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Review Article

Mental Health Care Act 2017: Review and upcoming issues

Prasanna Kumar Neredumilli, V. Padma, S. Radharani
Department of Psychiatry, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India.

Abstract Mental Health Care (MHC) Act 2017 is published in the Gazette by Government of India. It is aimed at
strengthening human rights of persons with mental illness. Changes such as advance directive and nominated
representative are new, and review boards and responsibilities of government are clearly emphasized. The
objective of this article is to give an overview of MHC act 2017 and its upcoming issues while implementing it.

Keywords: Advance directive, Mental Health Care Act 2017, nominated representative

Address for correspondence: Dr. Prasanna Kumar Neredumilli, Department of Psychiatry Government Hospital For Mental Care, Visakhapatnam,
Andhra Pradesh, India.
E‑mail: drprasannakumar12@gmail.com

INTRODUCTION Management of persons suffering from mental illness

Legislation plays a vital role in the treatment of persons
suffering from mental disorders. Insight of illness may not
be present in majority of mental disorders when compared
to physical illness and the law guides for treatment in
a proper direction. In India, different legislations have
come. Mental Health Care (MHC) Act 2017 has passed
through different timelines. It was passed and approved
by Parliament and got assent by the president in April
2017 and eventually come into force from May 29, 2018.
Earlier with the Mental Health Act (MHA) 1987, there was
a start for human approach for treating mental disorders
with provisions for human rights but without emphasis on
issues like consent. Provisions for voluntary admissions
and special circumstances were started. As it involved the
department of police and honorable courts in admission
and discharge procedures, it had failed to remove virtual
criminal flavor on admission of patients with mental illness.
There was no time frame for maximum period of inpatient
hospitalization for persons admitted involuntarily with
exception of special circumstances.
was being done mostly in inpatient settings in hospitals
and closed wards, and they were at disadvantage position
as there were chances for vulnerability and human rights
violation. These violations in human rights could lead to
further psychiatric issues such as depression and anxiety.
Convention on the rights of persons with disabilities (CRPD)
was passed by the United Nations (UN) General Assembly
in 2006 and was signed and ratified by India in 2007 and
made India eventually responsible for the revision of
disability laws in India and introduction of MHC Act[1]
2017. MHC act is published in the spirit of UNCRPD
with human rights of person with mental illness (PMI)
and review board acting as the backbone on the fulcrum
of mental capacity.
As per MHC act 2017, mental health professional (MHP)
includes psychiatrist, professionals having a postgraduate
degree including Ayurveda in Mano Vigyan Avum
Manas Roga or Homoeopathy in Psychiatry or Unani in
Moalijat (Nafasiyatt) or Siddha in Sirappu Maruthuvam,

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DOI: How to cite this article: Neredumilli PK, Padma V, Radharani S. Mental
10.4103/AMH.AMH_8_18 health care act 2017: Review and upcoming issues. Arch Ment Health
2018;19:9-14.

© 2018 Archives of Mental Health | Published by Wolters Kluwer ‑ Medknow 9

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Neredumilli, et al.: Review of mental health care act 2017
and also a professional registered with the concerned State
Authority under Section 55 (clinical psychologists, mental
health nurses [MHNs], and psychiatric social workers) and
they will become eligible for assessing mental capacity
and eventually for admitting them as inpatient in
independent admissions as per the 2017 act. Mental health
establishment (MHE) includes inpatient establishments
of all health establishments including all other medical
treatment modalities as specified by act for care of
PMI excluding residential places. This makes even the
multispecialty hospitals and general hospitals under the
purview of the act for registration as MHE and these
hospitals may not register due to unnecessary fears which
may lead to decreased treatment options for PMI. The
Indian Psychiatric Society has given representations to
government to remove general hospital from registration
as MHE, but the Government did not consider it. The act
highlighted the importance of clause “meant for care” for
PMI, and this is reflected for defining places like sheltered
accommodation for not specifying MHE registration as
seen in draft rules.
Even though it may appear that the MHCA 2017 may not
be applicable to MHP practicing at outpatient services
or establishments without registration, there are some
sections of the act they too have to follow. These include
advance directive (AD), aspects of confidentiality, rights
to access basic medical records by patients, and provisions
of treatment procedures such as electroconvulsive
therapy (ECT), psychosurgery, seclusion, and emergency
treatment.
The definition of mental illness encompasses in broader
sense and is not equated with unsoundness of mind and has
to be determined by international classification of diseases
(ICD 10) and not by the past treatment or hospitalization.
The broader definition of mental illness may lead to
persons having milder mental illness to be branded as
having mental illness leading to stigma and further may
affect the persons for accessing treatment. The clause
“mental conditions associated with abuse of alcohol or
drugs” signify that deaddiction centres may come under
the purview of act unless they specify that they give care
for only substance abuse persons.
If a person (including PMI) is able to understand the
information for decisions admission, treatment or
personal assistance or appreciate reasonably foreseeable
consequences of decision or communicate the decision
by means of speech, expression or gesture, then he is
deemed to have capacity to make decision regarding MHC
treatment and can write AD and is eligible for admissions
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on independent basis. Persons suffering from neurotic
disorders and psychotic disorders with the exception of
chronic disorganized psychosis,delirium,dementia and
organic psychosis may have capacity and may be considered
under this act and eventually has to be admitted on
independent basis. The clause “mental capacity” segregates
PMI and this segregation may raise doubts whether MHC
Act is in true spirit of UNCRPD or not. There needs to
be further information by the guidance document of the
expert committee.
ADVANCE DIRECTIVE
A person who is not a minor having mental capacity can
write directive as specified by mental health authority
regarding his intention for the way he/she wishes to
be cared for and not to be cared for and can appoint
nominated representative (NR) in spite of whether he/she
is having past illness or had treatment for mental illness.
NR has to sign if name is mentioned in AD and also
signatures by two witnesses have to be taken. In case PMI
comes alone and has not written or given AD, he/she may
be given treatment after consent and may be admitted as in
patient admission. If PMI wants to be treated at corporate
hospital only and relative is not in a financial position to
give treatment, then relative or caregiver or MHP may apply
to board for review of AD. PMI suffering from psychosis
may perceive that harm will be done by known persons like
family members or unknown persons and may write AD
and thereby cannot get treatment. In these situations also,
MHP or relative may approach the board for review of AD.
The provision of AD may not be aware in illiterate persons
and implementation of these sections by them is debatable.
The past literature also reveals that implementation of AD
has been difficult.[2] However, there are some favorable
aspects of AD for MHP and these include nonapplicability
of AD in emergency treatment, duty of PMI or NR to
make access of AD, and MHP not liable if not given copy
of AD or for unforeseen consequences of valid AD.
NOMINATED REPRESENTATIVE
Psychiatric illness may cause burden to caregivers and
in turn can affect the care of PMI. The MHC act 2017
has given sections for support of PMI by way of NR.
The NR can be a relative or caregiver, suitable person
appointed by board, or person of organization registered
under societies registration act and may be revoked by
board. NR shall not be minor and has to give consent in
writing to MHP. NR can seek information of diagnosis and
treatments, rehabilitation, planning discharge, application
for admission, and give consent if required.
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Neredumilli, et al.: Review of mental health care act 2017
The high caregiver burden with mental disorders
can sometimes lead to orphanage of PMI leading to
wandering aimlessly and NR could support in this issue.
In situations where the PMI has not written NR, may be
due to unawareness of the act, then relative or caregiver
can be deemed to be considered as NR and if not willing
then the board appoints a suitable person. In admission
where PMI is voluntarily admitted as independent
admission, NR is not necessary to stay with him. In
cases where family is included in delusional rubric of
patient, there are chances of appointing other person
who may not be having good intent as NR and the role
of NR in this type of cases may not be appreciable. The
Indian Psychiatric Society has highlighted that AD and
NR are not patient friendly, but the government has not
considered the representation.
The state shall maintain a panel of trained caregivers[3] whose
antecedents are verified by police and having them will help
family members to attend to their personal duties. There
are rules for providing emergency service number available
to family caregivers at every district headquarter to call
for help. Special care shall be taken by the government
regarding vulnerable caregivers such as single, adolescent,
and elderly caregivers.
HUMAN RIGHTS
Human rights are given major importance and includes
the right to access MHC treatment, cost affordability
and good‑quality mental health services, accessibility, and
without discrimination. The facilities include acute care
and outpatient and inpatient treatment.
There are sections in MHC act 2017 for PMI to have a
dignified life, protection from cruel treatment, self‑hygiene,
privacy, proper clothing, pay for work, living in community,
adequate food, no tonsuring, no force of uniforms,
emergency and ambulance services, mobile, e‑mail facilities,
and free legal services. Insurance for mental disorders and
treating the PMI according to International guidelines.
There are provisions for not separating woman and child
below 3 years of age and if separated for more than 30 days
it should be approved by authority. This act has given
significance for rights of PMI receiving inpatient treatment
and grossly neglected the rights of PMI of community.
Unemployment is reported to be significant in persons with
mental disabilities[4] when compared to other disabilities,
and this issue is not give importance in this act.
Government has to take measures and they include
allocating budget in terms of adequacy,priority,equity
Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018
and legal aid. It shall support establishments for PMI to
live in less restrictive community and in family. The other
measures include conducting programmes for suicide
and stigma prevention. Measures for increasing human
resources of mental health services were mentioned.
However, feasibility and practical implementation in real
scenario may be debatable. Regarding confidentiality,
information of PMI has to be made available only to NR
and MHP and has to be protected from others except in
threat to life. In cases of NR who sometimes may not be a
family member, the availability of confidential information
can affect the privacy of information of PMI.
The duties of central and state Government includes
establishment of halfway homes, sheltered accommodation,
and Supported accommodation, hospital and community
based rehabilitation services. The supported accommodation
is for those who have own or rented accommodation without
caregiver, and they will get domiciliary care at doorstep.
The government shall start child mental health services,
provide psychotherapies like cognitive behavior therapies
and also include mental health in school syllabus. There
shall be counselor in secondary schools. Elderly PMI shall
have quality mental health services.
The major importance of human rights in MHCA 2017
will eventually lead changes in aspects of caring PMI and
may include upgrade facilities in sanitary and environmental
conditions, making preventive measures to all forms of
abuse to PMI, facilities for caring both mother and child,
maintaining records and to release information to PMI
or NR or board if needed, aspects of confidentiality and
facilities of telephones or e‑mail, and providing details of
board and free legal services.
CENTRAL MENTAL HEALTH AUTHORITY AND
STATE MENTAL HEALTH AUTHORITY
Central Mental Health (CMH) Authority comprises
20 members with 3‑year term and maximum age of 70 years
and have to meet every 6 months and may be joined by
televideo conference. CMH comprises of secretary, joint
secretaries of department of health and family, director
general of health services, director of central institutes,
mental health professional with 15 years experience,
psychiatric social worker, clinical psychologist, MHN, two
members of PMI, caregivers, persons of nongovernmental
organization (NGO), and persons relevant to mental health.
CMH shall register MHE, have quality norms of MHE,
supervise MHE, maintain national register of MHP, train
MHP, and advise central government on MHC.
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Neredumilli, et al.: Review of mental health care act 2017
State mental health authority shall meet not <4 times a
year and comprises principal secretary, joint secretary,
head of mental health institute, eminent psychiatrist, MHP,
psychiatric social worker, clinical psychologist, MHN,
two members of PMI, caregivers, and persons of NGO.
The Indian Psychiatric Society has requested to include
professional associations of psychiatrists in authorities,
the government has not considered.
MENTAL HEALTH ESTABLISHMENT
REGISTRATION
MHE registered as clinical establishment can apply
for registration with fees as prescribed, after fulfilling
standards specified by authority and within 10 days without
inquiry can get provisional registration having validity for
12 months. This is followed by publishing online or print of
all particulars of MHE by authority within 45 days. MHE
has to submit the evidence for minimum standards within
6 months from the date of such standards specified by the
authority. The authority shall give public notice for filing
objections, and MHE has to submit evidence and if there are
no objections communicated to MHE, then it is deemed to
get permanent registration. The authority shall conduct audit
of all registered MHE every 3 years. In case if MHE fails in
aspects of human rights or persons of MHE had committed
an offence then the authority may issue showcause, and
at last, registration may be canceled. MHE has to display
certificate, website, phone, and address of board. Among
the members of AUDIT, there shall be psychiatrist and one
a representative of an organization for PMI.
MENTAL HEALTH REVIEW BOARD
Mental Health Review Board will be set up mostly in
every district as per the CMH recommendation and will
be for a term of 5 years. Review board members can be
holding office up to the maximum age of 70 years and
members comprise Honourable District Judge (retired
also considered), representative of district collector,
psychiatrist, medical practitioner, and two persons can
be either PMI or caregivers or persons of NGO. The
proceedings are deemed to be judiciary proceedings as per
the IPC 193, 219, 228 and also shall be held in camera. They
have to dispose application given by MHP for supported
admissions within 7 days for Section 89, 21 days for Section
90, and 90 days for others. Their remuneration and salaries
will be met by central authority grants. The functions of
board includes registering and reviewing AD, appoint
NR, decide objections against MHP and MHE, deciding
for nondisclosure of PMI information, visit jails, protect
human rights.
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Mental illness comprises different disorders and, in
some cases of delusional disorder where the delusion is
systematized, it will be difficult for nonpsychiatrists to
recognize this as mental illness, and in these types of cases
psychiatrist has to give extra effort as he/she is the only
person of board having adequate knowledge for mental
illness and has to convince the other board members. As
the board will be set up at district level or areas specified
by authority, it will become difficult for the PMI and MHP
staying in remote areas for access of board and it may lead
to delay in treatment.
ADMISSION AND TREATMENT
Voluntary admission as per the MHA 1987 is changed as
independent admission (Section 86 of MHC act 2017 and
Section 17 of 1987) and refers to admission of PMI who
has the capacity to make MHC and treatment decisions or
requires minimal support in making decision and has mental
illness of severity requiring admission, likely to benefit or
understand the nature and purpose of admission. Informed
consent has to be taken. The person admitted in this section
may himself be discharged even without the consent of
medical officer. MHP includes psychiatric social worker
and mental health nurse, and they may admit PMI in MHE
as per the act. But whether they will be having considerable
experience in assessing capacity for treatment decisions is a
matter of debate. In cases of PMI not able to understand the
purpose or nature of treatment resulting in not accepting the
treatment and also unable to take care himself, violent, then
the PMI has to be admitted as supported admission (Section
89 of MHC act 2017 and Section 19 of MHA 1987)
after application given by NR provided PMI shall not be
readmitted within 7 days. It is followed by examination
by psychiatrist and MHP and if the findings are as per
this section of the act, then PMI can be admitted for a
maximum period of 30 days after taking AD and it has to
be reported to board. Consent can be obtained from NR
and the consent from PMI has to be reviewed every 7 days.
If admission requires more than 30 days or readmission
within 7 days (section 90), they should be examined by two
psychiatrists and can be admitted for a maximum period of
90 days if they satisfy norms as per this section of the act
and have to inform the board for permission, taking account
of AD and consent should be reviewed fortnightly along
with planning for community‑based treatment. While the
PMI is receiving treatment as per supported admission and
in case if NR wishes for discharge of PMI then he has to
apply to the Board. In this section, the treating psychiatrist
should be cautious for checking consent and record notes
and intimating the board at regular intervals as specified.
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If admission is extending beyond 90 days, it can be
extended for 120 days at first instance and thereafter for
180 days each time after complying with the provisions of
this section of act. Provisions for involuntary admission
of PMI with disability/chronicity may not be in tune with
UNCRPD, but in psychological disorders it is different as
there may situations of harm or death of himself or others
by PMI may eventually require these types of sections for
safety and protection of PMI or others.
PMI who are wandering, not capable of taking care of
himself can be taken under protection by police officer
and after informing NR they may produce before public
health establishment (100 of MHC Act 2017, 23 of MHA
1987). If he / she had mental illness then PMI has to be
treated as per the provisions of act and in case if he/she
is not eligible as per independent admission then has to be
examined by psychiatrist and MHP as per section 89. In
case of PMI is ill treated or neglected then the police officer
may produce for 10 days in MHE and after assessment the
treatment of PMI has to be followed as per the provisions
of the act (101,102 of MHC Act 2017, 25 of MHA 1987).
In case of prisoners act, Air force act, Army act, Navy act
and code of criminal procedure can be treated at psychiatric
ward in medical wing of prison and when there is no facility
of psychiatric ward they can be transferred to MHE after
permission from board (103 of MHC Act 2107, 27 of MHA
1987). As per the rules under section 121 of MHC Act there
shall be screening for all inmates of prison during the time
of entry including Mental status examination, urine testing
for common drugs of abuse, protocols for dealing prisoners
with suicidal risk, counselling for stress and prison after
care services. When proof of mental illness is challenged
during the judicial proceedings of honourable court then
the honourable court may send to board for scrutiny (105
of MHC Act 2017,26 of MHA 1987).
In admission of minor (Section 87 of MHC act 2017 and
Section 16 of MHA act 1987), NR of minor has to give
application to medical officer and after being examined
by two psychiatrists or psychiatrist and medical officer or
psychiatrist and MHP and if they are satisfied as per the
norms of this section then the minor can be admitted in
separate accommodation from adults, consent taken from
NR and informed and informed to board. If admission
lasts more than 30 days, it should be again informed to
the board. In case of minor girl and NR is male, a female
attendant should be appointed by NR.
Emergency treatment
Medical treatment can be given for mental illness by
registered medical practitioner to a PMI either at MHE
Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018
or at community for a maximum period of 72 h with
informed consent of NR to prevent death or irreversible
harm to health of person or person inflicting serious harm
to himself or person causing serious damage to property.
Electroconvulsive therapy (ECT) shall not be used as form
of treatment in this section of emergency treatment. There
is provision of transportation of PMI to nearest MHE.
ECT without anesthesia, sterilization of PMI, and chained
procedures shall not be performed. PMI shall not be kept
in seclusion and only physical restraint should be used to
prevent imminent harm and to be recorded in medical
notes. Board permission has to be taken for ECT in minors
and in case of psychosurgery.
ECT is effective treatment and has been using since long
time with less side effects. Imposing ban on unmodified
ECT may lead to removal of efficacious treatment for
the PMI of remote distant places where anesthetist may
not be available. ECT is a lifesaving option in emergency
psychiatric situations like suicide and removing its role
cannot be replaced. The Indian Psychiatric Society has
highlighted the importance of unmodified ECT, but the
Government has not considered.
There are provisions for psychiatrist responsibility for
PMI care and future treatment in consultation with PMI
or NR. But for PMI who are not interested to continue
medication after discharge or stopped treatment after going
into community, there are no alternative provisions to deal
with them. Provisions for rehabilitation and managing
the assets/property of PMI are not given in this act. The
research should be conducted with informed consent from
PMI, state authority, and institutional ethics committee.
If a person contravenes the act there are fines ranging
from imprisonment of 6 months, ten thousand rupees to
2 years, five lakh rupees. There is provision for the central
government for control over CMH. In cases of difficulties
that arise in giving effect to the act, the central government
may publish orders for making provisions not consistent
with act. In view of communication and travel difficulties,
there are provisions for Northeastern states regarding
relaxations for time frames. As per the MHC act 2017, a
person who commits suicide is presumed to have severe
stress and shall not be punished. However, the clause
“unless proved otherwise” of this section may make police
to investigate for the cause. There will be no prosecution or
legal proceedings against authority or board when done in
good faith. However, relaxations for legal proceedings done
in good faith were given to authorities and board but not
to MHP and other personnel directly involved in treatment.
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Neredumilli, et al.: Review of mental health care act 2017
The future favorable ray of hope for MHPs includes guidance
document by expert committee on mental capacity as mental
capacity is the backbone for AD and admission procedures.
The other includes the power of central authority to modify
or make additional regulations on AD after periodical review.
CONCLUSIONS
Mental health care Act 2017 is published with main
emphasis of Rights of PMI in every aspect. MHP
should give utmost importance to the Rights, address the
transitions from MHA 1987 to MHCA 2017 including
taking care to record and maintain case notes at every stage.
Financial support and sponsorship
Nil.
14
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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prsindia.org/uploads/media/Mental%20Health/Mental%20
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2. Zelle H, Kemp K, Bonnie RJ. Advance directives in mental
health care: Evidence, challenges and promise. World Psychiatry
2015;14:278‑80.
3. Draft Rules and Regulations under Mental Healthcare Act, 2017.
Available from: https://mohfw.gov.in/sites/default/files/Final%20
Draft%20Rules%20MHC%20Act%2C%202017%20%281%29.pdf.
[Last accessed on 2018 Jun 11].
4. Drew N, Funk M, Tang S, Lamichhane J, Chávez E, Katontoka S,
et al. Human rights violations of people with mental and
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