Phase 3: Psychiatry & Ethics
Mental Health Care Act 2017 & Psychopharmacology
Module Overview
This module covers the Mental Health Care Act 2017, psychiatric pharmacology, ECT procedures, and defense mechanisms. These topics are frequently tested in NORCET with emphasis on legal aspects.
1Mental Health Care Act 2017
High-yield for AIIMS NORCET - know the legal provisions!
| Provision | Key Points |
|---|---|
| Decriminalization of Suicide | Section 115: Attempted suicide NOT punishable Exception: If used to avoid legal obligations |
| Advance Directive | Person can specify treatment preferences Valid during periods of mental incapacity |
| Nominated Representative | Person can appoint someone to make decisions If no nomination: Relative → Caregiver → Authority |
| Right to Access | Every person has right to mental healthcare Government must provide affordable services |
| Admission Types | 1. Independent: By person's own request 2. Supported: With nominated representative 3. Emergency: Risk to self/others (72 hours max) |
| Prohibited Treatments | ❌ Chaining ❌ Unmodified ECT (without anesthesia) ❌ ECT on minors without safeguards |
Exam Tip
MHCA 2017 decriminalized attempted suicide (Section 115). Previously punishable under IPC Section 309.
2Psychopharmacology
1. Lithium - The Mood Stabilizer
Therapeutic Range
0.6 - 1.2 mEq/L
Narrow therapeutic index!
Toxic Level
> 1.5 mEq/L
Watch for toxicity signs!
| Toxicity Level | Signs & Symptoms |
|---|---|
| Mild (1.5-2.0) | Nausea, vomiting, diarrhea, tremor, drowsiness |
| Moderate (2.0-2.5) | Confusion, slurred speech, ataxia, muscle twitching |
| Severe (>2.5) | Seizures, coma, renal failure, arrhythmias |
Nursing Interventions for Lithium
- • Monitor serum lithium levels (weekly initially, then monthly)
- • Ensure adequate sodium and fluid intake (dehydration ↑ toxicity)
- • Watch for drug interactions (NSAIDs, diuretics, ACE inhibitors)
- • Educate patient about early toxicity signs
2. Extrapyramidal Symptoms (EPS)
Caused by typical antipsychotics (Haloperidol, Chlorpromazine)
| EPS Type | Onset | Features | Treatment |
|---|---|---|---|
| Acute Dystonia | Hours to days | Muscle spasms, torticollis, oculogyric crisis | Benztropine IV/IM |
| Akathisia | Days to weeks | Restlessness, inability to sit still | Beta-blockers, Benzodiazepines |
| Parkinsonism | Weeks to months | Tremor, rigidity, bradykinesia, shuffling gait | Anticholinergics |
| Tardive Dyskinesia | Months to years | Lip smacking, tongue movements, choreoathetosis | Often irreversible! Stop/switch drug |
3. Neuroleptic Malignant Syndrome (NMS)
Medical Emergency - Know FEVER!
Fever (>38°C)
Encephalopathy
Vitals unstable
Elevated CPK
Rigidity (lead pipe)
NMS Treatment
- • Stop the offending antipsychotic immediately
- • Dantrolene (muscle relaxant) for rigidity
- • Bromocriptine (dopamine agonist)
- • Supportive: Cooling, hydration, ICU monitoring
3Electroconvulsive Therapy (ECT)
Remember the ATS sequence for ECT procedure!
ECT Procedure - ATS Sequence
Atropine
Pre-medication
Reduces secretions, prevents bradycardia
Thiopental
General Anesthesia
Short-acting barbiturate
Succinylcholine
Muscle Relaxant
Prevents injury from convulsions
| Indication | Contraindication |
|---|---|
| ✓ Severe depression with suicidal risk | ✗ Recent MI (<3 months) |
| ✓ Catatonia | ✗ Raised intracranial pressure |
| ✓ Treatment-resistant schizophrenia | ✗ Recent stroke |
| ✓ Pregnancy with severe depression | ✗ Pheochromocytoma |
Side Effects of ECT
- • Most common: Short-term memory loss (anterograde & retrograde)
- • Headache, muscle aches
- • Confusion (transient)
- • Nausea
4Defense Mechanisms
| Mechanism | Definition | Example |
|---|---|---|
| Denial | Refusing to accept reality | "I don't have cancer" (despite diagnosis) |
| Projection | Attributing own feelings to others | "You're angry at me!" (when self is angry) |
| Displacement | Redirecting emotions to safer target | Yelling at spouse after boss criticized you |
| Rationalization | Making excuses to justify behavior | "I failed because the test was unfair" |
| Repression | Unconsciously blocking painful memories | No memory of childhood abuse |
| Suppression | Consciously pushing thoughts aside | "I'll think about it tomorrow" |
| Regression | Returning to earlier developmental stage | Adult thumb-sucking during stress |
| Sublimation | Channeling impulses into socially acceptable | Aggressive person becomes surgeon (MATURE) |
| Humor | Using humor to cope with stress | Laughing about a bad situation (MATURE) |
Exam Tip
Mature defense mechanisms: Sublimation, Humor, Altruism, Suppression. These are considered healthy coping strategies.
Key Takeaways
- MHCA 2017 decriminalized attempted suicide (Section 115)
- Lithium therapeutic range: 0.6-1.2 mEq/L, toxic >1.5 mEq/L
- NMS = FEVER: Fever, Encephalopathy, Vitals unstable, Elevated CPK, Rigidity
- ECT sequence = ATS: Atropine → Thiopental → Succinylcholine
- Tardive Dyskinesia = Late onset, often irreversible EPS