Ghana College of Physicians and Surgeons Faculty of Psychiatry Pre-AGSM Workshop 27 November 2012

1. Ghana College of Physicians and SurgeonsFaculty of PsychiatryPre-AGSM Workshop27 November 2012 The Role of the Medical Practitioner in the new Mental Health Act Akwasi Osei

2. Learning objectives • Be able to explain the need for the mental health law • Be able to give an overview of the law • Understand relationship between Mental Health Authority and the Ghana Health Service • Know how the law affects doctors • Know sanctions for violating provisions of the law

3. outline • Why a law in mental health • Content of law • Where do non-psychiatric doctors come in? • The psychiatric doctor’s role • Conclusion

4. Why a law in mental health • To protect the rights and interests of persons with mental illness (PWMI) • They are vulnerable • They have peculiar problems • Poverty and stigma, • Discrimination and marginalisation • human rights abuse, etc • To ensure best practice for them

5. To overhaul and restructure the mental health system in Ghana • To ensure adequate attention for mental health care • Law is a tool for social engineering • To fulfil international obligations for human rights of PWMI • World trend and best practice worldwide

6. Content of the law • 10 Sections, 100 articles, 44 pages • Section 1: The Mental Health Authority (MHA) • Establishment of the MHA • Purpose and functions of the MHA • Governing board of the MHA, the Mental Health Board (MHB) • Meetings of the MHB • Committees of the MHB

7. Section 2: Administration of the MHA • Establishment of an integrated Mental Health Authority • CEO as head, Functions of the CEO • Divisions of the Mental Health Authority • Management at Regional and District levels for mental health care • Administration and staffing of Psychiatric Hospitals

8. Section 3: Mental Health Review Tribunal • Composition and functions of the Tribunal • Meetings of the Tribunal • Discharge of patients by the Tribunal • Review of court orders for patients • How to apply to the Tribunal for review • Annual report of Tribunal

9. Section 4: Visiting Committees • Establishment of visiting committees • Membership of a visiting committee • Duties and responsibility of a visiting committee • Submission of report • Other visitors

10. Section 5: Voluntary treatment • Walk-in and referral on voluntary basis • Procedures for admission of a voluntary patient • Discharge of a voluntary patient • Circumstances under which a voluntary patient may not be discharged in spite of his wish

11. Section 6: Involuntary treatment • Redefinition of involuntary • Role of the court in involuntary treatment • Procedures of appeal • Requirements of specific treatment plan • Order for prolonged treatment • Length of prolonged treatment order

12. Emergency cases and Certificate of urgency • Duration and procedures of admission for emergency/urgent/involuntary cases • Facilities that can admit involuntary patients • Temporary discharge of involuntary patient • Discharge of involuntary patient

13. Section 7: Rights of persons with mental disorder • Non-discrimination • Basic human rights including civil and political rights and right to refuse admission and or treatment • Spells out lawful limitations of the rights • Standard of treatment at par with physical health

14. Procedures for Seclusion and restraint • Complaints about management • Confidentiality, Privacy and autonomy • Access to information • Employment rights

15. Section 8: Protection of vulnerable groups • Females, Children, Aged, Persons with mental retardation • Competence, capacity and guardianship and limited guardianship • Review of guardianship • Special treatments • Psycho-social rehabilitation

16. Persons with mental disorder found in public places • Warrant to search for and remove persons with mental disorder • Security psychiatric hospitals • Offender with mental disorder • Removal of patients to country of origin

17. Section 9: Mental Health Fund • Establishment of the Mental Health Fund • Purposes and management of the Fund • Sources of money for the Fund • Bank accounts for the Fund • Management committee of the Fund and its functions • Accounts and audit and annual reports of the Fund

18. Section 10: Miscellaneous provisions • Financing of mental health care • Funds of the Authority, • Accounts, Audit, Annual and other report reports • Notice of sudden death of patient • Offences for violating these provisions

19. Offences for neglecting rights of, and discriminating against, persons with mental illness • Application of Act • Regulations (LI) and Interpretation • Transitional provisions, Repeal and Commencement

20. What the law seeks to do • Integrate mental health care into general health services • Mainstream mental health • Improved mental health care: availability, accessibility (geographical, financial), acceptability, and good quality • Eliminate or reduce stigma, discrimination and human rights • Incorporate and regulate traditional and faith based healers in mental health care

21. When the law is fully implemented • No more vagrant psychotics on the streets • Truly free mental health care • Widespread mental health services • Widespread knowledge of mental health issues through massive public education • Numerous mental health workers • Hotline mental health services • Crisis intervention mobile mental health services

22. Now, Psychiatrists per 100,000

23. Psychiatric nurses/100,000

24. With the law enforced Psychiatric Hospital Services Personnel

25. So where do you come in as doctors?

26. MHA in MOH Organogram

27. Divisions of the MHB and collaboration with GHS/THS

28. Mental health flow chart National LSPH Psych, Psycho, etc MHA Rehab Psych, Psycho, MAP Regional RMHC RHMT RPH RH District MAP, Psycho, trained providers DMHC DHMT DH Sub-district CPN, CMHO, trained providers HC GP Com’ty Com’ty workers(formal, informal) CHPS CC CMHO, CPO, Soc workers, TFBH, NGO, Vol

29. Provisions for doctors and other health professionals • Provision: Full integration of mental health into general health care at all levels: CHPS, Sub-District, District, Regional (Articles 2.d, 3.b-e, 11, 17) • Implication: • All doctors are expected to be knowledgeable about mental health issues, to administer primary mental health treatment. • All doctors should be able to recognize and treat mental illness, and when necessary refer to specialty services • Doctors will be retrained in basic mental health care

30. Provision: Health directors are obliged by law to include mental health care in their services (Articles 2.d, 3.b-e, 11, 17) • Implication: • It is no longer a matter of personal discretion. • Any Regional, District, Medical director who says mental health is not his/her priority has violated the law and is subject to sanction

31. Mutual incorporation of mental health and GHS management structures at regional and district levels • Mental Health Coordinators will be members of their respective Regional or District Health Management Team, and will collaborate closely with the Regional or District Health Director (18.1.c., 18.2., 20-23)

32. Mental Health Sub-Committees will be established within the Regional and District Health Management Teams, and will advise the Mental Health Coordinators and collaborate with the Regional and District Health Management Teams (18-22) • Regional and District Health Directors, or their representatives, will be members of Mental Health Sub-committees

33. Doctors’ responsibility to respect rights of mental health care users • It is unlawful to discriminate against or stigmatize the mentally ill • PWMD are entitled to the same fundamental rights as a fellow citizen, and therefore shall not be subjected to discrimination (54)

34. A person with mental disorder is entitled to the same standard of care as a person with physical health problems, and shall be treated on an equitable basis including quality of in-patient food, bedding, sanitation, buildings, levels and qualifications of staff, medical and related services, and access to essential medicines (57)

35. A person with mental disorder is entitled to humane and dignified treatment, and shall not be subjected to torture, cruelty, forced labour, or any other inhumane (Art. 57.3) • Mental health care is free, and mental health patients are entitled to insurance for treatment of physical health problems under the National Health Insurance Scheme (88)

36. A patient shall have free and full access to information about the mental disorder and the treatment plan for the patient (62) • A person shall be entitled to psycho-social rehabilitation and aftercare services, including supervision, rehabilitation, and vocational training (72)

37. Women, children, and the aged shall not be discriminated against with respect to admission, treatment, or community care, and will be given separate accommodations upon admission (64-66)

38. Rights violations will be prosecuted • Anybody who breaches the rights of a person with mental disorder as defined by the Act commits an offence and is liable on summary conviction to a fine of not more than five thousand penalty units, or to a term of imprisonment of not more than ten years, or to both the fine and imprisonment (96)

39. Specific provisions for mental health workers • Voluntary treatment (39-41) • A psychiatrist or head of the facility may admit a person seeking voluntary treatment. • Consent of a voluntary patient must be obtained before treatment is given, and the patient reserves the right to refuse treatment. • A voluntary patient may request to be discharged from the facility, and the request must be granted within 24 hours unless at that time the patient meets the requirements for involuntary admission.

40. Involuntary treatment (Art. 42-53) • New definitions of voluntary and involuntary admission • Involuntary means involuntary, includes a patient being tied and brought to the hospital by a relative • Involuntary admission and treatment can only be authorized by a court order, where the application must be supported by recommendations from a medical practitioner and from a mental health, or by Certificate of Urgency. • Prolonged treatment requires the recommendation of the psychiatrist or head of the facility, and must be approved by the Mental Health Review Tribunal.

41. In emergency cases, a medical practitioner may approve admission and treatment without a court order, but after completing Certificate of Urgency, and the person may not be detained for more than 72 hours. • On the expiry of the period specified by the court, the involuntary patient shall be discharged, unless by court prolongation.

42. Seclusion or restraint may only be practiced under strict institutional guidelines (57-58): • A person may be placed in involuntary seclusion or minimal mechanical restraints only when there is imminent danger to the patient or others • The seclusion or restraint must be authorized by the head of the facility or the senior nurse in charge of the ward • The documentation of the seclusion or restraint shall be placed immediately in the clinical notes of the patient

43. A person shall not be admitted to a mental health facility merely for mental retardation, unless there is evidence of gross misbehavior or perceptual disturbances (67) • Informed consent must be obtained for any intrusive or irreversible procedure (29) • Electroconvulsive therapy without anaesthesia is discouraged

44. The doctor’s role in a court order for involuntary admission/treatment • Anybody can make an application to the court for the temporary involuntary admission and treatment of a person with mental disorder wherethere is a substantial risk that the disorder will deteriorate seriously (Article 42) • The application will need to be supported by the recommendation of a medical officer and that of a mental health practitioner • The recommendation should detail reasons (history, mental state exam and diagnosis)

45. Emergencies and certificate of urgency • In an emergency, anybody (relative, friend, police, on-looker, etc) can send a patient straight to a mental health facility or any health facility for a Certificate of Urgency (Art 48) • At the health facility any medical officer, after satisfying himself that the patient requires emergency care, will fill a Certificate of Urgency to enable him admit the patient

46. A Certificate of Urgency is a form specially designed by the MHA to authorize admission as an emergency case • All health facilities will have copies of the Certificate of Urgency • Admission on Certificate of Urgency shall be for 72 hours after which the patient shall be released or else application to the Mental Health Review Tribunal can authorise an extension

47. “Certificate of Urgency" means a certificate issued by a medical practitioner for involuntary admission initiated by the police or any other person for an urgent or emergency case (Art. 97);

48. Emergency or urgent case is a case in which a person's mental disorder requires to be quickly addressed when there is a high risk or imminent danger of the condition seriously deteriorating or of the person causing harm to self, others or personal property (Art. 97)

49. Fees for court order reports • A mental health practitioner who is appointed by a court to examine a person for the purposes of this Act shall be paid the fees determined by the Minister (Art 77)

50. Forms and documentations • MHA will design special forms: • Admission forms • Transfer forms • Certificate of Urgency • Appeal form • Discharge form • Consent form • etc