Understanding India's Mental Healthcare Act, 2017

Indian Mental Healthcare Act, 2017
(IMHA)
Dr. Ruchi Kushwaha
Hospital Administrator

Conduct Protocol
 Burden of Mental illness worldwide
 Burden of Mental illness in India
 The UN-Convention on the Rights of Persons with Disabilities (UN-CRPD)
 India’s Mental Health Legislation
 National Mental Health Program (NHMP)
 Indian Mental Healthcare Act (IMHA) 2017
 Critical Insight into the Act
 Conclusion
 References

Burden of Mental illness worldwide
 The global burden of disease report states that mental disorders account
for 32.4% of years lived with disability (YLDs) and 13% of total
disability-adjusted life years (DALYs)
 Over 322 million people are estimated to suffer from depression,
equivalent to 4.4% of the world’s total population
 The total estimated number of people living with anxiety disorders in the
world is 264 million equivalent to 3.6% of the world’s total population
 In the year 2015, it is estimated that 788 000 people died due to suicide
 Suicide accounted for close to 1.5% of all deaths worldwide, bringing it
into the top 20 leading causes of death in 2015

Burden of Mental illness in India (1/2)
 Mental health is a major concern in India; major depressive disorder is the
leading cause of years lived with disability and anxiety is the ninth leading cause
 It is estimated that just over one in ten people in India have a mental health
issue, one in twenty people suffer from depression, and 0.8% have a “common
and severe mental disorder”
 It is estimated that 2.5 million people have schizophrenia, 8.8 million have
bipolar affective disorder (BPAD), 36.8 million have anxiety disorders and 13.4
million have alcohol dependence
 Males in the 30–49 age group have the highest prevalence of mental morbidity
 In addition to the impact on these individuals and their families, this has major
implications for India’s productivity

Burden of Mental illness in India (2/2)
 Despite the large burden of mental illness only 10% of Indians with mental
health problems receive evidence based treatments
 Treatment gaps greater than 70% exist due to insufficient funding of
mental, neurological, and substance use disorders
 India’s spending on mental health care has consistently been inadequate
 In 2011, India spent 4.16% of its GDP on health; 0.06% of this was
allocated at a national level for outpatient psychiatric care
 India’s number of mental health beds is well below average with only 2.15
beds per 100,000 compared to the global figure of 6.5

Background (1/3)
 For the financial year 2017–2018, the proposed health expenditure of
1.2% of gross domestic product in India
 It is among the lowest in the world and the public health expenditure has
consistently declined since 2013–2014
 India spends 0.06% of its health budget on mental health care, which is
significantly less than what Bangladesh spends (0.44%)
 Most developed nations spend above 4% of their budgets on mental
health research, infrastructure, frameworks, and workforce, according to
2011 WHO report

Background (2/3)
 India is implementing a variety of initiatives to address this large need,
close the treatment gap, and reduce the DALYs lost to mental,
neurological and substance misuse disorders
 These initiatives need to be supported by clear, pragmatic and robust
mental health law in line with international human rights legislation
 Mental health legislation is an essential part of delivering high quality
mental health care and is especially necessary to protect the rights of
individuals receiving such care

Background (3/3)
 India has previously led the way in the developing world in attempting to
shift the care of individuals with mental illness from asylums to
community-based treatments
 However, without clear legislation and policies and a lack of community
based services, results were less than satisfactory
 India now leads the way globally in revising mental health legislation in
line with international human rights standards
 With so many countries needing to revise their laws concerning mental
health, India’s proposed revision and its implementation will be highly
relevant to many other countries, especially those who have also ratified
the UN Convention on the Rights of Persons with Disabilities (UN-CRPD)

The UN-Convention on the Rights of Persons
with Disabilities (UN-CRPD) (1/2)
 In 2006, the UN-CRPD was published and it came into force in 2008
 Since then it has been signed by over 160 countries
 India ratified the UN-CRPD in 2007
 Under the UN-CRPD, persons with disabilities include those with long-
term mental or intellectual impairment
 The UN-CRPD attempts to emphasize and address the attitudinal and
environmental barriers that individuals with impairments face
 This has been perceived as a progressive and irreversible step away from
a “medical model” of disability and towards a social model
 Rao et al., describe it as a move from a “charity based” to a “rights based”
approach to disability

The UN-Convention on the Rights of Persons
with Disabilities (UN-CRPD) (2/2)
 The UN-CRPD appears strongly opposed to involuntary treatments and
affirms the legal capacity of individuals at all times
 The convention requires that ratifying countries revise their laws to make
them concordant with the convention
 Consequently, India’s Mental Healthcare legislation needed to be
reformed and the UN-CRPD duly prompted the drafting of two important
pieces of legislation in India:
1. The Mental Healthcare Act 2017 (IMHA) and
2. The Rights of Persons with Disability Act 2016 (RPDA)

India’s Mental Health Legislation (1/2)
 The first mental health legislation in India was introduced by the British
colonial government in 1858, when three Acts relating to mental health
were adopted:
1) The Lunacy (Supreme Courts) Act
2) The Lunacy (District Courts)Act
3) The Indian Lunatic Asylum Act
 These acts focused on asylum-based care but, due to the conditions that
many patients found themselves in, pressure mounted on government to
reform mental healthcare more generally
 In 1912, the Indian Lunacy Act was passed.

India’s Mental Health Legislation (2/2)
 Following Indian independence, the Indian Psychiatric Society submitted
a revised mental healthcare Bill in 1950 which was finally enacted as the
Mental Health Act in 1987
 From the perspective of international law, moreover, the 1987 legislation
was not in line with the UN-CRPD when it was published in 2006
 Consequently, India has recently revised its mental health legislation with
a new law that has been greatly anticipated

National Mental Health Program
(NHMP)

Background
 Recognizing that Persons with mental illness constitute a vulnerable
section of society and are subject to discrimination in our society
 Families bear disproportionate financial, physical, mental, emotional and
social burden of providing treatment and care for their relatives with
mental illness
 Persons with mental illness should be treated like other persons with
health problems and the environment around them should be made
conducive to facilitate recovery rehabilitation and full participation in
society

Introduction
 To address the huge burden of mental disorders and shortage of qualified
professionals in the field of mental health, Government of India has been
implementing National Mental Health Program (NMHP) since 1982
 The district Mental Health Program was added to the Program in 1996
The Program was re-strategized in 2003 to include two schemes:
• Modernization of State Mental Hospitals
• Up-gradation of Psychiatric Wings of Medical Colleges/General
Hospitals
 The Manpower development scheme (Scheme-A & B) became part of the
Program in 2009

Components of NMHP
1. Treatment of Mentally ill
2. Rehabilitation
3. Prevention and promotion of positive mental health

Objectives
 To ensure the availability and accessibility of minimum mental healthcare
for all in the foreseeable future
 To encourage the application of mental health knowledge in general
healthcare and in social development
 To promote community participation in the mental health service
development
 To enhance human resource in mental health sub-specialties

Strategies
 Integration mental health with primary health care through the NMHP
 Provision of tertiary care institutions for treatment of mental disorders
 Eradicating stigmatization of mentally ill patients and protecting their
rights through regulatory institutions like the Central Mental Health
Authority, and State Mental health Authority

Components of NMHP
District and sub-district level activities under NHM:
1. District Mental Health Program:
 Envisages provision of basic mental health care services at the community level
 Service provision: provision of mental health out-patient & in-patient mental
health services with a 10 bedded inpatient facility
 Out-Reach Component:
 Satellite clinics: 4 satellite clinics per month at CHCs/ PHCs by DMHP team
 Targeted Interventions
 Life skills education & counselling in schools
 College counselling services
 Work place stress management
 Suicide prevention services

 Sensitization & training of health personnel: at the district & sub-district
levels
 Awareness camps: for dissemination of awareness regarding mental
illnesses and related stigma through involvement of local PRIs, faith
healers, teachers, leaders etc
 Community participation
 Linkages with Self-help groups, family and caregiver groups & NGOs
working in the field of mental health
 Sensitization of enforcement officials regarding legal provisions for
effective implementation of Mental Health Act

 As of now, 241 districts have been covered under the scheme & it is
proposed to expand DMHP to all districts in a phased manner
 Financial support @ Rs. 83.2 lakhs per DMHP
 Manpower (on contractual basis):
 Psychiatrist
 Clinical Psychologist
 Psychiatric Nurse
 Psychiatric Social Worker
 Community Nurse
 Monitoring & Evaluation Officer
 Case Registry Assistant
 Ward Assistant/ Orderly

2. PPP Model Activities
 Financial support @ Rs. 5 lakhs per NGO
 Under this component, there is a provision for the state governments to
execute activities related with mental health in partnership with Non-
Government Organizations/Agencies as per the guidelines of the NRHM
in this regard
 The levels and the areas of partnership of the state government with the
Non-Government Organizations/Agencies may be as follows

Levels and the areas of partnership
Sl.
No. Levels Areas of participation
1.
District
Local IEC, Day-care, Residential/Long-term Residential Continuing Care Centres,
Supplementation or Innovative Mental Health Services, Training/Sensitization of
health workers; Hiring of a private Psychiatrist/Clinical Psychologist/Psychiatric
Social Worker/Psychiatric Nurse on contract. Psychiatrists @ Rs 2500/- per day
(ten days a month + 4 days/ month for outreach activity/training); Clinical
Psychologists/Psychiatric Social Worker @Rs 2000/- per day (ten days a month +
4 days/ month for outreach activity/training); Psychiatric Nurse @Rs 1000/- per day
2.
State
Advocacy, Local IEC, Dedicated Mental Health Help-line, Training/Sensitization of
health workers, Ambulance services

3. Day Care Centre
 Financial support @ 50,000 per centre per month
 Provides rehabilitation and recovery services to persons with mental
illness so that the initial intervention with drug & psychotherapy is followed
up and relapse is prevented
 Helps in enhancing the skills of the family/caregiver in providing better
support care
 Provides opportunity for people recovering from mental illness for
successful community living
 Financial support of Rs. 6.00 lakhs is earmarked per centre per year

4. Residential/ Long Term Continuing
Care Centre
 Financial support @ 75,000 per centre per month
 Financial support of Rs. 9.00 lakhs is earmarked per centre per year
 Chronically mentally ill individuals, who have achieved stability with
respect to their symptoms & have not been able to return to their families
and are currently residents of the mental hospitals, will be shifted to these
centres
 Residential patients in these centres will go through a structured program
which will be executed with the help of multidisciplinary team consisting of
psychologists, social workers, nurses, occupational therapists, vocational
trainers and support staff

5. Community Health Centres
Services available:
 Outpatient services & inpatient services for emergency psychiatry patients
 Counseling services
Manpower:
 Medical Officer
 Clinical Psychologist or Psychiatric Social Work

6. Primary Health Centres
Services available:
 Outpatient services
 Counseling services in accessing social care benefits
 Pro-active case findings and mental health promotion activities
Manpower:
 Community Health Workers (Two)

7. Mental Health Services
 For those activities, state or district specific, which need to be added to
the package of activities carried out by the district mental health team
 Such mental health services will be delivered through government mental
hospitals or medical colleges/hospitals with department of psychiatry
 Under the overall supervision of the Head of Psychiatry Department
 Financial support of up-to Rs. 15.00 lakhs per year per medical
college/hospital/mental hospital

8. Mental Health Helpline
 A country wide 24 hours dedicated help-line to provide information to
public on mental health resources, emergency situation and crisis
management, information pertaining to destitute mentally ill patients,
registration of complaints on Human Rights Violation of mentally ill and
assistance on medico-legal issues
 Linked with district hospitals, medical college/hospitals, mental hospitals,
private mental health facilities, NGOs and all other mental health service
providers of the state

9. Tertiary level activities
Manpower Development Schemes (Centre of Excellence or Scheme-A
& Scheme-B)
Scheme A. Centres of Excellence in Mental Health
 Up- gradation of 10 existing mental hospitals/ institutes/ Med. Colleges
will be taken-up to start/ strengthen courses in psychiatry, clinical
psychology, psychiatric social work & psychiatric nursing
 Financial Support of upto Rs. 33.70 cr will be provided to each centre and
would include capital work (academic block, library, hostel, lab, supportive
departments, lecture theatres etc.), equipments, faculty induction and
retention during the plan period
 As of now, 15 mental health institutes have been funded for developing as
Centres of Excellence in Mental Health

Scheme B. PG Training Departments of Mental
Health facilities
 Government Medical Colleges/ Government Mental Hospitals will be
supported for starting / increasing intake of PG courses in Mental Health
 Financial support of upto Rs. 0.86 to 0.99 cr per dept. would be provided.
The support includes physical work for establishing /improving
department in specialties of mental health, equipments, tools and basic
infrastructure & for engaging required faculty for starting/ enhancing the
PG courses
 Till date, 39 PG Departments in 15 Medical Colleges/ Mental Hospitals in
mental health specialties viz. Psychiatry, Clinical Psychology, Psychiatric
Nursing and Psychiatric Social Work have been provided support for their
establishment /strengthening

10. Up-gradation of two Central MH
Institutes
 Up-gradation of two Central MH Institutes to provide Neurological
and Neuro-surgical Facilities on the pattern of NIMHANS (CIP,
Ranchi & LGB, Tezpur)
 LGB Regional Institute of Mental Health, Tezpur and Central Institute of
Psychiatry, Ranchi to be up-graded
 Basic Neurological & Neurosurgical facilities to be included on the pattern
of NIMHANS
 Support involves physical work for establishing departments in Neurology
& Neurosurgery, equipments & tools and for engaging required faculty

11. Support to Central and State
Mental Health Authorities
 Central Mental Health Authority (CMHA) & State Mental Health Authority
(SMHA) are meant for regulation & co-ordination of mental health
services under the central & state governments respectively
 Support to be provided for purchase of infrastructure (non-recurring) and
Office and Professional Expenses (recurring)
• Non-Recurring support to CMHA & each SMHA: Rs. 2.0 lakh
• Recurring support to CMHA & each SMHA: Rs. 7.0 lakh

12. Research & Survey
 For carrying out research & survey in different regions of the country in
the field of mental health
 Help in understanding regional needs and framing plan and strategies in
future for various parts of the country
 Budget for the remaining period is Rs. 18.00 cr (Rs. 6.00 cr per year)

13. Monitoring & Evaluation
 Standard formats for recording and reporting have been developed and
circulated
 These will be used by medical colleges/institutes (under Manpower
Development Scheme), District, CHC and PHC
 Continuous evaluation of the activities of the program is being do

14. Central IEC
 The central level dedicated website will be introduced to provide on hands
information on mental health resources, activities, plans, policy and
programmes
 Extensive mass media activities will be supported at district and sub-
district level. The support for TV /RADIO programs and innovative media
campaigns on mental health in vernacular languages through local
channels and other media
Central Level
IEC
2014-15 2015-16 2016-17
Total (in Rs
lakh)
1500 1500 1500 4500

15. Central Mental Health Team
 A Central Mental Health Team would supervise and implement the
programme and provide support to the Central Mental Health Authority
 Team would consist of
 One Consultant (Mental Health) with salary of Rs 70,000 pm
 One Consultant (Public Health) with salary of Rs 60,000 pm
 Two Research Associates with salary of Rs 35,000 pm
 One DEO with salary of Rs 15,000 pm
 Budget Provision for Central Mental Health Team for a period of 3 years is
Rs 1.17 crore

16. Mental Health Information System
 An online data monitoring system and will also facilitate bilateral
communication between participating units
 is expected to bring significant improvement in the implementation as
there shall be possibility of mid course correction based on the feedback
MHIMS
2014-15 2015-16 2016-17
Total (in Rs
lakhs)
100 150 150 400.0

17. Training/Workshops
 Trainings will be provided to master trainers from each state/UT who shall
further train DMHP team and other staff working in the field of mental
health
 Trainings will be standardised and delivered at identified centres
 The standardized training manuals are being formulated and circulated to
all stakeholders
 Budget for the remaining Plan period is Rs. 15.00 cr (Rs. 5.00 cr per
year)

Indian Mental Healthcare Act
(IMHA) 2017

Background
 Health encompasses the composite union of physical, spiritual, mental, and
social dimensions according to the World Health Organization (WHO), which
recognizes that
“Mental Health and well-being are fundamental to quality of life, enabling
people to experience life as meaningful, become creative and active
citizens.”
 Mental health is significantly different from general health as in certain
circumstances mentally ill people may not be in a position to make decisions on
their own
 Mental illness lasts for a protracted period and has a lifelong impact which
gradually result in a poor quality of life
 Those who suffer rarely get access to appropriate medical counseling and
treatment as their families try to hide their condition out of a sense of shame
 This attitude not only harms patients but also leaves them vulnerable to
exploitation, abuse, neglect, and marginalization

Introduction (1/3)
 On the 8 August 2016 the Rajya Sabha (the upper house of the Indian
parliament) unanimously passed The Mental Healthcare Bill, 2016
 The stated aim of the Bill was “to provide for mental healthcare and
services for persons with mental illness and to protect, promote and fulfil
the rights of such persons during delivery of mental healthcare and
services and for matters connected therewith or incidental thereto.”
 This has now been adopted as the Indian Mental Healthcare Act (IMHA)
which received the assent of the President on 7 April, 2017

Introduction (2/3)
 An Act to provide for mental healthcare and services for persons with
mental illness and to protect, promote and fulfil the rights of such persons
during delivery of mental healthcare and services and for matters
connected therewith or incidental thereto
 “Mental illness” means a substantial disorder of thinking, mood,
perception, orientation or memory that grossly impairs judgment,
behaviour, capacity to recognise reality or ability to meet the ordinary
demands of life, mental conditions associated with the abuse of alcohol
and drugs, but does not include mental retardation which is a condition of
arrested or incomplete development of mind of a person, specially
characterised by subnormality of intelligence

Introduction (3/3)
 The new act defines “mental illness” as a substantial disorder of thinking,
mood, perception, orientation, or memory that grossly impairs judgment or
ability to meet the ordinary demands of life, mental conditions associated
with the abuse of alcohol and drugs
 This act rescinds/revoked the existing Mental Healthcare Act 1987 which
had been widely criticized for not recognizing the rights of a mentally ill
person and paving the way for isolating such dangerous patients
 This act has overturned 309 Indian Penal Code which criminalizes
attempted suicide by mentally ill person
 Another highlight of this Act is to protect the rights of a person with mental
illness, and thereby facilitating his/ her access to treatment and by an
advance directive; how he/she wants to be treated for his/her illness

Need of the Act (1/3)
 According to a study conducted by the National Institute of Mental Health
and Neurosciences, India, in 2016, across 12 different states, the
prevalence of depression for both current and lifetime is 2.7% and 5.2%,
respectively
 Approximately 1 in 40 and 1 in 20 people are suffering from past and
current episodes of depression all over the country
 This survey has shown that the lifetime prevalence of mental disorder is
13.7% as a whole, which would mean at least 150 million Indians are in
need of urgent intervention
 Mental illness in vulnerable age groups such as adolescent and in
geriatric population accounts for more than half of the total burden

 Another report regarding the projected burden of mental illness conveys that it
will increase more rapidly in India than the other countries over the next 10 years
and will account for one-third of the global burden of mental illnesses, a figure
greater than all developed countries put together
 Another critical aspect is the existing infrastructure and workforce in our country
to address this health challenge
 There are just about 40 mental institutions (out of which only nine are equipped
to provide treatment for children) and fewer than 26,000 beds available for a
nation comprising 150 billion people
 The WHO report on the Mental Health Atlas reveals that there are just three
psychiatrists, and even lesser number of psychologists for every million people
in India, which is 18 times fewer than the commonwealth norm of 5.6
psychiatrists/100,000 people

 Keeping in view the massive health burden of mental illness in our
country, existing inadequate infrastructure/workforce, the social stigma
attached, and glaring shortcomings of Mental Healthcare Act 1987, it
becomes imperative for the government and various stakeholders to
address these issues
 There is also a need to work on the country’s international obligation
toward the mentally ill people as per the Convention on Rights of Persons
with Disability (2007) and its optimal protocol
 Hence, a patient-centric bill that safeguards available, affordable, and
accessible mental healthcare services was a long due in India

Objectives
 To establish central and state authorities for licensing and supervising
psychiatric hospitals
 To establish such psychiatric hospitals and nursing homes
 To provides a check on working of these hospitals
 To provides a custody of mentally ill person who are unable to look after
themselves and dangerous for themselves

Chapters in Act
Sl. No. Chapters Contents
1. Chapter I Preliminary
2. Chapter II Mental illness and capacity to make mental
healthcare and treatment decisions
3. Chapter III Advance directive
4. Chapter IV Nominated representative
5. Chapter V Rights of persons with mental illness
6. Chapter VI Duties of appropriate government
7. Chapter VII Central Mental Health authority

Sl. No. Chapters Contents
8. Chapter VIII State Mental Health authority
9. Chapter VIX Finance, Accounts and Audit
10. Chapter X Mental Health establishment
11. Chapter XI Mental Health review boards
12. Chapter XII Admission, Treatment & Discharge
13. Chapter XIII Responsibilities of other agencies
14. Chapter XIV Restriction to discharge functions by
professionals not covered by profession
15. Chapter XV Offence and penalties
16. Chapter XVI Miscellaneous

Chapter I: Preliminary (1/4)
 Advance directive - a written document made by a person expressing
their wishes
 Authority - central mental health authority or state mental health authority
 Board - mental health review board
 Care-giver - providing care to a person with mental illness
 Mental illness - a substantial disorder of thinking, mood, perception,
orientation or memory that grossly impairs judgment, behavior, capacity to
recognize reality or ability to meet the ordinary demands of life, but does
not include mental retardation

 Informed consent - consent given for a specific intervention, without any
force, undue influence, fraud, threat, mistake or misrepresentation, and
obtained after disclosing adequate information including risks and
benefits and alternatives to the specific intervention in a language and
manner understood by the person
 Least restrictive alternative/least restrictive environment or less
definitions restrictive option - offering an option for treatment or a
setting for treatment
 Minor - not completed eighteen years

 Local authority - municipal corporation or municipal council, or zilla
parishad, or nagar panchayat, or panchayat
 Mental healthcare - analysis and diagnosis and treatment as well as care
and rehabilitation of a person for his mental illness or suspected mental
illness
 Mental health establishment - any health establishment, meant for the
care of persons with mental illness, does not include a family residential
place where a person with mental illness resides with his relatives or
friends

 Mental health nurse - diploma or degree in general nursing or diploma or
degree in psychiatric nursing
 Mental health professional – psychiatrist, a post-graduate degree
(ayurveda) in mano vigyan avum manas roga or a post-graduate degree
(homoeopathy) in psychiatry or a post-graduate degree (unani) in moalijat
(nafasiyatt) or a post-graduate degree (siddha) in sirappu maruthuvam
 Prisoner with mental illness - a person with mental illness under-trial or
convicted of an offence and detained in a jail or prison

Chapter II:
Mental illness and capacity to make mental
healthcare and treatment decisions (1/4)
Mental illness shall be determined in accordance with such nationally or
internationally accepted medical standards
No person or authority shall classify a person as a person with mental
illness, except for purposes directly relating to the treatment or in other
matters as covered under thisAct
Mental illness of a person shall not be determined on the basis of political,
economic or social status or membership of a cultural, racial or religious
group, or for any other reason not directly relevant to mental health status
of the person

Chapter II:
 Past treatment or hospitalization, shall not by itself justify any present or
future determination of the person’s mental illness.
 It has to be declared by a competent court.
 Capacity to make mental healthcareand treatment decisions:
• Understand the information
• Appreciate any reasonably foreseeable consequence of a decision or
lack of decision
• Communicate the decision by means of speech, expression,
gesture or any other means

Chapter II:
Any advance directive made contrary to any law for t
h
e time being in force
shall be ab initio void
 Manner of making advance directive - regulations made by the Central
Authority
 Maintenance of online register
Revocation, amendment or cancellation of advance directive
 Advance directive do not apply to emergency treatment
Duty to follow advance directive - medicalofficer, psychiatrist

Chapter II:
 Power to review, alter, modify or cancel advance directive
 Application to the concerned Board
 Hearing to all concerned parties
 Considerations
• made by the person out of his own free will and free from force, undue
influence or coercion
• intended to apply to the present circumstances sufficiently well informed to
make the decision capacity to make decisions
• content is contrary to other laws or constitutional provisions
Duty to ensure the medical officer has access to t
h
eadvance directive

Chapter III: Advance Directive (1/2)
 Every person, who is not a minor, shall have a right to make an advance
directive in writing
 The way the person wishes to be cared and treated for The way the
person wishes not to be cared and treated for The individual or individuals,
in order of precedence, he wants to appoint as his nominated
representative
May be made by a person irrespective of his past mental illness or
treatment for the same
Invoked only when the person ceases to have capacity to make decisions
Effective until such person regains capacity to make decisions

Chapter III: Advance Directive (2/2)
The legal guardian shall have right to make an advance directive in writing in
respect of a minor, till such time he attains majority
Review of advance directives -central authority can make regulations and
modifications to protect patient’s rights
Liability of medical health professional in relation to advance directive
 In case of unforeseenconsequences
 If the valid copy notprovided

Chapter IV: Nominated Representative (1/2)
 Appointment and revocation of nominatedrepresentative
 If not a minor- right to appoint a nominated representative
 nomination - made in writing on plain paper with the person’s
signature or thumb impression
 nominated- shall not be a minor, be competent to discharge the duties or
perform the functions, and give his consent in writing .
Where no nominated representative is appointed- a relative, care-giver,
Director of the Department of Social Welfare, or his designated
representative
 The person or board may revoke the appointment

Chapter IV: Nominated Representative (2/2)
 Nominated representative of minor - the legal guardian shall be their nominated
representative, unless the concerned Board orders otherwise
 Revocation, alteration, etc., of nominated representative by Board
Duties of nominated representative:
• Consider the wishes and the best interests provide support
• Seek information on diagnosis and treatment
• Access to the family or home based rehabilitation services involved in admission
and discharge
• Right to give or withhold consent for research appoint a suitable
attendant

Chapter V: Rights of persons with
mentalillness (1/4)
 Right to access mental health care without discrimination
 Provisions–
• Outpatient and inpatient,
• Half-way homes, sheltered accommodation, supported accommodation
• Home based rehabilitation
• Hospital and community based rehabilitation establishments
• Child and old age mental health services

mentalillness (2/4)
 Government roles
Integrate mental health services into general healthcare services
 Access toall
 Mental health services shall be available in each district
 Reimbursement of costs
 Persons below the poverty line are entitled to mental health treatment and
services free of any charge
All medicines on the Essential Drug List shall be made available free of
cost to all persons with mental illness
 Budgetary provisions in termsof adequacy, priority, progress and equity

mentalillness (3/4)
Right to community living and not be segregated from society
Right to protection from cruel, inhuman and degrading treatment
 Right to live with dignity
Protected from all forms of physical, verbal, emotional and sexual abuse
 Right to equalityand non- discrimination
A child under the age of three years of a woman receiving care at a mental
health establishment shall ordinarily not be separated from her except in
cases of harm
 Reviewed every 15 days

mentalillness (4/4)
 Right toinformation.
 Right toconfidentiality
No photograph or any other information relating to a person with mental
illness undergoing treatment at a mental health establishment shall be
released to the media without the consent of the person with mental illness
 Right to accessmedical records
 Right to personal contacts and communication
 Right to legalaid
Right to make complaints about deficiencies in provision of services

Chapter VI: Duties of appropriategovernment
 Promotion of mental health and preventive programs
Creating awareness about mental health and illness and reducing stigma
associated with mental illness
 Appropriate Government to take measures as regard to human resource
development and training
Co-ordination between services such as those dealing with health, law,
home affairs, human resources, social justice, employment, education,
women and child development, medical education to address issues of
mental health care

Chapter VII: Central Mental Health
Authority (1/4)
 Establishment of Central Authority.
 Composition of Central Authority.
Secretary or Additional Secretary ,Department of Health & Family Welfare –
chairperson
 Joint Secretary ,Department of Health and FamilyWelfare, member
Joint Secretary ,Department of Ayurveda, Yoga and Naturopathy, Unani,
Siddha and Homeopathy - member
 Director General ofHealth Services––member

Authority (2/4)
Joint secretary ,department of disability affairs of the ministry of social
justice and empowerment –member
 Joint secretary ,ministry of women and child development–member
Directors of the central institutions for mental health –
members
One mental health professional having 15 years experience in the field -
member
One psychiatric social worker having 15 years experience in the field -
member
 One clinical psychologist having 15 years experiencein the field –member

Authority (3/4)
One mental health nurse - 15 years experience in the field –
member
 Two persons representing persons who have or have had mental
illness –members
 Two persons representing care-givers of persons with mental
illness or organizations representing care-givers - members
Two persons representing non-governmental organizations
which provide services to persons with mental illness –members
 Two persons representing areas relevant to mental health, if
considered necessary

Authority (4/4)
 Term of office – 3 years, eligible for reappointment, shouldn’t be above 70
years of age
 Salaries and allowances of chairperson and members
 Resignation - by notice in writing under his hand addressed to the Central
Government three months prior
 Filling of vacancies - within two months
 No act or proceeding of the Central Authority shall be invalid by vacancies,
defect in appointment, irregularity etc
 Member not to participate in meetings in certain cases
 Officers and other employees of Central Authority
 The chief executive officer shall be the legal representative of the Central Authority

Chapter VIII: Central Mental Health
Authority (1/4)
 Establishment of stateauthority
 Composition of stateauthority
Secretary or principal secretary ,department of health o
f state government–
–chairperson
Joint secretary ,department of health of the state government –
member
 Director of health services or medical education –member
 Joint secretary , department of social welfare of the state government—
member

Authority (2/4)
Head of any of the mental hospitals in the state or head o
f department of
psychiatry at any government medical college –member
One eminent psychiatrist from the state not in government service –member
One mental health professional having 15 years experience in the field —
Member
One psychiatric social worker having 15 years experience in the field –
member
One clinical psychologist having 15 years experience in the field –member
One mental health nurse having 15 years experience in the field–member

Authority (3/4)
 Two persons representing persons who have or have h
a
dmental illness–members
 Two persons representing care-givers of persons with mental illness or
organizations representing care-givers– members
 Two persons representing non-governmental organizations which provide services
to persons with mental illness— members
 Term of office – 3 years, eligible for reappointment, shouldn’t be above 70
years of age
 Salaries and allowances of chairperson and members
 Resignation - by notice in writing under his hand addressed to the state
Government three months prior
 Filling of vacancies - within two months

Authority (4/4)
No act or proceeding of the state Authority shall be invalid by vacancies,
defect in appointment, irregularity etc
 Member not to participate in meetings in certain cases
 Officers and other employees of state Authority
The chief executive officer shall be the legal representative of the state
Authority
 Meetings ofState Authority
 Not lessthan four times a year
All decisions of the State Authority shall be authenticated by the signature of
the chairperson or any other member authorized by the State Authority in
this behalf

Chapter IX: Finance, Accounts andAudit
Grants by Central Government to Central Authority and state government
to state authority
 Central and state Mental Health Authority Fund
 Accounts and auditof Central and state Authority
The accounts of the Authority shall be audited by the Comptroller and
Auditor-General of India at such intervals as may be specified by him
 Annual report of Central and state Authority

Chapter X: Mental Health Establishments
 The government has to set up the Central Mental Health Authority at national
level and State Mental Health Authority in every state
 All mental health practitioners (clinical psychologists, mental health nurses, and
psychiatric social workers) and every mental health institute will have to be
registered with this authority
 These bodies will
a) Register, supervise, and maintain a register of all mental health
establishments
b) Develop quality and service provision norms for such establishments
c) Maintain a register of mental health professionals
d) Train law enforcement officials and mental health professionals on the
provisions of the act
e) Receive complaints about deficiencies in provision of services
f) Advise the government on matters relating to mental health

Chapter XI: Mental Health Review
Boards (1/2)
 Constitution of mental health review boards
 Composition of board:
District judge, or an officer of the state judicial services who is qualified to
be appointed as district judge or a retired district judge - chairperson
Representative of the district collector or district magistrate or deputy
commissioner of the districts in which the board is to be constituted
 Two members - a psychiatrist and a medical practitioner
Two members who shall be persons with mental illness or care- givers or
persons representing organizations of persons with mental illness or care-
givers or non-governmental organizations working in the field of mental
health

Chapter XI: Mental Health Review
Boards (2/2)
Terms and conditions of service of chairperson and members of Board
 Decisions of Authority and Board
 Applications toBoard
 Proceedings before Board to be judicial proceedings
 Meetings
 Central Authority to appoint Expert Committee to prepare guidance document
 Powers and functions of Board
 Appeal to High Court against order of Authority orBoard
 Grants byCentral Government

Chapter XII: Admission, Treatment and
Discharge
 Admission of person with mental illness as independent patient in mental
health establishment
 Admission of minor
 Admission and treatment of persons with mental illness, with high support
needs, mental health establishment, beyond thirty days(supported
admission beyond thirty days)
 Leave of absence and Absence without leave or discharge
 Transfer of persons with mental illness from one mental health
establishment to another mental health establishment
 Emergency treatment
 Prohibited procedure

Decriminalizing suicide and prohibiting
Electroconvulsive Therapy
 It decriminalizes suicide attempt by a mentally ill person
 It also imposes on the government a duty to rehabilitate such person to
ensure that there is no recurrence of attempt to suicide
 A person with mental illness shall not be subjected to electroconvulsive
therapy (ECT) therapy without the use of muscle relaxants and
anaesthesia
 Furthermore, ECT therapy will not be performed for minors

Responsibility of certain other Agencies
 A police officer in charge of a police station shall report to the Magistrate if
he has reason to believe that a mentally ill person is being ill-treated or
neglected
 The bill also imposes a duty on the police officer in the charge of a police
station to take under protection any wandering person
 Such person will be subject to examination by a medical officer and based
on such examination will be either admitted to a mental health
establishment or be taken to her residence or to an establishment for
homeless persons

Financial punishment
 The punishment for violating of provisions under this Act will be
imprisonment up to 6 months or Rs. 10,000 one or both
 Repeat offenders can face up to 2 years in jail or a fine of Rs. 50,000–5
lakhs or both

Critical Insight into the Act (1/4)
 The concept of advance directive, which gives patients more power to
decide certain aspects of their own treatment, has been picked up from
the West; however, unlike developed countries, local factors such as
existing mental health resources and lack of awareness about mental
illness in India have not been taken into account
 Mentally ill persons who suffer from serious psychological disorder often
lack the ability to make sound decisions and do not always have a relative
to speak on their behalf; in such a situation, treating physician is the best
to take decisions
 Hence, from a physician perspective, this new directive will definitely
lengthen the time of admission of mentally ill persons

 The act recognizes the right to community living; right to live with dignity;
protection from cruel, inhuman, or degrading treatment; treatment equal
to persons with physical illness; right to relevant information concerning
treatment, other rights and recourses; right to confidentiality; right to
access their basic medical records; right to personal contacts and
communication; right to legal aid; and recourse against deficiencies in
provision of care, treatment, and services
 However, the estimate of expenditure required to meet such obligations
under the law is not available
 It is also not clear how the funds will be allocated between the central and
the state governments

 The act also assures free quality treatment for homeless persons or for
those belong to below poverty line (BPL), even if they do not possess a
BPL card
 In our country, where mental illness is considered equal to depression,
the obvious financial burden on government will be too high
 While the new act makes several provisions, it provides no guidelines or
rules of implementation
 The newly introduced decriminalization of suicide is definitely welcome
move but there could be very much possibility of misuse of this bill

 However, in cases of dowry-related burning/attempted homicide, this can
be twisted as attempted suicide and will not warrant the needed attention
 In developing countries like India, persons with mental illness and their
situations are being aggravated by socioeconomic and cultural factors,
such as lack of access to healthcare, superstition, lack of awareness,
stigma, and discrimination
 The bill does not direct any provisions to address these factors
 The mental healthcare bill does not offer much on prevention and early
intervention

Conclusion
 The new Mental Healthcare Act 2017 is supposed to change the
fundamental approach on mental health issues including a sensible
patient-centric health care, instead of a criminal-centric one
 The guidelines need to be reviewed on aspects such as primary
prevention, reintegration, and rehabilitation because without such
strengthening, its implementation would be incomplete and the issue of
former mental health patients will continue to exist
 Hence, being optimistic about the bill, there is a need to wait and watch
for its proper implementation

References
 http://indiacode.nic.in The Mental Healthcare Act, 2017 No. 10 of 2017
 http://www.ijabmr.org on Saturday, February 2, 2019, IP:157.43.77.86]
 Duffy and Kelly
Int J Ment Health Syst (2017) 11:48 DOI 10.1186/s13033-
017-0155-1
 Dghs.gov.in>content>1350_3_National Mental Health Program

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Understanding India's Mental Healthcare Act, 2017

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