Clinician Awareness and Attitude About Decriminalization of Suicide Attempt as per Mental Health Care Act 2017: A Cross-sectional Study

Abstract

Background:

The decriminalization of suicide under Section 115 of the Mental Healthcare Act (MHCA), 2017 marked a paradigm shift in India, reframing suicide attempts as manifestations of severe stress requiring care rather than punishment. However, gaps in clinician awareness and ambiguity regarding medico-legal responsibilities may hinder effective implementation of the law in clinical settings. This study aimed to assess non-psychiatric clinicians’ awareness and attitudes regarding the decriminalization of suicide under the MHCA, 2017, and to explore potential implementation gaps.

Methods:

A cross-sectional questionnaire-based study was conducted among 134 clinicians from non-psychiatric departments at a tertiary-care center in central India. A structured, self-administered questionnaire assessed sociodemographic characteristics, awareness of legal provisions related to decriminalization, and attitudes toward its impact on stigma, help-seeking, and clinical practice. Descriptive statistics were computed, and subgroup comparisons based on years of clinical experience (≤1 year vs. >1 year) were performed using the chi-square test.

Results:

Most clinicians were aware that suicide has been decriminalized in India (76.1%) and that individuals attempting suicide are presumed to be under severe stress (84.3%). Nearly four-fifths (79.1%) recognized the government’s obligation to provide care and rehabilitation. However, 80.6% believed that reporting suicide attempts to legal authorities remains mandatory, and only 51.5% were aware of professional immunity from civil or criminal liability. Attitudes toward decriminalization were largely positive: 55.2% agreed that it reduces stigma, 56.8% felt it encourages help-seeking, and 88.8% reported a greater likelihood of psychiatric referral following decriminalization. Subgroup analysis did not reveal significant differences across experience levels.

Conclusion:

Non-psychiatric clinicians demonstrated generally favorable awareness and supportive attitudes toward the decriminalization of suicide. However, persistent misconceptions regarding medico-legal obligations suggest an implementation gap. Targeted training, legal-literacy initiatives, and clear institutional protocols are needed to ensure consistent, rights-based care in alignment with the MHCA 2017.

Keywords

Clinician awareness decriminalization India mental health law suicide attempt

Key Messages:

Question: What is the level of awareness among non-psychiatrists regarding the decriminalization of suicide under the MHCA 2017?

Findings: Most clinicians were aware of decriminalization and the need for care, with positive attitudes and reduced stigma, but misconceptions about medico-legal responsibilities remained.

Meaning: Despite positive attitudes, gaps in medico-legal knowledge can affect decision-making, underscoring the need for targeted training and clear protocols to ensure consistent, patient-centered care.

Suicide refers to a deliberate act by an individual to end their own life.¹ Worldwide, it accounts for a significant public-health burden, with an estimated seven lakh deaths reported in 2021 across all age, gender, and socioeconomic groups.² In India, suicide continues to represent a major mental health challenge, with national statistics indicating a steady rise in both completed suicides and attempted acts over recent years.³ Recent data show that suicide rates in several central Indian states, including Madhya Pradesh, ranged between 14.7 and 17.5 per 100,000 population during the early COVID-19 period, underscoring the persistent regional burden.⁴

In the Indian legal context, the earlier position under the Indian Penal Code (IPC), 1860, treated attempts to commit suicide as a punishable offense under Section 309, which specified imprisonment up to one year, a fine, or both.⁵ The Mental Healthcare Act (MHCA) 2017 marked a major shift by decriminalizing suicide under Section 115, recognizing those who attempt suicide as being under severe stress and mandating state-provided care and rehabilitation. However, despite this reform, many clinicians remain uncertain about its legal and clinical implications.^6,7 Moreover, the state is mandated to provide care, treatment, and rehabilitation for such a person to reduce the risk of recurrence.³

The situation presents a two-pronged problem—on one hand, there are medical and clinical challenges in caring for people who attempt suicide with empathy and respect for their rights; on the other, there is confusion about legal duties, reporting requirements, and dealing with law-enforcement agencies. Lack of awareness or misconceptions can lead to inappropriate reporting, inadequate referral, and stigmatizing attitudes, all of which may compromise patient care. Furthermore, the introduction of the Bharatiya Nyaya Sanhita (BNS) 2023, which omitted IPC 309 and reinforced the decriminalization of suicide, makes it even more crucial to evaluate how clinicians interpret and apply these updated legal frameworks in practice.⁸

While previous Indian studies have examined psychiatrists’ perspectives, limited data exist regarding non-psychiatric clinicians who frequently serve as first responders in emergency settings.^9,10 Misinterpretation of medico-legal obligations in this group may directly influence referral practices, documentation, and patient experience.

Assessing non-psychiatric clinicians’ awareness and attitudes will help identify knowledge gaps, guide sensitization programs, and ensure that the intent of MHCA 2017, to provide care, treatment, and rehabilitation for individuals in crisis, is effectively translated into clinical reality. This evidence can also inform institutional protocols and policy interventions aimed at improving the interface between law and healthcare in suicide prevention. The study aims to evaluate the awareness and attitudes of non-psychiatric clinicians regarding the decriminalization of suicide as per the MHCA 2017 in India.

Methods

This study adopted a cross-sectional, questionnaire-based design to assess the awareness and attitudes of clinicians toward the decriminalization of suicide as outlined in the MHCA, 2017. The research was conducted among doctors working in hospitals affiliated with a tertiary-care center in central India for one month from November 1, 2023, to November 30, 2023. Ethical approval for the study was obtained from the Institutional Ethics Committee of the tertiary-care center in central India.

Clinicians from non-psychiatric departments who had managed at least one suicide attempt case in the past year were recruited through purposive sampling to reflect the real-world clinical workforce that commonly manages suicide attempt cases in tertiary-care settings. Doctors working in the department of psychiatry or those not engaged in treating patients with suicide attempts were excluded.

A self-administered structured questionnaire served as the data collection tool. This instrument, designed by the investigators, was developed through a group discussion with a panel comprising medical professionals, mental health experts, psychiatrists, and resident doctors, ensuring adequate representation from each department. All panel members involved in the development process were excluded from the final study sample. It was based on existing literature and the provisions of MHCA 2017, consisted of three sections: (a) Sociodemographic and professional details such as age, gender, qualification, experience, and job designation; (b) items assessing awareness of MHCA provisions related to decriminalization of suicide, including Section 115; and (c) attitude items evaluating clinicians’ beliefs regarding the impact of decriminalization on stigma, help-seeking, and patient care.

Data were collected through both online (Google Forms) and paper-based questionnaires, depending on clinician preference and accessibility. Participants were approached during duty hours and were given 5–10 minutes to complete the survey. Participation was entirely voluntary, and confidentiality and anonymity were strictly maintained. No personally identifiable information was recorded, and respondents retained the right to withdraw at any time without consequence.

Drawing on previous Indian studies that reported approximately 45%–50% clinician awareness regarding the decriminalization of suicide, an estimated sample size of 125 participants was considered sufficient to provide preliminary data with acceptable precision. To accommodate possible non-response, the target was slightly increased, and ultimately 134 valid responses were obtained.

Descriptive statistics were computed for all awareness and attitude variables and expressed as frequencies and percentages. For subgroup comparisons, clinicians were categorized by years of casualty experience (≤1 year vs.>1 year). Awareness items with three response options (yes/no/maybe or do not know) were analyzed using the chi-square test of independence (2 × 3 contingency tables). Five-point Likert-scale attitude responses were collapsed into three categories for subgroup analysis: Negative (strongly disagree + disagree), neutral, and positive (agree + strongly agree), and compared across experience groups using the chi-square test (2 × 3 tables). A p value < .05 was considered statistically significant.

Results

A total of 134 clinicians participated in the study (Table 1). The mean age of participants was 27.22 ± 2.73 years. The majority belonged to the 26–30 years age group (66.4%), followed by the 21–25 years age group (25.4%), and only a small proportion were above 35 years (8.2%). Males constituted 55.2% and females 44.8% of the total sample. More than half of the participants (53.7%) possessed an Doctor of Medicine/Master of Surgery (MD/MS) qualification, followed by Bachelor of Medicine, Bachelor of Surgery (MBBS) (41%), Diplomate of National Board (DNB) (3.7%), and Doctorate of Medicine/Magister Chirurgiae (Super-specialty degrees) (DM/MCh) (1.5%). The highest representation came from the medicine department (27.6%), followed by surgery (17.9%), emergency medicine (11.2%), Ear, Nose, and Throat (ENT) (9%), obstetrics and gynecology (9%), and anesthesiology (7.5%). Participants from orthopedics comprised 7.5%, and others (community medicine, burns and plastic surgery, psychiatry) together accounted for 10.4% of the sample. Most respondents were academic junior residents (64.9%), followed by medical officers (11.9%), non-academic junior residents (11.2%), and senior residents (10.4%), with a small number of faculty members (1.5%). Regarding experience, 44.8% had less than one year of experience in casualty duties, 38.1% had 1–5 years, and 16.4% had more than five years.

Table 1.

Sociodemographic Characteristics of Participants (N = 134).

Variable	Category	Frequency (n)	%
Age group (years)	21–25	34	25.4
	26–30	89	66.4
	31–35	10	7.5
	36–40	1	0.7
Gender	Male	74	55.2
Gender	Female	60	44.8
Highest qualification	MBBS	55	41
	MD/MS	72	53.7
	DNB	5	3.7
	DM/MCh	2	1.5
Department	Medicine	37	27.6
	Surgery	24	17.9
	Emergency medicine	15	11.2
	ENT	12	9
	Obstetrics and gynecology	12	9
	Anesthesiology	10	7.5
	Orthopedics	10	7.5
	Others (community medicine, burns and plastic surgery, psychiatry)	14	10.4
Position	Academic junior resident	87	64.9
	Medical officer	16	11.9
	Non-academic junior resident	15	11.2
	Senior resident	14	10.4
	Faculty	2	1.5
Experience in casualty	<1 year	61	45.5
	1–5 years	51	38.1
	>5 years	22	16.4

ENT = Ear, nose, and throat.

Most clinicians were aware that suicide has been decriminalized in India, with 76.1% answering “yes.” A similar majority (84.3%) correctly recognized that the MHCA presumes individuals attempting suicide to be under severe stress, and 79.1% were aware of the government’s obligation to provide care and rehabilitation. However, a significant number (80.6%) believed that medical professionals are still required to report attempted suicides to the police or competent authorities, indicating some misunderstanding of legal responsibilities. Only 51.5% of respondents were aware that professionals are protected from civil or criminal liability upon reporting, whereas 27.6% denied this and 20.9% were uncertain.

Overall, clinicians demonstrated supportive attitudes toward decriminalization. About 55.2% agreed that decriminalization reduces stigma and discrimination, while 56.8% felt it would encourage help-seeking among individuals with mental health issues. After decriminalization, 70.9% reported they would be more likely to notify legal authorities about suicide attempts, and 88.8% stated they would be more likely to refer patients for psychiatric evaluation or counseling. The Likert-scale options were included to quantify the strength of clinicians’ agreement regarding the potential effects of suicide decriminalization on stigma, help-seeking, and clinical referral behaviors.

Awareness responses were comparable between clinicians with ≤1 year and >1 year of experience. No statistically significant differences were observed in knowledge regarding decriminalization status, presumption of severe stress, government responsibility for care, reporting obligations, or professional immunity. Overall, awareness patterns were similar across both experience groups.

Attitudinal responses did not differ significantly between experience groups. Perceptions regarding stigma reduction, encouragement of help-seeking, and likelihood of reporting or psychiatric referral were similarly distributed among clinicians with ≤1 year and >1 year of experience. Supportive attitudes toward decriminalization were consistent irrespective of clinical experience.

Discussion

The present study was conducted at a tertiary-care center in central India to assess non-psychiatric clinicians’ awareness and attitudes regarding the decriminalization of suicide as per the MHCA, 2017. This study holds particular relevance in India’s current legal and public-health landscape, as the MHCA represents a legal and ethical transition, reframing suicide as a mental health and social-care issue rather than a criminal act.⁹ As emphasized by Vadlamani and Gowda, while the act shifts the emphasis from punishment to psychosocial care, hospitals often continue to register such cases as medico-legal and inform the police, primarily to rule out abetment, homicide, or other criminal elements.¹⁰ Thus, although the individual who attempts suicide is no longer punishable, the involvement of law-enforcement may still occur depending on the circumstances. Clinicians are therefore expected to balance therapeutic confidentiality with legal responsibility, ensuring timely psychiatric referral and appropriate documentation while upholding the patient’s rights and dignity. Despite this, several studies have indicated variable clinician awareness and lingering confusion about medico-legal responsibilities.¹¹ From a clinical standpoint, physicians often face a practical dilemma: Whether to treat the patient solely as a medical emergency, to report the case as a medico-legal matter, or to refer the patient immediately to psychiatric services. This uncertainty stems from concerns about potential legal scrutiny, administrative repercussions, and ethical conflicts that may arise during routine clinical practice. Such ambiguity not only affects clinical decision-making but also highlights the urgent need for clear institutional guidelines and sensitization programs to help clinicians navigate the interface between legal obligations and patient care.

The Mental Health Review Boards (MHRBs) constituted under the MHCA 2017 further strengthen the rights- based framework by serving as oversight bodies for care, treatment, and rehabilitation of persons with mental illness, including those who attempt suicide.⁶ These boards are empowered to review complaints and ensure that management remains therapeutic rather than punitive. Awareness of the role and functioning of MHRBs among clinicians may enhance legally compliant, patient- centered care, thereby reinforcing the practical implementation of decriminalization.

Most respondents were young clinicians aged 26–30 years, with postgraduate residents constituting the majority. This demographic profile reflects the typical workforce structure of Indian tertiary-care hospitals, in which junior and postgraduate residents are primarily responsible for emergency and inpatient care. Given that many participants completed their medical training after the enactment of the MHCA 2017, it is plausible that they were exposed to its provisions during their academic curriculum.

The multidisciplinary representation across departments such as medicine, surgery, and emergency medicine enhances the practical relevance of the findings, as these specialties frequently manage suicide attempt cases in acute settings. A substantial proportion of participants were MBBS-qualified doctors and junior residents. Although this may limit the depth of formal training in mental health legislation, these clinicians often serve as first responders in casualty and emergency services. Their level of awareness is therefore particularly important, as early documentation, medico-legal interpretation, and referral decisions at this stage may influence the overall trajectory of care.

Awareness among participants was generally high: 76% correctly identified that suicide has been decriminalized in India, and 84% recognized that individuals who attempt suicide are presumed to be under severe stress and exempt from punishment (Table 2). These figures correspond to those of Malhotra et al.⁹ who reported 82% awareness of Section 115 provisions among Indian psychiatrists. However, this overall awareness was accompanied by important procedural misconceptions. A substantial proportion of clinicians (approximately 81%) believed that reporting suicide attempts to the police remains mandatory, and only about half were aware of the legal immunity available to medical practitioners.

Table 2.

Awareness Regarding Decriminalization of Suicide.

Awareness Item	Response	Frequency (n)	%
Is suicide now decriminalized in India?
	Yes	102	76.1
	No	25	18.7
	Maybe	7	5.2
MHCA presumes those attempting suicide have severe stress and shall not be punished
	Yes	113	84.3
	No	10	7.5
	Maybe	11	8.2
The government shall provide care, treatment, and rehabilitation
	Yes	106	79.1
	No	10	7.5
	Maybe	18	13.4
A medical professional must report attempted suicide to the competent authority
	Need to report	108	80.6
	Need not report	14	10.4
	Do not know	12	9.0
Professional immune from civil/criminal liability when reporting
	Yes	69	51.5
	No	37	27.6
	Maybe	28	20.9

MHCA = Mental Healthcare Act.

This partial understanding mirrors earlier observations among non-psychiatric clinicians, who have been shown to exhibit limited familiarity with the procedural aspects of the MHCA and continuing confusion regarding medico- legal reporting and documentation practices.^3,11 Such confusion may stem from the historical enforcement of Section 309 of the IPC, which criminalized attempted suicide, prescribing simple imprisonment or a fine for those who survived a suicide attempt. Although the provision was effectively decriminalized under the MHCA 2017 and later omitted in the BNS 2023, its legacy continues to influence hospital documentation and police reporting practices. In contrast, Section 307 IPC, which pertains to attempt to murder, remains in force and is often invoked by law-enforcement authorities when there is suspicion of abetment, coercion, or homicidal intent behind the act. This overlap in medico-legal interpretation often contributes to clinicians’ uncertainty about their reporting obligations and the boundaries of psychiatric confidentiality.

Clinicians in this study demonstrated positive attitudes toward decriminalization (Table 3). More than half agreed that removing criminal penalties may reduce stigma and discrimination against individuals who attempt suicide, and a similar proportion believed that it could encourage help-seeking for mental health concerns. These findings align with international evidence suggesting that legal reform and destigmatization are associated with greater willingness to access care.^12–14 Notably, a substantial majority reported that they would be more likely to refer patients for psychiatric evaluation following decriminalization, reflecting increased recognition of suicide attempt as a mental health emergency rather than a criminal act. However, a small proportion of respondents expressed neutrality, possibly indicating residual uncertainty regarding legal procedures or limited training in suicide risk assessment. Similar ambivalence has been reported among medical and nursing trainees in Indian settings, underscoring the importance of structured education and suicide prevention training programs.^15,16 Overall, these findings suggest a gradual shift from punitive perceptions toward a more empathetic, rights-based clinical approach.

Table 3.

Attitudes Toward Decriminalization of Suicide.

Attitude Statement	Strongly Disagree Percentage (%)	Disagree Percentage (%)	Neutral Percentage (%)	Agree Percentage (%)	Strongly Agree Percentage (%)
Decriminalization reduces stigma/discrimination	12.7	7.5	24.6	23.9	31.3
Decriminalization encourages help-seeking	11.9	10.4	20.9	28.4	28.4
More likely to report attempts post-decriminalization	6.7	1.5	20.9	32.1	38.8
More likely to refer to psychiatry post-decriminalization	4.5	0	6.7	29.1	59.7

Subgroup analysis (Tables 4 and 5) did not reveal statistically significant differences in awareness or attitudinal variables between clinicians with ≤1 year and >1 year of experience. Knowledge regarding decriminalization, presum- ption of severe stress, reporting obligations, and professional immunity was comparable across experience groups. Similarly, attitudes toward stigma reduction, help-seeking, and psychiatric referral did not differ significantly. The absence of experience-related variation suggests that medico-legal ambiguity and supportive therapeutic attitudes are likely reflective of broader institutional practices rather than differences attributable to duration of clinical exposure.

Table 4.

Association Between Clinical Experience and Awareness Variables (N = 134).

Awareness Variable	Response	≤1 Year n (%)	>1 Year n (%)	χ²	p Value
Suicide decriminalized in India	Yes	46 (75.4)	56 (76.7)	0.07	.96
	No	12 (19.7)	13 (17.8)
	Maybe	3 (4.9)	4 (5.5)
Presumed under severe stress	Yes	51 (83.6)	61 (83.6)	0.01	.99
	No	6 (9.8)	7 (9.6)
	Maybe	4 (6.6)	5 (6.8)
Professional immunity available	Yes	29 (47.5)	40 (54.8)	0.87	.65
	No	18 (29.5)	19 (26.0)
	Do not know	14 (23.0)	14 (19.2)
Reporting is mandatory under the law	Yes	49 (80.3)	59 (80.8)	0.02	.99
	No	7 (11.5)	7 (9.6)
	Do not know	5 (8.2)	7 (9.6)

Table 5.

Association Between Clinical Experience and Attitude Variables (N = 134).

Attitude Variable	Response Category	≤1 Year n (%)	>1 Year n (%)	χ²	P Value
Decriminalization reduces stigma	Negative	12 (19.7)	15 (20.5)	0.31	.86
	Neutral	16 (26.2)	17 (23.3)
	Positive	33 (54.1)	41 (56.2)
Encourages help-seeking	Negative	14 (23.0)	16 (21.9)	0.08	.96
	Neutral	12 (19.7)	16 (21.9)
	Positive	35 (57.4)	41 (56.2)
More likely to report post-decriminalization	Negative	5 (8.2)	6 (8.2)	0.12	.94
	Neutral	13 (21.3)	15 (20.5)
	Positive	43 (70.5)	52 (71.2)
More likely to refer to psychiatry	Negative	6 (9.8)	3 (4.1)	1.02	.60
	Neutral	5 (8.2)	4 (5.5)
	Positive	50 (82.0)	66 (90.4)

This study has certain limitations. The single-center, cross-sectional design and use of purposive sampling may restrict generalizability to other settings. The sample was not uniformly distributed across professional designations, and subgroup comparisons were limited. Additionally, the questionnaire focused primarily on legal awareness and attitudes. It did not assess clinicians’ ability to differentiate between various forms of self-harm or apply medico-legal provisions in simulated clinical scenarios.

Future multicenter studies employing stratified sampling and comparative analyses across specialties, including psychiatry, would provide broader insight into implementation patterns across healthcare systems. Further research should also evaluate the impact of structured training programs, continuing medical education modules, and institutional sensitization initiatives on clinicians’ understanding of medico- legal responsibilities under the MHCA 2017 and the BNS 2023.

At a systems level, policymakers and hospital administrators should prioritize the development of clear institutional protocols for documentation, police notification, and psychiatric referral in cases of suicide attempt. Strengthening these frameworks may help ensure that legislative reform is translated into consistent, rights-based, and therapeutic clinical practice.

Conclusion

This study provides preliminary evidence that non-psychiatric clinicians in tertiary- care settings demonstrate a reasonable level of awareness regarding the decriminalization of suicide attempt under the MHCA, 2017, and broadly endorse its principles of compassion and rehabilitation over punishment. However, persistent uncertainty surrounding medico-legal procedures, particularly regarding police intimation and professional immunity, suggests that awareness alone may be insufficient to ensure consistent implementation in practice.

Addressing this knowledge–practice gap requires structured training initiatives, incorporation of mental health law into undergraduate and postgraduate curricula, and targeted legal-literacy programs for frontline clinicians. Clear institutional protocols aligned with the MHCA 2017 and the BNS 2023 are equally essential to ensure that legislative reform translates into consistent, rights-based, and patient-centered care.

Supplemental Material

Supplemental material for this article is available online.

Footnotes

Acknowledgements

Nil.

Appropriate Permissions from the Concerned Authorities

Nil.

Data Sharing Statements

Deidentified individual participant data will not be made available.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

No part of this article was written or generated by a generative AI tool. The authors take full responsibility for the accuracy, integrity, and originality of the published article.

Ethical Approval

Institutional ethics committee and review board, MGM medical College and MY Hospital, Indore.

Ref. No. EC/MGM/Nov23/14.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed Consent/Assent

Informed consent was obtained from the patient.

PROSPERO/CTRI Details

Nil.

Prior Presentations

Nil.

Registration

Not applicable.

Trial registry name: Not applicable.

URL: Not applicable.

Registration number: Not applicable.

Simultaneous Submission to Another Journal or Resource

Nil.

Status of Your Study (for Study Protocol)

Completed.

Citation Diversity Statement

The authors have made a conscious effort to include references that reflect diversity in terms of geography, gender, and academic perspectives. The cited literature represents a balanced selection of global and Indian research, ensuring inclusivity and minimizing bias in scholarly representation.

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