the paradigm shift, salient features of the mental health care act 2017, the amendmends of MHCA 2017, The core principles, the comparison with other legislations, the applicability, criticisms are included

1. Presenting and Discussing by
MS FATHIMA HASANATH K P &
MR JOSHIN SAMUEL
Under the joint guidance of
DR DIPANJAN BHATTACHARJEE &
MS POOJA AUDHYA

2. INTRODUCTION
• Government of India ratified the United Nations Convention on the Rights of Persons with
Disabilities in 2007.
• The law makers harmonised the national legislations such as Mental Health Act 1987 and Persons with
Disabilities Act 1995 with UNCRPD as there was need for a new act to suit the changing times.
• As per National Mental Health Survey 2014-16, prevalence for any mental morbidity was 13.6% life
time morbidity.
• Formulated National Mental Health Policy 2014 and MHCA 2017 to improve mental health services.
• Passed on 7th April 2017 and Came into force on 29th May 2018.

3. DEFINITION
“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.”

4. PARADIGM SHIFT IN MENTAL
HEALTH LEGISLATION IN INDIA
PRE-INDEPENDENT PHASE
• Indian Lunatic Asylum Act 1858
• Indian Lunacy Act 1912 (Custodial care)
 focused on the protection of public from
mentally ill
 Patients were considered dangerous to
society
 Neglected human rights
 Highly criticised by Indian Psychiatric
Society
POST INDEPENDENT PHASE
• Indian Psychiatric Society established in
1947
• Mental Health Act 1987 (treatment to
PMI)
• Person with Disabilities Act 1995 (social
model of disability care)
• Mental Health Care Act 2017 (Human rights
in psychiatric treatment)

5. MENTAL HEALTH ACT 1987
• Came into force on April 1993.
• Did not recognize the rights of mentally ill persons and paved the way for isolating
such dangerous patients.
• Act has overturned IPC 309 which criminalises attempted suicide by mentally ill
person.
• It had failed to remove virtual criminal flavour on admission of patients with mental
illness as it involved the department of police and honourable courts in admission
and discharge procedures.
• No time frame for maximum period of inpatient hospitalization for persons
admitted involuntarily with exception of special circumstances.
• Managements were done mostly in closed wards and there were chances for
vulnerability and human rights violation depression and anxiety.

6. NEED FOR A NEW LAW
Massive Health burden
• Current and lifetime prevalence of depression in India were 2.7% and 5.2% (NMHS
2016 by NIMHANS).
• Approx. 1/40 and 1/20 people suffering from past and current episodes of
depression in all over the country.
• 150 million people in need for urgent mental health intervention.
• Mental illness in vulnerable age groups (adolescent and geriatric) for more than
half of the total burden.
• Mental illness will increase more rapidly in India and will become 1/3 of global
burden for mental illness.

7. Existing inadequate infrastructure and workforce
• 40 mental institutions (9/40 institutions are equipped to provide treatment for
children) and >26,000 beds were available in a country comprising of 150 billion
people.
• 3 psychiatrist and 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 (WHO report on Mental Health Atlas).
Social stigma associated with mental illness

8. Shortcoming of Mental Health Act 1987
• For achieving the optimal protocol of UNCRPD 2007 more works to be done.
• A patient-centric bill that safeguards available, affordable, and accessible mental
healthcare services was a long due in India.

9. TIME LINE
Mental Health Care Rules
Rights of Person with Mental Illness 29 May 2018
Central mental health authority and mental health
board
29 May 2018
State mental health authority 29 May 2018
Guidance document for “mental capacity” assessment 16 August 2019
List of psychotropic drugs 16 August 2019
Central mental health care (CMHA) regulations 18 December 2020

10. MHCA: PREAMBLE
 To provide mental healthcare and treatment to person with mental illness.
To protect promote and fulfil the rights of PMI during delivery of mental health
services.

11. SALIENT FEATURES
• 126 sections arranged under 16 chapters.
• CHAPTER 1: Defined mental illness
• Included substance use disorders
• Excluded mental retardation
• Shall be determined based on ICD latest version
• Included PG AYUSH practitioners as medical professionals and also professionals (clinical
psychologists, mental health nurses, and psychiatric social workers) registered with the
concerned State Authority under Section 55.
• Mental health establishments (multi-speciality hospitals and general hospitals to increase
treatment options for PMI).

12. CHAPTER 2: ADVANCE DIRECTIVE
• A person who is not a minor and having “mental capacity”.
• The way the person wishes to be cared for and not to be cared for
• Can appoint a nominated representative (NR) in spite of past illness (having or had
taken treatment)
• Not applicable at the time of emergency.

13. CHAPTER 4: NOMINATED
REPRESENTATIVE (NR)
• Every person except a minor has the right to appoint a NR.
• NR shall not be a minor.
• If no responsible person is available to be NR, the Board shall appoint the director,
Dept. of Social Welfare or designated representative of the person.
• NR can seek information of diagnosis, treatment, rehabilitation, planning discharge,
application for admission, and give consent if required.

14. CHAPTER 5: RIGHTS OF PMI
“HEART AND SOUL OF THE ACT”
• Right to access MHC treatment (cost
affordable and in good quality) without
discrimination.
• To have a dignified life
• Protection from cruel treatment
• Self hygiene and privacy
• Proper clothing
• Pay for work
• Living in community
• Adequate food
• No tonsuring
• No force of uniform
• Emergency and ambulance services
• Mobile, e-mail facilities and free legal
services.
• Not separating women and child below
3 years and if separated not more than
30 days (should be approved by
authority.

15. CHAPTER 6: DUTIES OF APPROPRIATE
GOVERNMENT
• Allocating Budget
• Conducting programs for suicide and
stigma prevention.
• Establishment of
• Halfway homes
• Sheltered accommodation
• Supported accommodation
• Hospital and community based
rehabilitation services.
• Start child mental health services
• Provide psychotherapies
• Add mental health in school syllabus.
• Appoint counsellors in secondary
schools.

16. CHAPTER 7: STATE AND CENTRAL
MENTAL HEALTH BOARDS
Sec. 34: CMHA
• 20 members with 3-years term
• Maximum age of 70
• Meet every 6 months (tele-video)
• Secretary & joint secretary (dept of H and F),
director general of health services, director
of central institutes, MHP with 15 years
experience, PSW, CP, MHN, 2 persons of
PMI, caregiver, person of NGO and person
relevant to MH.
Sec. 34: SMHA
• Shall meet not <4 times a year
• Principal secretary, joint secretary, head
of MH institute, eminent psychiatrist,
MHP, PSW, CP, MHN, 2 members of
PMI, caregiver and persons of NGO.

17. STATE AND CENTRAL MENTAL HEALTH
BOARDS FUNCTIONS
Sec. 43:
• Register MHE.
• Have quality norms of MHE
• Supervise MHE.
• Maintain National register of MHP.
• Train MHP
• Advice Central government on MHC.

18. CHAPTER 11: MENTAL HEALTH
REVIEW BOARD
Sec. 73 and 74: Constitution of MHRB
• Will be set up mostly in every district
• For a 5 years term
• Members with a maximum age of 70
years
• Honourable District Judge (Retired also
considered), representative of district
collector, psychiatrist, medical
practitioner and 2 persons either can be
PMI or care givers or persons of NGO.
Sec. 82: FUNCTIONS
• Registering and reviewing AD
• Appoint NR
• Decide objections against MHP and
MHE.
• Deciding for non-disclosure of PMI
information.
• Visit jails.
• Protect human rights.

19. CHAPTER 12: ADMISSION AND
TREATMENT
• Sec. 86: Voluntary admission changed
as independent admission.
• Independent admission: admission of
PMI who has capacity to make MHC
and treatment decisions or requires
minimal support in making decision
and has MI of severity requiring
admission, likely to benefit or
understand the nature and purpose of
admission.
• Informed consent has to be taken.
• May discharge even without the
consent of MO.
• Sec. 89- Supported admission: after
application given by NR for 7 days.
• Can be admitted for a maximum period
of 30 days after taking AD from PMI.
• Consent of PMI has to be reviewed
every week
• Sec. 90: continue supported admission
(90/120/180)

20. • PMI who are wandering, not capable of taking care of himself can be taken under
protection by Police officer and after informing NR.
• In case of prisoners act, can be treated in the psychiatric ward of medical wing in the
prison and when there is no facility in the psychiatric ward, can be transferred to
MHE after taking permission from board.
• Sec. 87: Admission of Minor: NR of minor has to give application. If admission >30
days, it should be again informed to the Board.

21. EMERGENCY TREATMENT
• Medical treatment for of <72 hours.
• ECT shall not be used as a treatment in
this section of Emergency treatment.
• Provision of transportation for PMI to
nearest MHE.
Sec. 95: PROHIBITED
PROCEDURES
• ECT without aesthesia
• Sterilization of PMI
• Chained procedures
• Shall not kept in seclusion
• Physical restrained only can be used to prevent
imminent harm and should record in the file.
• For ECT in minors and psychosurgery- Board
permission has to be taken.

22. CHAPTER 15: OFFENCES AND
PENALTIES
• Non registration of MHE- penalty of Rs. 5,000/- for the first time and up to 5 lakhs
subsequently
• Non registered MHP who serves in a MHE- penalty of Rs. 25,000/-.
• Intervening the Act- fines ranging from imprisonment of 6 months, Rs. 10,000/- to 2
years, Rs. 5 lakhs.

23. DISCUSSION

24. NEED FOR THE MENTAL HEALTH
LEGISLATION
• To protect the rights of the person with mental illness (PMI)
• To address the stigma associated with mental illness.
• To provide quality care to PMIS

25. PREAMBLE OF MENTAL HEALTH
CARE ACT 2017
“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.”

26. CORE PRINCIPLES
• Mental Healthcare Act 2017, upholds patient autonomy, dignity, rights and choices during mental
healthcare.
• For the first time in the country’s history, access to mental healthcare is described as a right of every
citizen.
• To ensure that patient choice is respected even in individuals with impaired capacity, this Law uses
three tools:
1. Advance Directives (Sections 5-13 of the Act)
2. Nomination of Representatives (Section 14 of the Act)
3. Supported Decision-making

27. REMIT OF THE LAW
• The law covers all ‘substantive’ mental illnesses including substance misuse disorders.
Intellectual disability is, however, excluded.
• Mental illness as per Section 2(s) of this Act is a substantial disorder of thinking, mood,
perception, orientation or memory that grossly impairs (a)judgment, (b)behavior or
(c)capacity to recognize reality or ability to meet the ordinary demands of life.
• People with substance misuse disorders are explicitly brought under the purview of the Act.

28. • All institutions where people with mental illness reside for treatment and care (excluding family
homes) are considered as mental health establishments requiring registration with the
authorities.
• This includes all rehabilitation homes, prisons, places for religious healings and institutions
offering complementary therapies. General hospitals providing mental health care (in isolation
or in combination with physical healthcare) also come under the remit of the Act.
• This is clearly a welcome step forward, as the previous legislation was restrictive in its remit.

29. • Unlike the previous Mental Health Act of India (1987), the current law is restricted to mental
health care (rather than care of the mentally ill).
• There is a separate legislation, enacted in 2016, to cover certain other aspects of life of people
with disabling mental illness (Rights of People with Disabilities Act, 2016) (Ministry of Social
Justice and Empowerment, 2017).
• This change is firmly grounded on the principle of equality before law (Article 12) of The
United Nation’s Convention on Rights of Persons with Disabilities.

30. COMPARISON
Mental Health Act 1987 Mental Health Care Act 2017
Applicable only to specialty Mental Hospital Applicable to all settings
Admission- Voluntary, Involuntary and Reception Order from the
Magistrate.
Admission- Independent and Supported.
No provision for independent judicial review or appeal. Provision for quasi-judicial review and appeal (MHRB)
Compulsory inpatient treatment for MI posing risk (irrespective of
the capacity of the individual).
Supported inpatient admission and treatment are only for
incapacitous individuals meeting a threshold (including risk)
Substitute decision making for people undergoing involuntary
treatment.
Protects and promotes the rights of individuals during MHC.
Promotes choices of the individual through supported decision
making, AD and NR
No special safeguards for minors requiring psychiatric admission. Separate provision for minor admissions under section 87, with
additional safeguards.
A large role for judicial magistrate in admissions and discharge
decisions.
Minimal, if any, role for judicial magistrate in admission and
discharge decisions.
Remit of the law included not just mental healthcare, but care of
people with mental illnesses including guardianship.
The remit of the law is just mental healthcare.

31. CRITICAL EVALUTION
• MHCA completely ignore the importance of family.
• Advanced directive and nominated representative are going to increase litigation and paper
work.
• Advanced Directive may not be aware for illiterate persons (legal illiteracy).
• Need to have more work force for documentation and will lead to increase Mental Health
Care cost.
• The Indian Psychiatric Society has highlighted that AD and NR are not patient friendly, but
the government has not considered the representation.

32. • The procedure of NR and AD are not clearly provided.
• Neither the Act nor the rules define the constitution, procedure and terms of reference of the
MHRB.
• Psychotherapists and psychoanalysts are omitted from the act as the current definition of
“mental health professionals”.
• ECT without anesthesia, sterilization of PMI, and chained procedures shall not be performed. Is
it practice throughout our country?
• PMI may revoke, amended or cancelled AD many times in a day and family members finds the
difficult to handle such situations.
• Our society may not be ready yet for AD, as there is a scarcity of human recourses, economies
recourses and collective community efforts in treating PMI.
• AD will invite more litigation and heavy burden on the family members as the concept of AD is
not clearly defined.

33. • The law is applicable only to those who have severe Mental Disorders.
• MHCA does not discuss whether the personality disorders are defined in the mental illness that
needs to be resolved at the earliest or not.
• By mandating the registration of MH Establishment the act will invite the “license raj” of harassing
the mental health providers.
• The act ignores the presence of mental health programs in the country. The only way the act can
implement the right to mental health care is by enabling the implementation of NMHP across all
the state.
• Capacity to make mental health care and treatment discussion is flawed and have dangerous
consequences. (PMI can refuse treatment)
• There is a urgent need for clarification and for a guidance document to be released for the
assessment of the mental capacity.
• chapter 2 section 4 by default considers everyone to have capacity and before initiating
involuntary treatment one has to prove that PMI lacks capacity.

34. APPLICABILITY
• If MH services are not available, PMI are entitled to compensation from the state.
• People BPL, homeless, and destitute will be entitled to free MH treatment.
• The act provides right to live in community and avail free legal aid.
• All Health Professionals providing care or treatment to a PMI shall be obligated to keep
information about the patient confidential ( expect NR and other Health and Mental Health
Professionals)
• People are unaware of the laws, their rights and the forum to approach for any kind of help.
• It ensures that no person with mental illness will have to travel far for treatment.
• The responsibilities of other agencies such as the police with respect to people with mental illness
has been outlined in the 2017 Act.

35. • The act has made uniform regulation in establishing and regulating mental health care delivering
services including institution belonging to other alternative health system.
• The act regulates both private and public mental health sectors.
• There is a provision for involuntary admission with support of NR and appeals can be made to the
MHRB.
• It regulates research on PMI and use of restrain and Neurosurgical treatment for them.
• It states that any person who attempt to commit suicide shall be presumed, unless proved
otherwise, to have severe stress and shall not be tired and punished under IPC 309. Appropriate
government shall have duty to provide care, treatment and rehabilitation to such people.
• Provision for use of ambulance services in the same manner extent and quality as provided to
person with physical illness.
• Prescribes specific for police officers, provision for families for shifting the patients and finding
recourses from community in the time of crisis.

36. FUTURE
• Needs to make provision for involuntary treatment in all supported admission through informed
consent from the parents and family members.
• Need to do more research in our population before be introduce the concept AD and NR here.
• Mental Health Review Board lead to more away from the tardy judicial process and enables a fast
review through the Medical Board of hospital.
• There is an urgent need for the act to specify the duration for which the medical record should be
stored both the OP and IP. Implication of E-health in Mental health field.
• A clause need to be introduce where one family member should accompany and be with PMI
during inpatient treatment.
• Introducing community mental health treatment will reduce violence, prevents unnecessary
criminalization and encourages the use of less restrictive forms of inpatient treatment and brings
greater stability to the life of seriously mentally ill.
• Need for the modification in the section 99: “ state authority for grand permission for research”
should be replaced by “ as per ICMR guidelines”.

37. REFERENCES
• Duffy, R. M., & Kelly, B. D. (2019). India’s Mental Healthcare Act, 2017: Content, context, controversy. International
Journal of Law and Psychiatry, 62(July 2018), 169–178. https://doi.org/10.1016/j.ijlp.2018.08.002
• J.B. Bivin, mental health care act 2017; implications to psychiatric care practices, Government MH centre; Trivandrum,
September 2020, retrieved from https://www.slideshare.net/bivinjose/mental-healthcare-act-2017-238499172
• Namboodiri, V., George, S., & Singh, S. P. (2019). The Mental Healthcare Act 2017 of India: A challenge and an
opportunity. Asian Journal of Psychiatry, 44(February), 25–28. https://doi.org/10.1016/j.ajp.2019.07.016
• Neredumilli, P., Padma, V., & Radharani, S. (2018). Mental health care act 2017: Review and upcoming issues. Archives of
Mental Health, 19(1), 9–14. https://doi.org/10.4103/AMH.AMH_8_18
• P. A. Khan, Mental Health Act 1987, March 2016, NMS hospital; Jaipur, retrieved from
https://www.slideshare.net/PARVAIZKHAN2/mental-health-act-1987
• Times of India, august 2020, our journey to mental health act 2017, retrieved from
https://timesofindia.indiatimes.com/readersblog/eccentricdimensionist/our-journey-to-mental-healthcare-act-2017-
24432/

38. THANK YOU