Clinical practice guidelines for long-stay psychiatric services: Focus on admission procedures, covert medications, and proxy consultations

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 treatmentHowever, 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 consent of the PWMI. no treatment should be or continued without the informed consent of the as by the MHCA 2017. capacity is to be admission, of the or of the admission, it is to a capacity as per capacity is a PWMI who the capacity should not be admitted under Section a capacity is not to be for independent admission during a long stay at any MHE as a legal supported admission. it is to that capacity is a to and at any during the inpatient care as an independent admission, the PWMI is to be to the or purpose of their treatment capacity has to be as per the guidance deemed not to have the the admission under Section should be the MHCA does not explicitly resources for independent admissions under Section 86, it emphasizes the principle of the least restrictive a hospital-based MHE a PWMI under this it is to have less restrictive facilities within the MHE. The for the MHE will be as by MHCA The MHE can its policies the admission and treatment of PWMI as long as these policies not the provisions of the A lack of less restrictive facilities should not be a to the PWMI in a restrictive than necessary for the treatment of the PWMI. a PWMI admitted under Section the facility restrictive and they should be within as their admission is considered independent and these are not deemed to a significant of harm to or others, or of acute care services focused on management are not a facilities can to the needs of PWMIs admitted under Section However, a comprehensive community treatment plan is at all of facilities, the PWMI is in a long This plan should on the PWMI into the community and providing ongoing support to ensure their wellbeing. All long-stay PWMIs should have access to MHE should a of care for transitioning of psychiatric facilities to the The of these should be to the of hospital stay and of Mental Health admission under Section of the MHCA can at any MHE, it is a community-based MHE (C-MHE) or a hospital-based MHE The is that the PWMI provides informed consent for their stay and the admission criteria The the and of resources and of admissions as per MHCA 2017 are in 1: of MHE based on residential care of for inpatient care and use of in and as per MHCA 2017 have been discussed in the earlier IPS Psychiatric with mental illness not consenting for admission and treatment at mental health establishment All supported admissions under section for days, and stay under section The process for supported admission under both these sections is in for admission of at MHE Criteria for admission under sections and can the admission criteria into severity least restrictive and capacity The admission criteria for these are provided in of admission in MHE necessitates a by two psychiatrists and review by the The criteria for are requiring the to have over sections and criteria for admission of the of as per the capacity guidance document by the should that the PWMI capacity. No PWMI who has capacity should be admitted as supported admission. under Section should be a of capacity under Section the PWMI capacity during these their admission under this section must be the of days, there should be a review by Section to assess for continued admission under Section This review should also capacity of admission under Section those who lack capacity should be considered for admission at the MHE under Section under Section should for those admitted under Section who regain capacity will be while those who lack capacity under Section support can continue as supported admissions under Section with treatment decision by the nominated representative for Supported admission will require a should be provision of acute care services as These settings restrictive should have human resources to to the MHCA 2017 For there should be of the and related to the stay including taken to discharge from the restrictive of Mental Health of PWMIs under section and section should only at hospital-based MHE. the PWMIs the criteria for admission of harm to and or they will be restrictive and of medical The decision for supported admission under Section and Section is in and Figure for of Mental Healthcare 2017. to be as per capacity refers to Mental Health for of Mental Healthcare 2017. to be as per capacity admission be to this the admission be extended for an and for of refers to Mental Health OF PERSONS WITH MENTAL ILLNESS IN medication in consenting persons with mental illness for the PWMI admitted as independent admission should be with the informed consent of the PWMI after providing reasons for the a PWMI is they should be provided with about the of not medication, and should be No PWMI who has the capacity should be forced or given medication medication medication refers to the practice of of medication in a in or to a This does not the of medication in or to or through medical as long as the PWMI is of the The practice of medication significant and clinical and ethical the ethical aspects of covert medication the of patient and the risks to and covert medication be in it must be against its on the of and in the healthcare is a significant of professional guidance this of with in the Health covert medication is used for with mental In these cases, it is with to ethical and legal However, have that in settings like India, family and community a the ethical a Indian on covert medication The practice of covert medication in India was in a of an earlier of the Indian of in This included key articles that various aspects of covert medication, including ethical and legal practical and from both and These articles provided into the practice of covert medication in the Indian the ethical by healthcare and as as the for guidelines, particularly in of the MHCA 2017. For a of the key from these to of articles in the of the Indian of with a on covert medication practice and legal The MHCA 2017 emphasizes patient informed and the rights of on practices like covert the MHCA 2017, covert medication is particularly when to who have the capacity to make informed decisions. these and legal covert medication from India have that a significant of and healthcare resort to covert medication to with mental like and for covert medication at Mental Health Establishment in Indian settings on these the guidelines are for the use of covert medication in hospital The decision to covert medication can be considered for a PWMI who the capacity when admitted to the MHE. This decision should be made by the care with the consent of the nominated representative medication should be the PWMI is to medication and only used in exceptional circumstances after all to have The decision for covert medication, when the PWMI medication, is in Figure The and are outlined in for covert medication at a hospital-based MHE. medication refers to the practice of of medication in a to medication including to have or been for the of covert during Stay medication in the community by the In the guidelines on covert medication, it is that while the primary has been on its within hospital there is a of covert medication practices in community settings by the the lack of community-based services in India, these practices of when adequate support are not in a healthcare at the of and on it is to the ethical and practical when covert medication is used medication in the community significant ethical particularly the and rights of the PWMI. is a of covert medication is which can have on the and the with it is to ensure that covert medication is only in the best and when no other This provides a approach to covert medication in community the there should be an of the capacity to consent to their In who are as having the capacity to make informed should be informed of this capacity and to from using covert medication should only be considered the patient capacity and it is necessary for their and in the of the and Healthcare should engage in with and families, the ethical of covert medication and the of should on the including the of and the legal within which they must of covert medication practices by should be in the along with the for its use and any strategies medication and are considered restrictive a general the of using or for the PWMI must the and risks with not using the restrictive The can be or In both the use of or as a restrictive practice be considered under the at an MHE, with consent from the in a PWMI who it is the least restrictive option to the from harm to or into the severity of the and the of in the last a when there is a to the PWMI and from significant of a treatment that to create a for the PWMI and others, leading to or for restrictive The can be but has to be reviewed restrictive options have been and deemed or are established at the MHE to and of the should not be used as a of or to make for such as a of at the MHE. The decision to a should be made with the consent of the PWMI. In the PWMI capacity and requires a the decision should be made with consent from the For those should be by a capacity conducted within the the a lack of the should continue with the consent of the the PWMI the decision to continue the should be and to by the PWMI. of and in long stay guidelines for mental health services in India have been discussed in the earlier IPS guidelines on with the nominated representative or family For independent admission, the of a is not unless by the policies of the MHE. For PWMI admitted under supported admissions, capacity the PWMI not capacity. These provide an to the NR on the health treatment and any to the treatment that the NR is informed and involved in the ongoing care such as covert medication and should be only after consent from the For consent must be the of the and there is no to consent unless the PWMI the can only continue with the consent of the PWMI. the NR is not available, the to be have been as in Section of the MHCA 2017. The of these are in Figure Figure when (NR) is not In accordance with Section of Mental Healthcare 2017 In the of or significant in the the NR must be All with the NR or family should be including the of discussions, and any decisions This and while the and as per legal Additionally, MHEs should make to provide support and resources to and to the treatment and the they in the This can support and a and for all stakeholders MENTAL HEALTH The MHCA 2017 for the discharge of admitted to These on the of admission and the However, a discharge plan is a for all discharge from any MHE, of the and of admission as per Section of the is to that discharge is an ongoing and it should from the a PWMI is admitted to MHE. A community treatment plan is to be to when PWMI is admitted under section when for review to the for continued supported admission. a patient is the for their care must with the their nominated family and other relevant to a discharge The community treatment plan should be made with available resources the Mental Health which mandates the of at least one in across the The plan should the treatment and services that will be provided to the including for and of of proxy and refill management the of access to in of India, there is a for guidelines for proxy and refill provides a comprehensive to the Indian These recommendations are for the health and wellbeing of particularly in are not that proxy are in India, by issues such as to and like issues also the legal and ethical involved in proxy under the MHCA 2017, which emphasizes patient rights and informed By from like the and which have for refill through and proxy India can these best practices to its healthcare these guidelines will the and of care for that their treatment while with the MHCA for proxy and refill the of persons with mental illness The of the PWMI in the MHE needs to be informed to the at the The NR and family must be informed not at the A of the medical has to be by the of the MHE. A medical professional should the adhering to legal of the of care and with the are and support should be offered to the NR and in long stay The MHCA 2017 provisions in Section for that ethical are are to and informed consent from in that or any or In a is to provide such consent but does not to must be from the relevant Mental Health This is the Mental Health determination that the be conducted on individuals of informed is for the mental health of the by the and to relevant to the mental health needs of persons with mental illness. must also their avoid of and to both and international ethical guidelines, including with the Clinical and with the ethical guidelines established by the Indian of from an However, this provision does not the review of or review of PWMIs who are to provide informed consent as long as the of these individuals is These guidelines provide a and for PWMIs in a long stay in the Indian with the MHCA 2017. the appropriate admission of PWMIs who lack capacity and require support, the ethical use of covert medication and proxy consultation, and the of ongoing capacity The guidelines are designed to legal requirements and that care practices are grounded in while both and Additionally, it for transitioning PWMIs to community-based care possible, the to support and of are no of