Year : 2019  |  Volume : 61  |  Issue : 10  |  Page : 660--666

Mental Healthcare Act 2017 – Aspiration to action


Suresh Bada Math1, Vinay Basavaraju1, Shashidhara Nagabhushana Harihara1, Guru S Gowda1, Narayana Manjunatha1, Channaveerachari Naveen Kumar1, Mahesh Gowda2,  
1 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
2 Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Vinay Basavaraju
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
India

Abstract

There is no health without mental health. Recently conducted National Mental Health Survey quoted a prevalence of 13.7% lifetime and 10.6% current mental morbidity. To address this mammoth problem, an aspirational law was enacted titled “Mental Healthcare Act, 2017” (MHCA 2017). The act is progressive and rights based in nature. The whole dedicated Chapter 5 on “Rights of the person with mental illness” is the heart and soul of this legislation. However, the act mainly focuses on the rights of the persons with mental illness (PMI), only during treatment in hospital but is not equally emphatic about continuity of treatment in the community. The act fails to acknowledge and foster the role and contribution of family members in providing care to PMI. Although there are many positive aspects to the MHCA 2017, it may impact adversely on the mental health care in India. This article focuses on the shortcomings and challenges of the act and also makes attempts to offer alternatives considering the available resources and ground reality. Concepts such as “Advance directives” and “Nominated representatives” appear to be very attractive, idealistic, and aspirational, but not evidenced based in the Indian context considering the resources. The act fails to make an impact even after 22 months to attain the goal, and will require pervasive efforts to fulfil a purpose that directs its development. This law needs to be amended as per the local resources and requirements of the society.



How to cite this article:
Math SB, Basavaraju V, Harihara SN, Gowda GS, Manjunatha N, Kumar CN, Gowda M. Mental Healthcare Act 2017 – Aspiration to action.Indian J Psychiatry 2019;61:660-666


How to cite this URL:
Math SB, Basavaraju V, Harihara SN, Gowda GS, Manjunatha N, Kumar CN, Gowda M. Mental Healthcare Act 2017 – Aspiration to action. Indian J Psychiatry [serial online] 2019 [cited 2019 Oct 23 ];61:660-666
Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/10/660/255588


Full Text



 Introduction



In a welfare society, the state needs to make all efforts for social inclusion and provide opportunity and equal participation so that a democratic society benefits when all its members participate fully in the community affairs.[1] The Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2007.[2] The convention requires the laws of the country to align with the convention. There was a perceived and felt need for a new act to suit the changing times and also a need for it to be in line with the UNCRPD.[3] Hence, the lawmakers harmonized the national legislations such as the Mental Health Act, 1987[4] and Persons with Disability Act, 1995[1] with the UNCRPD.

The National Mental Health Survey was undertaken as a large scale, multicentered national study on the various dimensions and characteristics of mental health problems among individuals aged 18 years and above, across 12 Indian states during 2014–2016. As per the survey, overall weighted prevalence for any mental morbidity was 13.7% lifetime morbidity and 10.6% current morbidity.[5] In this regard, Government of India started to make efforts to improve the mental health services in the form of formulating the National Mental Health Policy (NMHP), 2014 and Mental Healthcare Act (MHCA), 2017. The latter was enacted with the support of all parties in both Houses of the Parliament (notified on May 29, 2018).[6]

The preamble of MHCA 2017 promises to provide mental healthcare and services for persons with mental illness (PMI) and to protect, promote, and fulfill the rights of such persons during delivery of mental healthcare and services.[3] However, the act is somewhat silent about providing the care in the community. The act is progressive, patient centric, and rights based. The Chapter 5 on “Rights of the persons with mental illness” is the heart and soul of this legislation. However, the act mainly focuses on the rights of the PMI only for the period they are taking treatment in a hospital, and it is silent about the care of the PMI in the community.[6]

However, the ground realities are far from what can be imagined about a civilized, democratic nation. Increase in invisible mental problems such as suicide attempts, aggression, violence, stress, widespread use of substances, internet addiction, mobile phone addiction, and marital discord and increasing divorce rates emphasize the need to prioritize and make a paradigm shift in the strategies to promote and provide appropriate mental health services in the community [6] for these invisible or minor ailments.[7]

MHCA 2017 is heavily influenced by the western model of legislation. It is based on individual rights, is patient centric, and gives the individual total autonomy over them, which comes in the way of the treatment unless the patient gives informed consent. On a closer look, this act is premised on a hypothesis that the mental healthcare providers and family members are the main violators of the rights of the PMI, which is unfortunate. On the other hand, the act does not take into account the family members' significant contribution, caregivers' burden, and the isolation and frustration they undergo because of PMI.[8] The act does not acknowledge or foster the contribution of family members' support and will in providing care. Unlike the west, in India, the family is the key resource in the care of PMI.[8] Families assume the role of primary caregivers for two reasons: first, because of the Indian tradition of interdependence and concern for near and dear ones in adversities. Second, there is a paucity of trained mental health professionals required to cater to the vast majority of the population.[8] Hence, even the clinicians depend on the family. Thus, having adequate family support is the need of the patient, the clinician, and the healthcare administrators.

The previous legislation, Mental Health Act, 1987, focused on admission and treatment of persons with severe mental illness in mental hospitals [4] when they are detained against their will. However, MHCA 2017 tries to regulate almost all mental health establishments (MHEs). This could be avoided by legislation focusing only on mental healthcare institutions where patients are admitted for treatment against their will. Mental Health Act, 1987 was not implemented across the country because of a severe shortage of resources.[4] However, MHCA 2017 has been introduced without addressing the issues which haunted the Mental Health Act, 1987.[9] This article focuses on the strengths and weaknesses of this legislation.

 Positive Aspects of the MHCA 2017



The heart and soul of this legislation are in Chapter 5 which safeguards the patients' right to access a range of mental healthcare facilities (such as inpatient and outpatient services; rehabilitation services in the hospital, community, and home; halfway homes; sheltered accommodation; and supported accommodation). If the services are not available, PMI are entitled to compensation from the state. Right to community living, right to confidentiality, right to access medical records, right to protection from cruelty and inhumane treatment, and right to equality and nondiscrimination are all ensured by the law.[3] The act seeks to ensure that mental healthcare facilities are available to all. Those below the poverty line, whether in possession of BPL (below poverty line) card or not, the destitute, and the homeless will be entitled to free mental health treatment. The act provides the right to confidentiality and protection from cruel, inhumane, and degrading treatment, in addition to the right to live in a community and avail free legal aid. It bans electroconvulsive therapy (ECT) without anesthesia and any type of ECT to children and restricts psychosurgery.[3]

A PMI has the right to confidentiality with respect to his/her mental health status, mental health care, treatment, and physical health care. All health professionals providing care or treatment to a PMI shall be obligated to keep such information which has been obtained during care and treatment confidential, except to the nominated representatives (NRs) to enable them to fulfill their duties and to other health and mental health professionals to enable them to provide appropriate care and treatment to the PMI and to protect any other person from harm or violence. The act, by including institutions belonging to other alternative health systems in the definition of MHEs, has made uniform regulations in establishing and regulating mental healthcare delivery services. The act regulates both public and private mental health sectors.[3]

This legislation revolves around “autonomy” and gives every person the right to make an advance directive. This is a written statement which explains “how they want to be cared” and “how they should not be cared for” in case they become incapacitated because of the mental illness. Further, the person (except minors) can also choose a NR to assist him/her with treatment-related decisions. Any information relating to a PMI undergoing treatment in a MHE shall not be released to the media without the consent of the PMI. The right shall also apply to all information stored in electronic or digital format in real or virtual spaces. The media also need to restrain themselves from depicting or disclosing the identity of the PMI during reporting in specific cases that go to the media. Under the act, there is a provision for involuntary admission with the support of the NR and also appeals can be made to the Mental Health Review Board (MHRB), which will also review all admissions that extend beyond 30 days.

MHCA 2017 also prohibits procedures such as sterilization of men or women when intended as a treatment for mental illness, unmodified ECT, seclusion, and chaining. The act also regulates research on PMI and the use of restraints and neurosurgical treatment for them. According to the Indian Penal Code 309, “Whoever attempts to commit suicide and does any act towards the commission of such offense, shall be punished with simple imprisonment for a term which may extend to 1 year or with fine, or with both.” However, MHCA 2017 states that any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said code. The appropriate government shall have a duty to provide care, treatment, and rehabilitation to a person having severe stress and who attempted to commit suicide, to reduce the risk of recurrence of an attempt to commit suicide. The act has provisions for use of the ambulance services in the same manner, extent, and quality as provided to persons with physical illness (Chapter V, Section 21) and prescribes specific duties for police officers in respect of PMI (Chapter XIII, Sections 100, 101), thereby clearly giving provisions for families, in case of emergency, for shifting the patient and taking necessary help of resources in the community for better crisis intervention.

 Drawbacks and Recommendation for Amending the MHCA 2017



Definition of mental illness

The act defines “Mental Illness” as “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, 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, especially characterized by subnormality of intelligence.” As per this definition, this act is applicable only to those who have “substantial” impairment in thinking, mood, perception, orientation or memory that grossly impairs judgment, behavior, capacity to recognize reality, or ability to meet the ordinary demands of life. This law does not apply to all PMI. In simple words, it applies to those who have severe mental disorders. Further adding to the complexities, the Section 3[3] says that mental illness shall be determined in accordance with such nationally or internationally accepted medical standards. The dilemma of whether one should follow Section 2(s) or Section 3 to define mental illness needs to be resolved at the earliest. Further, MHCA 2017 does not discuss whether it covers personality disorders or not.[10] The above issues need to be clarified at the earliest. Section 3 and Section 2(s) have to be combined, and the meaning should be conveyed as per the requirement of the law and preamble. However, the Section 3 (determination of mental illness) has to be stipulated for use exclusively for the clinical purpose by the clinician and needs to get priority during provision of mental healthcare services, and Section 2(s) has to be for legal purposes (legal definition) for MHRB in adjudicating the cases.

Mental Health Establishment (Sec 2p)

NMHP [11] advocates the integration of mental health into primary health care. However, the act mandates all the establishments to take registration for treating PMI; this may come in the way of integrating mental healthcare into general health care and thus the implementation of the policy. Many private hospitals and nursing homes may refuse to treat patients with mental illness as inpatients, explaining that they do not have the registration to do so. Hence, the act should be in line with NMHP. To encourage treatment in the general hospitals, they need to be kept out of the purview of registration.[6] The act enthusiastically moves forward (without acknowledging the meager available resources) to protect and promote human rights of PMI by mandating registration of the MHE. There are many hostels; prisons; jails; juvenile homes; child protection centers; reception centers; centers for destitute; beggars' homes; religious places such as temples, churches, and dargahs; and centers run by faith healers; these would need to take registration to keep PMI. This will defeat the purpose of the act and will invite “license raj” of harassing the mental healthcare providers. It would be prudent to keep the general hospital, primary health center psychiatry units, and other treatment providing centers in primary care to be kept out of the purview of registration [6] so that the act can be properly implemented.[12]

The act ignores the presence of a mental health program in the country. The act should have mandated all the states to implement NMHP, and the state mental authority should have been made responsible for the same — the only way the act can implement the right to mental healthcare is by enabling the implementation of NMHP across all states.

Capacity to consent

There are issues related to capacity to make decisions related to mental healthcare and treatment, and this may have serious consequences because

Section 4 of MHCA 2017, capacity to make mental health care and treatment decisions, is flawed and can have dangerous consequences. In a nutshell, this section dictates capacity in relation to the ability of the patient to (a) comprehend the information or (b) assess risk or (c) communicate his/her decision. If he/she has any one of the above components, a PMI can refuse treatment. That means a psychiatrist will only be able to provide treatment for the minority of the PMI, with difficulty. Hence, there is an urgent need for clarification and for a guidance document to be released for the assessment of the mental capacity, and amendments need to occur for the Section 4. The Section 4 needs to be amended by deleting “or” and introducing “and” between 4[1] a, b, and c [13]A PMI may refuse treatment due to (a) absent insight, (b) severe symptoms, or (c) his/her symptoms coming in the way of decision-making. Family members usually find it difficult to manage individuals with serious mental illness who have no insight, and usually, such patients refuse admission and treatment. Chapter 2, Section 4, by default, considers everyone to have capacity, and before initiating involuntary treatment, one has to prove that a PMI lacks capacity. In such context, act gives a provision to treat the patients through a valid advance directive (AD) or in its absence, a NR. Where there is no AD or NR appointed by a person, the law assumes relative or caregiver as NR for the admission and treatment-related decision.[14]

The Supreme Court of Canada (SCC) has dealt with a similar issue in a well-known celebrity case referred to as “Canada's Beautiful Mind”. SCC ruled that a law that allows a PMI to be incarcerated indefinitely in a hospital because the needed psychiatric treatment cannot, by law, be provided, is not justifiable in a caring democratic jurisdiction.[15] Hence, MHCA 2017 needs to make provisions for involuntary treatment in all supported (involuntary) admissions through informed consent from the parents and/or family members to restore liberty by treatment. It has been stated, very rightly, that in the regulation of involuntary treatment, a balance must be found between the duties of care and protection and the right to self-determination.[12] It would be prudent that for all admissions under the Sections 89 and 90, the capacity need not be assessed, and the consent needs to be taken from the NR so that the treatment can be given importance and the patient's true liberties can be restored.

Advance directives and nominated representatives

ADs are legal documents that allow any adult to spell out their decisions in writing about their future mental health care when they become mentally ill. A PMI may revoke, amend, or cancel AD many times in a day, and family members will be finding it difficult to handle such situations. Only the MHRB has the powers to amend or overrule the AD.[16] This would need to be done in a very short time to enable the treatment (24–48 h). There is a dearth of human resources (medical and judicial), economic resources, and collective community efforts in treating PMI. This may mean that our society may not be ready yet for AD. It would be prudent to do more research in this area in our population before we introduce the concept of AD here.[17]

The concept of ADs operates on the basic premises that “if a person develops mental illness…” Which mental illness? If multiple illnesses occur? If it becomes comorbid with a physical illness? What severity? Under what circumstances? There is a need for more clarity on the issues related to AD and whether every treatment detail needs to be included in the AD by the patient. Such scenarios may prove to be a deterrent in providing care for the patient. AD will invite more litigations and heavy burden on the family members. It is advisable that the AD are kept out of the purview of the act.[9] A Cochrane review on advance treatment directives for people with severe mental illness reported that there are too few data available to make definitive recommendations to introduce it.[17] Even in the west, this has certainly not had its intended benefit. For the Indian reality, to be rushing in with legislation on this count is rather hasty and ill-conceived.[18]

Implementation of AD and NR in India can be a challenging issue with respect to current availability of human resources and also socioeconomic constraints. Other challenges are multiple revocations of AD and NR and the supremacy of MHRBs in decisions related to challenging AD and NR. These issues may result in difficulties to provide care by other stakeholders such as family, nongovernmental organizations, and mental health professionals. The above situations may result in disharmony between patient and family.[8] Ultimately, the family may disown the patient, and this may have serious consequences in the form of abandoning of the patient who may end up as wandering mentally ill, and all this would defeat the very purpose of the act in protecting the patient. We need to consider the fact that the family members are the true value and assets in the Indian context. Hence, the family members should be the natural guardians until proven otherwise. AD and NRs break the very backbone and fabric of our society, “the family.” The clause on NR may need amendment in consideration with the Indian society.

Mental Health Review Boards

The district-level MHRBs, which are quasi-judicial bodies overseeing the effective implementation of the mental healthcare delivery system, could introduce new hurdles for treatment delivery and unnecessary delays. This could be simply because of the nonavailability of the judicial workforce and other resources to operate at the level of every district. If these issues are not addressed, this may cause a delay in initiating treatment, which may cause an enormous amount of stress on the care providers. Delay in addressing the issue can defeat the purpose of the act. If these boards do not operate on a day-to-day basis at the level of each hospital, then this can cause a serious adverse impact on the mental healthcare system. Unfortunately, mental healthcare is taking a turn similar to a western country, where involuntary mental health care becomes a legal decision more than a clinical one. Mental healthcare is becoming a tedious, prolonged, and costly judicial proceeding. These MHRB need to have a time limit (<72 h) to take a decision, especially with regard to capacity to consent for treatment issues. The mainstream judicial system may be incapable of handling such complaints because of its time constraints and the huge backlog of cases.[14] These boards need to move away from the tardy judicial process/procedures and enable a fast review through the medical board of the hospital, which will assist in faster decision-making, enabling the families for treatment and unburdening the judiciary with these mental healthcare-related cases. Alternatively, consumer-friendly mental healthcare boards can be created at every hospital, using local resources such as an independent psychiatrists, family caregivers, and recovered patients, or a board of visitors can be created at each hospital (along the lines of Mental Health Act, 1987) to perform similar functioning. The first level of review could be independent hospital review board (similar to the Ethics Committee), as most issues could be easily addressed at the patient's doorsteps.[6]

Right to information

The act also gives power to a NR to unlimited information on patients illness (Section 22). There is an urgent need to define information. Mental health professionals have expressed reservations over such sharing of information, describing it as “breach of confidentiality” as per Medical Council Ethics 2002.[19] This issue impinges on the fundamental right to privacy. Medical records shall be shared only with patients or with appropriate legal authorities on obtaining a written request. The information is shared without the PMI's consent only when he/she has lost the mental capacity. There is also an urgent need for the act to specify the duration for which the medical records should be stored for both the outpatients and the inpatients. The MHCA has not defined 'information'. This will cause more confusion and conflict between Section 22 (Right to information) and Section 25 (Right to Access Medical Records).

Punishment for contravention of provisions of the Act

Punishments prescribed in the act are too harsh, and there is no provision to assess whether a contravention is accidental, due to practical difficulties, or deliberate. Medical personnel are already covered under various legislations such as the Consumer Protection Act, Medical Council of India, State Medical Council, National Human Rights Commission, and civil and criminal laws against medical negligence. There are various commissions such as the Human Rights Commission, Women's Commission, and Child Welfare Committee to protect the rights of the PMI. Unlike the other patients, behavior and responses of mentally ill are different, especially in patients with paranoid delusions. Such people are likely to complain against hospital/doctors or other personnel as a consequence of their paranoid delusions, resulting in a cascade of legal proceedings. Such litigation-based mental healthcare can give rise to defensive practice, and tendency to avoid care of such patients will only harm such patients and their family members. This will also increase the cost of mental health care. Before passing pecuniary or imprisonment adjudication, MHRB or the relevant courts need to establish the malafide intention of the mental health professionals. The errors of judgment in areas such as the evaluation of symptoms, diagnosis, assessment of capacity, decision about a need for admission (dangerousness criteria) or involuntary treatment, or risk assessment are more likely in mental healthcare services because in PMI, these variables are dynamic and change more frequently than in persons with other disorders.

Community Treatment Order

As per the Act, the psychiatrist is expected to be responsible for patient care and treatment after discharge. This clause (Section 98) is idealistic but may not be possible in custodial care (involuntary patients), destitute patients, and voluntary admissions, wherein only the patient can be briefed or counseled regarding future treatment. The decision to accept/refuse treatment is patient's choice, and the absence of discharge planning should not be a ground for negligence since there are other factors such as active cooperation of the patient and family members, that will ensure continuity of care. If the lawmakers are very serious about this issue of “the continuity of care,” or “community treatment,” or “provision of care,” then they should enable the mental healthcare providers and family members by introducing the compulsory community treatment order (CTO).

Unfortunately, the act is silent on the much-needed CTO. The inclusion of compulsory CTOs may play a significant role in providing care for chronically ill patients and also better the lives of the family members and caregivers. Availability of CTO to the family members and caregivers enables them to provide continuous care. The CTO brings relief to families of a PMI, encourages the use of less restrictive forms of inpatient treatment, reduces violence, prevents unnecessary criminalization, and brings greater stability to the lives of the seriously mentally ill. Hence, there is a need to have a CTO in place. New York's Compulsory CTO is comprehensive and can be adopted with minor modification suiting our society, culture, and resources. Implementation of such a law can bring in the continuity of care after discharge.

Research

Along with existing Indian research guidelines by a regulatory authority such as Drug Controller General of India, Indian Council of Medical Research (ICMR),[20] and Institutional Ethics Committee, the act mandates the State Mental Health Authority (SMHA) to grant permission for research, when the participating person lacks capacity. Before submitting to SMHA, researcher has to fulfill the following requirements for research such as a) free and informed consent from NR and PMI; (b) role of research in promoting the mental health; (c) need of proposed research; (d) conflict of interest involved; (e) proposed research follows all the national and international guidelines and regulations; and (f) ethical approval has been obtained from the Institutional Ethics Committee where such research is to be conducted. There is a need for a modification in the Section 99 (2 and 3): “State Authority to grant permission for research” should be replaced by “as per ICMR guidelines.”

Role of family

The act does not specify the role of the family members in providing care in the hospital environment. There is a need for the hospitals/institutions to make a provision in their bylaws based on the patient needs in high support situations. There is a high need that family members need to be involved in the provision of care. This process not only protects the patient's rights but also gets the family members involved in active treatment processes such as psychoeducation, supervised medication, family therapy, to be cotherapist, and also in rehabilitation process. All these make a huge difference in continuity and outcome of the treatment.[8] If there are no family members, the medical board (comprising of two mental health professionals) can make provisions, to surpass the requirement of a family member. Hence, there should be an emphasis on such admissions along with their relative (by blood, marriage, or adoption) to encourage family support during an acute crisis which provides moral, emotional, and physical support to the ailing PMI.[8] Not involving family members will drive the mental hospital to the 19th century overcrowding and institutionalization syndrome. Many institutions across India have popularized the concept of family participation during inpatient care. A clause needs to be introduced wherever involuntary in-patient treatment is required, by default one family member needs to accompany and be with the PMI during inpatient treatment. The duration for inpatient criteria for supported admission need not apply when family members are physically present in the ward (24 × 7) and participate in treatment and decision-making process. A separate category for admission with family members needs to be introduced and promoted.

Treatment/intervention

The treatment and intervention procedures need to be as per the national professional guidelines. The MHRB needs to take the professional bodies' opinion in case of conflict in treatment and intervention procedures. ECT as a form of treatment is indicated for depressive patients with high degree of suicidal ideas/attempt and acutely agitated and disruptive patients, to cite a few. In emergencies, ECT as a form of treatment has been banned in the act. ECT is also banned in minors. If this clause is not removed, effective treatment will be denied for patients with an acute illness whose life can otherwise be saved with an ECT.[14] Waiting for the Board's approval for ECT in minors or emergency is equivalent to withholding the much-needed treatment. The act should not prohibit or ban medically acceptable procedures. There should be clinical autonomy for providing mental health care.

Lack of resources

The act is highly loaded with the rights-based ideology and in this respect is similar to the mental health legislations of many western countries. However, the resources those countries have are many folds higher than those of India. Implementation of MHCA 2017 will face challenges due to the scarcity of resources.[21] There have also been serious doubts raised about workforce, economics related to implementation, and political will for successful implementation of the act. The major limitation is lack of resources, especially in the semi-urban and rural areas. There are logistic issues such as poor infrastructure, inadequate mental health workforce, low budget for mental healthcare, and lack of mental health resources in general healthcare settings.[4] If minimum mental health services are not available in the district where the patient resides, such persons are entitled to access any other mental health services in the district, and the costs of treatment at such establishments will be borne by the appropriate government. This compensation-based mental health services can result in false claims and could exhaust the existing meager resources. Instead of discussing the compensation, the act needs to focus on a well thought-through and detailed road map for improving mental health workforce, similar in lines with the Mental Health Act of 2007 in the United Kingdom. There is also an urgent need to introduce psychiatry at the undergraduate level (MBBS) so that every doctor will have the knowledge to treat mental illness.[4] This responsibility needs to be entrusted to a specific agency for implementing and monitoring the progress of workforce development. The need of the hour is in addressing major challenges such as lack of mental health workforce, financial aid, and stigma, which are the major threats to develop comprehensive psychiatric services in the community.[6]

Budget

The act is aspirational on the financial expense part and does not mandate the state to allocate budget for the smooth functioning of state authority and respective district boards. Further, there is no realistic road map for budgeting mental health services, rehabilitation services, and medications.[22] Similarly, the workforce for implementing the act is scarce, both in the judiciary, paralegal domains and also in the area of providing care and treatment. Hence, training of the workforce needs to be considered to fill the existing gap. The act should mandate the provision of adequate resources for the proper functioning of these constitutional bodies.[13]

 Conclusion



MHCA of 2017 focuses mainly on the human rights of PMI. It is prudent for the lawmaker to account for the culture of the land, newer scientific developments in the mental health field, analyze the met-unmet needs of the patients and families, and make provisions to bridge the treatment gap. There is also a need to make provisions to enhance the resources and skill building among professionals/workers in the field of mental health, to provide comprehensive healthcare services, to promote mental health and well-being, and to make provisions for adequate financial support/budget (for plan and nonplan expenditures). The need of the hour is a law that can be implemented in practice and can cater to the health needs at all levels of prevention (primary, secondary, and tertiary) while also protecting the rights of the family, professionals, and end users. There is an urgent need to amend the existing law to convert it from an aspirational law into a law of action.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Suresh Bada Math is the Member of 'the Committee of Experts' constituted by the Ministry of Health and Family Welfare, Nirman Bhavan, New Delhi dated 23rd May, 2017 for framing Rules and Regulations under the MHCA 2017.

References

1Rao GP, Ramya VS, Bada MS. The rights of persons with disability bill, 2014: How “enabling” is it for persons with mental illness? Indian J Psychiatry 2016;58:121-8.
2Narayan CL, Shikha D, Narayan M. The mental health care bill 2013: A step leading to exclusion of psychiatry from the mainstream medicine? Indian J Psychiatry 2014;56:321-4.
3Mental Healthcare Act, 2017. Available from: http://www.prsindia.org/uploads/media/Mental%20Health/Mental%20Healthcare%20Act,%202017.pdf. [Last accessed on 2018 Dec 18].
4Math SB, Murthy P, Chandrashekar CR. Mental health act (1987): Need for a paradigm shift from custodial to community care. Indian J Med Res 2011;133:246-9.
5Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health Survey of India, 2015-2016: Summary. Bengaluru: National Institute of Mental Health and Neurosciences; 2016.
6Rao GP, Math SB, Raju MS, Saha G, Jagiwala M, Sagar R, et al. Mental health care bill, 2016: A boon or bane? Indian J Psychiatry 2016;58:244-9.
7Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res 2007;126:183-92.
8Avasthi A. Preserve and strengthen family to promote mental health. Indian J Psychiatry 2010;52:113-26.
9Antony JT. A decade with the mental health act, 1987. Indian J Psychiatry 2000;42:347-55.
10Duffy RM, Kelly BD. Concordance of the Indian mental healthcare act 2017 with the World Health Organization's checklist on mental health legislation. Int J Ment Health Syst 2017;11:48.
11National Mental Health Policy – Vikaspedia. Available from: http://www.vikaspedia.in/social-welfare/differently-abled-welfare/policies-and-standards/national-mental-health-policy. [Last accessed on 2019 Feb 18].
12Duffy RM, Narayan CL, Goyal N, Kelly BD. New legislation, new frontiers: Indian psychiatrists' perspective of the mental healthcare act 2017 prior to implementation. Indian J Psychiatry 2018;60:351-4.
13Duffy RM, Kelly BD. India's mental healthcare act, 2017: Content, context, controversy. Int J Law Psychiatry 2019;62:169-78.
14Kala A. Time to face new realities; mental health care bill-2013. Indian J Psychiatry 2013;55:216-9.
15Gray JE, O'Reilly RL. Supreme court of Canada's “beautiful mind” case. Int J Law Psychiatry 2009;32:315-22.
16Gowda GS, Noorthoorn EO, Lepping P, Kumar CN, Nanjegowda RB, Math SB. Factors influencing advance directives among psychiatric inpatients in India. Int J Law Psychiatry 2018;56:17-26.
17Campbell LA, Kisely SR. Advance treatment directives for people with severe mental illness. Cochrane Database Syst Rev. 2009;(1):CD005963.
18Sarin A. On psychiatric wills and the Ulysses clause: The advance directive in psychiatry. Indian J Psychiatry 2012;54:206-7.
19Medical Council of India. Code of Ethics Regulations. Available from: http://www.mciindia.org/RulesandRegulations/CodeofMedicalEthicsRegulations2002.aspx. [Last accessed on 2018 Dec 28].
20National Ethical Guidelines for Biomedical and Health Research involving human participants. Indian Council of Medical Research [Internet]. Available from: https://icmr.nic.in/sites/default/files/guidelines/ICMR_Ethical_Guidelines_2017.pdf. [Last cited on 2019 Mar 13].
21Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, et al. Mental health systems in countries: Where are we now? Lancet 2007;370:1061-77.
22Math SB, Srinivasaraju R. Indian psychiatric epidemiological studies: Learning from the past. Indian J Psychiatry 2010;52:S95-103.