expressed wishes, values, and preferences 4
• Evidence that decisions are in the patient's best interests 4

Role of Mental Health Review Boards

Mental Health Review Boards serve as quasi-judicial authorities to ensure the rights of persons with mental illness during supported admissions 6:

• They review admission decisions and treatment plans 6
• The boards are meant to protect patient rights during mental healthcare delivery 6
• Implementation has faced challenges due to resource constraints and ambitious six-member composition 6

Supported Decision-Making Spectrum

The MHCA 2017 promotes a spectrum of support ranging from minimal to complete assistance 2:

• Minimal or no support for those with substantial capacity 2
• Complete support through nominated representative for those lacking capacity 2
• Decision by nominated representative is restricted only to those with demonstrated incapacity 2

Practical Implementation Challenges

Several operational difficulties have emerged in the five years since enactment 3:

• Many psychiatrists report that capacity assessment and nominated representative provisions hinder treatment delivery 3
• The distinction between independent and supported admission can be unclear in clinical practice 3
• Treating psychiatrists advocate for amendments to make the process more similar to other medical disciplines 3