Covert medication; the last option: A case for taking it out of the closet and using it selectively

Abstract

Covert medication is the practice of hiding medication in food or beverages so that it goes undetected. Tablets may be crushed or liquid forms of medication may be used for patients who are either not in a position to give consent or refuse consent because of lack of insight. It is commonly practised in two distinct settings. The first is typically in the western world, in old patients, mostly suffering from dementia, admitted in nursing homes. The second is typically in resource strapped developing countries, in patients with psychosis, mostly at home, when patients refuse medication. The latter, from all accounts available, occurs on a large scale, but has not been studied owing to its questionable ethical and legal status and it is not discussed in the open by professionals. This paper examines the pros and cons of covert medication and argues that it should be acknowledged and studied like other therapeutic practices.

CONCEPT AND DEFINITIONS

Covert medication is the practice of hiding medication in food or beverages so that it goes undetected.[1] Tablets may be crushed or liquid forms of medication may be used for patients who are either not in a position to give consent or refuse consent because of loss of insight.

Covert prescribing is the practice of supplying a prescription to a family member or a health care worker, knowing fully well that the medication is going to be used for an unwilling patient.

Terms ‘surreptitious medication’ or ‘surreptitious prescribing’ are some times used inter-changeably with covert medication/prescribing, but should ideally be reserved for situations where the intent is malafide.

PRACTICE OF COVERT MEDICATION

Practice of covert medication is by no means limited to speciality of psychiatry. It is not an uncommon situation in paediatrics and in geriatric medicine. In the latter situation, an example would be the use of antihypertensives or anti-diabetic medications given to un co-operative and forgetful patients. However, when used in psychiatry, the practice raises some fundamental ethical and legal questions, for reasons, which will be discussed here.

The practice of covert medication for psychiatric patients occurs primarily in two settings, so fundamentally different from each other that it is conceptually in-correct to consider them together for purpose of any meaningful discussion:

1. First, typically, is the setting of long term care nursing homes for patients of dementia, where medication is given covertly to control behavioural symptoms associated with dementia, in patients who refuse to take medication on their own. A similar situation may arise in institutionalised patients of mental sub normality who have disruptive behavioural symptoms.

2. The second distinct setting where covert medication is used commonly is in the context of patients of schizophrenia or bipolar disorder who refuse to take medication, because they think they do not need it.

The above two settings differ from each other in following important ways:

1. Patients in category A, because of the effects of the illness ie dementia (or mental subnormality), lack capacity to understand about pros and cons of non-treatment and hence are not in a position to give legal consent. Most of the times, this absence of capacity is long lasting.

   Patients in category B, on the other hand, either have legal capacity to give a valid consent and are refusing this consent, or temporarily they may lack capacity.

2. The setting A is typical of developed countries where specialised institutions for long term care of dementia and mental sub- normality are available, while setting B is typical of developing countries, most of which do not have even basic mental health services for involuntary treatment of severe mental illnesses like schizophrenia and bipolar disorder, within easy reach of majority of population.

3. The setting A is an institutional setting where carers who may have to resort to covert medication are mental health professionals while setting B is of a patient living with the family and the person who has to be medicated covertly is a family member.

4. Since, patients in setting A obviously lack capacity, covert medication to them is, ethically and legally, a less contentious and more defensible issue than covert medication to patients in category B, who have capacity and refuse consent.

Treatment, without an informed consent to patients in category A is often compared to other medically ill patients who are unable to give consent e.g patients who are unconscious or patients of febrile delirium in a medical ward or patients who are confused after a head injury in a neuro-surgery ward. Treatment of such patients, without consent is allowed under common law.

Professional societies in some countries have prescribed guidelines for covert medication, but these pertain only to setting A. The Royal College of Psychiatrists (2004),[2] thus, has a “College Statement on Covert Administration of medicines. “However this statement allows covert medication only in severely incapacitated patients like those suffering from advanced dementia, delirium and severe mental retardation with behavioural symptoms.

Similarly, the UK Central Council for Nursing Midwifery and Health Visiting (UKCC)[3] has, for example, issued guidance to nurses stating that “disguising medication in food or drink can be justified in the best interests of patients who actively refuse medication but who lack the capacity to refuse treatment”. Covert medication “may be considered to prevent a patient from missing out on essential treatment where the patient is incapable of informed consent”. The guidelines emphasise that such action should be taken only as a contingency measure in an emergency, and after discussion with the clinical team and the patient's carers.

No guideline anywhere, covers covert medication, at home for patients of mania or schizophrenia (who have capacity), as practiced in India and other developing countries. This practice is clearly illegal in most of the countries, amounting to battery and is certainly deemed unethical by most professional societies. Thus a nurse was suspended by the hospital administration in UK for giving haloperidol mixed in tea, on the orders of a consultant, to an elderly excited patient who actually improved and when he was told about it the next day, he thanked the nurse.[4] Similarly, an emergency physician in California was officially reprimanded and warned for injecting haloperidol into a sealed orange juice can which was given to a highly excited patient, who was violent and refused medication. The official version was that he should have been detained under relevant sections of mental health act and given an injection forcibly without any subterfuge.[5]

According to Latha (2010), although covert treatment is not well described in the psychiatric literature, it is, nevertheless, more common than one might imagine. In a study of 50 elderly patients, 79 % received their medication surreptitiously. For patients with dementia this figure was 94 %. In a survey of 21 psychiatrists, 38% admitted to having participated in surreptitious prescribing.[6] This figure is likely to underestimate the true practice, because many respondents felt uncomfortable on direct questioning about admitting to deceiving their patients.

Fear of professional censure results in minimal discussion or recording in patients’ case notes, which serves to compound the atmosphere of secrecy and suspicion.[4,7]

Studies from developing countries, where covert medication is typically used by families for patients of psychosis are even fewer and all of these are relatively recent.

In the only clinical study of Indian patients given medication covertly,[8] the authors studied 67 patients of schizophrenia who were non-compliant. The medication was given covertly by the family but on the advice of a psychiatrist. 91% of patients showed significant clinical improvement. 15% showed adverse effects in the form of drowsiness and extra-pyramidal symptoms. During the course of the treatment, 26% became aware of their being medicated covertly but by then had regained sufficient insight to continue the treatment.18% of patients when came to know about covert medication showed anger and resentment.

Since the practice of covert prescribing is questionable both ethically and legally, even the large number of psychiatrists who privately admit that they have no qualms using it, do not enter it in case notes of patients. Scientific programmes of psychiatric conferences do not include discussions on covert medication and ethics committees of psychiatric societies have no guide-lines about it, as if it does not exist. There is a conspiracy of eerie silence.[9] compares it to a prude's attitude towards sex. Everybody does it and whispers about it privately, but nobody is willing to discuss it publicly. Even in academic discussions about non-compliance, covert medication is the proverbial elephant in the room, according to him.

In Singh's view (2008),[9] whenever a strongly felt need in medicine is prohibited, it leads to secretiveness and practised on the sly. Qualified persons donot own it up and it does not get reported in standard peer reviewed literature because of fear of professional censure. Singh compares the situation about covert medication today to that of abortion before it got legallised.

Two larger contextual issues are important in order to understand the practice of covert medication in developing countries:

1. In a developed Western country, if a patient with a psychotic illness is disruptive and refuses treatment, community mental health teams are legally empowered with community treatment orders or equivalent mechanisms are available. In India, there is no provision of a community treatment order, either in the Mental Health Act (1987),[10] or in the draft of the new Mental Health Care Act (2010)[11] and even if it were there, there are no Community Mental Health Teams and families are left to cope with their own devices.

   On paper, a family could approach the police to take the patient to a judicial magistrate who could after a prescribed procedure, pass a reception order for admission of the patient to a psychiatric hospital. This mechanism is so cumbersome and the nearest psychiatric hospital often so far away, that it is no surprise that this channel is hardly ever used. Police is also not approached because of its un-friendly image, its lack of sensitivity to mental health issues and the associated social stigma. This context of optionless-ness should not be lost sight of in a discussion on covert medication as practised in developing countries.

2. The second major contextual issue is the cultural role of the family vis-a-vis the individual in Eastern societies. The great premium put on individual autonomy in the Western societies is at wide variance with the pervasive concept of familial inter dependence in the East, where collective goals and rights of family are culturally considered at par with individual rights.

Khurshid in 2006, in a short paper titled, “A Tale of Two Cities” published in the American Journal of Psychiatry, laid bare, the stark dilemma faced by an Indian Psychiatrist in USA who had earlier worked in India.[12] He describes the case of a young Indian boy with systemetised paranoid delusions, who refuses medication even after several rounds of counselling. The desparate mother then requests the psychiatrist to prescribe something, that she could mix in his food. The author recalls similar case of a young girl whom he had treated years back in Delhi with risperidone drops which the family had added to the food. The girl had improved, regained insight, took medication on her own and went back to her studies and eventually became a school teacher. The author does not remember having had any qualms about not having an informed consent, making patient well, being the only goal. However he refuses to prescribe any medication for the young boy in USA. While talking about his changed mindset, he wonders, if by putting too high a premium on personal autonomy of his young patient and by letting him deteriorate, he had taken some steps actually backwards.

Whether the Western societies have stretched the notion of individual autonomy in persons with severe mental illness so far that it is paradoxically violating their right to timely treatment has been highlighted by Tim Salmon in 2006,[13] an author and father of a patient of schizophrenia in a poignant article “My Son Has Schizophrenia, Why Cant’ the System Cope?” He wonders what is the merit of the argument “You are a free agent, after all, free to act against your best interests until you are found roaring naked in the street at Mornington Crescent at 3am or shouting abuse at a blank wall in Stoke Newington at lunchtime… or worse. Then you are detained and sectioned. Can anyone explain to me wherein lies the value of the freedom to refuse medication, go round the bend and end up detained in hospital?”

What the proponents of Covert Medication Say:

1. In a resource strapped country where the nearest admission facility is very far and community mental health services non existent, this is often the only option to treat an insight less, unwilling patient who is often disruptive

2. Leaving the psychosis un-treated or delaying the treatment leads to harmful sequelae like prolonged individual and family suffering and poorer outcomes[14,15]

3. Covert medication can actually decrease the chances of a forced admissions

4. Covert medication is a less cruel alternative to physical restraint and isolation[16]

5. With-holding medication may infact amount to denying patient's right to prompt treatment.[17]

The arguments against covert medication:

1. Insight sometimes comes to a patient when he reallises that there is a connection between non-compliance and relapse. Covert medication interferes in that realisation hence with insight[18]

2. Since patient believes that he is not on any medication, he might take some other medication or a substance of abuse, which may have harmful interaction with the the drug which is being covertly given. This may also expose the psychiatrist and the hospital to liability[17]

3. If the patient discovers that he is being given medication miixed in food, he will develop distrust of the family and his paranoid ideas may get re-inforced. Such distrust is often very long lasting and actually interferes in treatment in the longer run in some cases

4. medication if encouraged will actually lead to less discussion about and less research into why patients are non-compliant in the first place[17]

5. the garb of controlling aggression, covert medication may be misused by a family member to subdue a relative for personal benefit or convenience

6. It violates the priciple of personal autonomy and amounts to battery

7. It can be used to justify shoddy clinical practice.[19]

Recent developments in medical ethics and focus on human rights of persons with mental illness with increasing importance accorded to personal autonomy of patients, has brought some attention of stake-holders to the practice of covert medication.

It has also revived interest and a willingness to discuss the practice on the part of psychiatrists, particularly those, who are either working in India or are Indians working abroad. The highly controversial topic has been intensely debated recently in the closed e-groups frequented by mental health professionals in India. A vast majority of psychiatrists are of the view that if a known psychiatric patient, often carrying a diagnosis of schizophrenia or bipolar disorder, relapses at home and refuses treatment, in the absence of any equivalent of a community mental health team of the West, there is no option for the family, other than covertly mixing in patient's food, an antipsychotic medication, liquid forms of which are conveniently available. These psychiatrist also see nothing wrong in prescribing the required medication to a family member till the patient improves well enough to come himself for treatment. In this, psychiatrists are strongly supported by carers and relatives of the patients.

The issue becomes even more contentious when some psychiatrists do not see anything wrong in providing a prescription for an antipsychotic medication for a patient, they have never set their eyes upon and who has refused to come for treatment. The history given by a well meaning family member is considered sufficient to formulate a tentative diagnosis and a treatment of sorts is initiated, with the hope that sooner or later the patient will improve enough to gain some degree of insight and will join the treatment process. Most of these psychiatrists have success stories to tell, of having helped out distraught families and of rapid turn -around in behaviour of highly disturbed psychotic patients, which apparently validates the practice.

The opposite school of thought among the mental health professionals criticizes this practice as being too paternalistic and an assault on personal autonomy of patients, only to be countered by the argument that a young man who believes that all his actions and thoughts are remotely controlled by CIA through special gadgets has hardly any personal autonomy left, and any treatment, howsoever given, will in fact restore it. The caregivers, according to this argument actually help the patient get into a mental condition to decide for himself.

To get a real feel of the thinking process which alternately tends to drive or derail the logic behind the process, I reproduce below some of the illustrative postings on one of the popular e-groups (Indian_Psychiatry@yahoogroups.com) in India, which has 468 psychiatrists as members:

An interesting case vignette highlighting the dilemmas

Dear All,

I guess the idea of trying to main-stream something which is being done out of necessity anyway, has some merit. I have not participated in a ‘covert medication programme’ except on a couple of occasions in as many decades, which was in case of known old (not new) patients. However I do-not feel ‘uppity’ about not having resorted to it more often, because I know that it is often necessary for the option starved Indian middle class families who almost never call police to take away an excited family member (I am talking as if the police are waiting to come and as if a magistrate is waiting to sign a reception order!)

Many years back, I saw a young engineering student from Chandigarh who was brought by his father, an ex-army officer. I prescribed some anti-psychotics for his aggressive- paranoid behaviour. A few days later, the distraught father rang me up saying that the patient had out-right refused to take any medicine (“Shove it yourself” was the exact phrase narrated). He wanted to know if he could mix the medicines in food. I strongly dissuaded him, citing all the reasons that I knew against such a practice and advised him to slowly ‘nurture’ a consent.

I had forgotten all about them till four years later when father came to my office (‘for a courtesy call’, he told the receptionist out-side) and presented me a box of sweets (it was ‘lohri’ time). He happily informed me that the boy was now an engineer, had a good job, was married, had a two years old daughter and now a son, hence the sweets (daughters in most sections of Punjabi society do not merit either ‘lohri’ or sweets).

And, almost as an aside, told me that my medicine had done a miracle and that the boy was still receiving it unknowingly, laced into his breakfast for all of four years. Whenever the father forgot to put it in food, after a few days, the boy would ‘look strange and suspicious’. Incidentally, buying medicines without a prescription has never been a problem in Punjab. After the boy got married the father took his wife into confidence who improvised things and became an expert on making an omelette with onions, tomatoes and a dash of haloperidol. Since she found her husband quite nice and caring while on just a tablet a day, she did not object.

After listening to him, I sat him down and lectured him about the side effects of long term haloperidol, about his having been too paternalistic (he kept saying, ‘but I am the father’) about having smothered insight and having cheated not just the son but the daughter-in-law too (and he kept saying ‘but they are so happy’)

In the end, I told him that it was upto him to carry on doing what he was doing but legally and ethically it was wrong.

I presume that the father went home and told the boy about the omelettes and persuaded him to take the medicine on his own, since it had done such a whale of good to him. The boy looked hurt, insisted that he felt fine and switched over to boiled eggs.

I do know that a month later, the wife had left the patient and gone to her parents along with the children because she could not stand the accusation that the newly born son was not only not his, but his father's since the wife and him were together in so many conspiracies against him. He stopped going for work because ‘people followed him on motor-cycles’.

After six months or so he was admitted in a government facility in Chandigarh, treated and restored to father but the wife had meanwhile filed for divorce.

The point here is that, for all its ethical defects (an over-bearing and lying father, crooked chemists, secret conspiracies about how to medicate the patient etc), the system , in its own way had managed a difficult situation against heavy odds till a smart aleck like me , had come along with fancy notions, to torpedo a stable, settled family. The point also is that had I been empowered with some guide-lines and some legal sanction, I could have passed these on to the father who would then probably have handled things much better for all concerned.

We also know that for decades to come the only community mental health teams that we are going to have are the families and as has been suggested here, we should look for ways to empower them and allot them a role in a due process of OPD medication (without consent).

And we cannot take even the families for granted for ever. They may atomize and get lost in the rapidly rising dust of globalization sooner than we think.

Cheers.

AK

A real life, thought provoking account by a psychiatrist who has also been a carer

Dear all,

I have been following this debate with interest. I sometimes feel that some members want to be ‘politically / legally correct’ at the expense of ignoring the plea of the suffering families, not withstanding the fact that we are talking about a population of people who have “no touch with reality”, to use a psychiatric jargon.

I wonder how many of you have had the occasion / experience of treating your dear kith and kin with this disease, Schizophrenia, at close quarters. How many have actually lived and looked after them, playing a dual role of the doctor (though not directly, as they, I presume, would be under the care of your colleague) and a care giver at the same time. I have been there and done it all, both to my only sister and also to my wife's only brother. They lived with us off and on for nearly 20 years. (They are both not alive now.)

I can tell you one thing, it is not easy and all our theories and sage advice fly out of the window, in moments of crisis, which are plenty and unpredictable. There were occasions when we needed to resort to “covert” medication and we had no qualms about it. Our desire was to see them get better and not get entangled with the ‘correctness’ of our action. We had responsibilities to our elders in the family and also to our young growing children and more importantly to do anything at all to see that they improve and suffer less. I can proudly acknowledge the immense support from my wife in this, who herself is a psychiatrist.

At certain times in our life we need to sit back and look at things dispassionately, and ask ourselves as to what is our role as doctors? Is it to cure/ heal / reduce distress and if not possible at least reduce suffering to the person as well as their family members (who, in this case, could be elderly / infirm parents, spouses and children all living together in the same space, day after day). As we are aware any one with severe with psychiatric illness does not suffer alone, the entire family partakes in the suffering in one way or the other.

The improvement in their symptoms and their level of functioning, the relief and satisfaction in the families, validates my actions and convinces me that its worth helping them in any way I can. If we need to get a legal sanction for it so be it. I am sure the legal pundits amongst us will strive to achieve that. I will continue to help such families and the clients (who are psychotic and lacking total insight, after examining them, at least once) wherever possible, with this type of treatment with the full knowledge of what I am doing and try and help them to accept treatment at the earliest possible occasion.

Warmly,

SK

Dividing the cases into those seen in the past and those ‘face-less’ patients never seen

Dear All,

I agree with you that covert medication is a common practice in India. I also think that it is necessary and in long term, is in interest of the patient, in majority of the cases. But I do think that it does not have to be as common as it is. From this perspective there are two distinct types of patients: 1. Those that one has never seen. 2. Those that one has seen, assessed and treated and who, during subsequent course of the illness stop/refuse medication and relapse. It is much easier to defend the practice for the second category, both on purely medical and ethical grounds, than it is for the first one. Most of us have talked of success stories and good intentions because these are far commoner than misuse of the practice. But bad stories are there too. I have seen, as I am sure most of you have, husbands feeding haloperidol to wives for years for having had a manic episode once, because he has learned that it keeps her from getting too assertive about his drinking. Happens the other way too. Wives mixing disulfiram in husband's morning ‘lassi’ is even commoner at least in my part of the country. Covert medication as a tool of social engineering and gender subjugation would be a fascinating area to study in Indian setting! As far as guidelines are concerned, Indian Psychiatric Society cannot do it, because unlike the Royal College of Psychiatrists, it is not a regulatory body. In India the only regulatory body for doctors is Medical Council of India. I do not think that they would or even should do it. That leaves us with the only option of weaving it into the under construction amendments to the Mental Health Act. If we do it, it will have to be allowed through the families route because we do not have outreach teams (I do not think that we should even think of banning it) How much would that change things, how much harassment that might cause are the questions to be addressed. Like CA said if something aint too broken, should n’t it be left alone? I do not really know for sure.

AK

The views about covert medication actually depend upon who is the patient and who, the carer

Dear Friends,

I hope you do not mind if I take the liberty of asking the following questions?

Presuming they were unwell, would you administer medication covertly to your…

1. ...parents without their consent?

2. ...adult children without their consent?

3. ...spouse without consent?

4. ...friend/colleague without consent?

Let me know ask the same questions the other way around....

Presuming you are unwell, would you want medication administered covertly to you by your...

1. ...parents without your consent?

2. ...adult children without your consent?

3. ...spouse without your consent?

4. ...friend/colleague without your consent?

Now the last set of questions...

Presuming your son/daughter is unwell, would you want medication administered covertly to them by their...

1. ...parent in laws without their consent?

2. ...spouse without their consent?

3. ...friend/colleague without their consent?

I know my answers firmly, though these answers have certainly changed over the last few years. I always thought that law made matters certain by introducing black/white or right/wrong dichotomy whilst ethics dealt with matters on a spectrum of shades. May be all stakeholders (especially patients/carers/general public and also professionals) need to debate whether we deal with covert administration of medication by using ethical principles (with necessary variation in practice that follows) or legislate whether it is right or wrong.

NA

Pointing out lack of evidence base and need for field studies for covert medication

Dear Sir,

It is my understanding that lack of community / home based resources (CMHT, Home treatment) , national mental health work force development plans, needs assessments etc. are making us consider other alternatives including covert administration as a means to address the gaps in MH service delivery in Public and Private sector. Just adding my tuppence worth of my views on this matter. Covert administration may be common place for a variety of reasons, but as Dr. S points out, it remains an unfathomed territory. For every example of success with covert administration, there can possibly be equally compelling untold stories of abuse /harm/ death and adverse reactions which is not captured in our mainstream psychiatric work /research or media too. And this can be a potential worry.

With all the best will, training and supervision, we all may have witnessed numerous drug administration errors committed by the trained workforce in In-patient units. (Some of the errors in ICU, have produced interesting and instantaneous results). Are the fa mily members willing to take the risk of dealing with the non-intentional overdoses, dystonic reactions, toxic sedation and any other potential complication as a result of their actions? Are the families ready to deal with the blame that may follow an untoward incident and what other spin offs can evolve Family - Doctor relationships/ transgressions etc. In the event of abuse in the hands of a tyrant significant other, a careless exercise of authorizing this process, puts the practitioner in question, not having considered the risk in the first place.

Clearly this can be empowering the family member/s caring for the ill person. Intelligence, Carers’ burden, negative emotional states, relational dynamics, sensitivity, tolerance and several other issues can cloud and or influence the practice and outcome of covert administration. Is there an expectation on part of the psychiatrist to prescribe safely carrying out this extended risk assessment covering all aspects and coming out with a customised and individualised care plan. Also do we have the resources needed for raising the awareness to ensure the safety of such practice by educating the family members. To an angered and stressed carer C A can come across as a difficult option to chose, an authoritative carer is likely to use it with punitive rigour and then there will be some unavoidable guilt that may fall upon the families who avoid this responsibility.

I suppose one of us can take the initiative and advocate the needs to scope out and carry out an impact assessment of this option to the DHFW/SJ to get funding for this specific piece of work. In the process, it can help us all to see if CA is needed in the first place and what other options we can mobilise too. Simply having this provision (CA) in mental health act covered without any of these like: evidence base, a national template, some working guidelines, safeguards, implementation plan and other governance structures can be setting wide variations in practice, abuse and feed the hungry media. Thanks.

JpR

An online survey on the same e-group found that 75% of responders admitted to covert prescribing while 88% felt that changes in the Mental Health Act are necessary to legitimise the practice. However the small number of responders (24) made meaningful conclusions difficult.

CAPACITY AND ABILITY TO GIVE INFORMED CONSENT

1. A patient who has been diagnosed to be suffering from carcinoma prostrate is given information about the overall prognosis of the illness, various treatment options available and detailed pros and cons of each option and also pros and cons of non treatment. After having assimilated this information, the patient lets the doctor know his choice of option. A patient may, knowing fully well that non-treatment may lead to an earlier death, may still opt for no treatment for reason of a better quality of life, considering the side effects of drugs and procedures or for any other reasons, which may or may not be comprehensible to the doctor or the family. No body thinks of forcing a treatment on him although most of those around him think the decision to be ‘wrong’, because his personal autonomy is supreme from an ethical point of view.

2. Comparison is sometimes made of such a patient who is suffering from schizophrenia and who refuses treatment, with the argument that like the patient with carcinoma, this patient should be allowed to live with schizophrenia if that is his wish.

There are two moot differences between the two examples:

1. The patient with carcinoma has a full knowledge that he has a serious illness and still makes an informed decision to take no treatment.

   • a)
     The patient with schizophrenia if, he has full knowledge and acceptance that he has schizophrenia and does not want treatment would be said to have made an informed decision which should be accepted by everybody
   • b)
     But that is often not the case and patient's decision to take no treatment is based on the wrong premise that he actually has no disease and that the whole ‘facade’ is a web of lies by people inimical to him; which clearly means that the person is not in a position to take an informed decision because of a loss of insight into presence of illness, which loss of insight is a product of the nature of the illness. Since, he cannot take an informed decision, and if no body else takes a decision on his behalf to treat him, his right of access to care will actually be violated by non-treatment.

2. Even if the patient has insight as in 1(a) above, but if, as a result of his illness, he is disruptive and violent and encroaches upon human rights of those around him, his own rights would have to be curtailed for the minimum possible time in the least restrictive manner and this may include treatment.

ADVANCE DIRECTIVES

The draft of the new Mental Health Care Act has a provision for writing of legally binding advanced directives by patients during the phases of normalcy regarding the manner in which they would like to be treated or not treated at all in the event of a future mental illness. Advanced directives can also be written by people who have never had a mental illness so far. If a patient, who is recovered does not want to be covertly treated in the event of a future relapse, he can write this and nominate a person who can enforce it if required. Advanced directives, however are being introduced for the first time in the country and it is not clear yet to what extent these will be used. Potential of their misuse by a relative who has a vested interest in patient's non treatment is a also a distinct possibility which cannot be easily lost sight of.

COVERT TREATMENT AND RIGHT TO INFOMATION ACT

Under the right to infomation act, a recovered patient who has been in the past treated in a public hospital with covert methods of treatment, has a right to details of such a treatment. However, the catch lies in the fact, that the details may not have been deliberately recorded in patients case file, since the legality of procedure is not clear.

SECTION 89 OF INDIAN PENAL CODE

“Nothing which is done in good faith for the benefit of a person under twelve years of age, or of unsound mind, by or by consent, either express or implied, of the guardian or other person having lawful charge of that person, is an offence by reason of any harm which it may cause, or be intended by the doer to cause or be known by the doer to be likely to cause to that person provided- Firstly: That this exception shall not extend to the intentional causing of death, or to the attempting to cause death; Secondly: That this exception shall not extend to the doing of anything which the person doing it knows to be likely to cause death, for any purpose other than the preventing of death or grievous hurt, or the curing of any grievous disease or infirmity; Thirdly: That this exception shall not extend to the voluntary causing of grievous hurt, or to the attempting to cause grievous hurt, unless it be for the purpose of preventing death of grievous hurt, or the curing of any grievous disease of infirmity; Fourthly: That this exception shall not extend to the abetment of any offence, to the committing of which offence it would not extend.”

It is curious that this blanket provision providing immunity to any act ‘done in good faith and for benefit of child or insane person, by or by consent of guardian has not attracted the attention of rights activist so far for being an extreme example of paternalism easily liable to misuse. Although “Unsoundness of mind” is not defined, the provision, as it exists seems to convey that covert medication is not a legal offence, since it is done in good faith and with guardians consent.

MENTAL HEALTH ACT

One view holds that any future change in Mental Health Act should try to mainstream covert medication, keeping in mind all aspects of absent community mental health outreach services, highly disruptive unwilling patients and the harms of untreated psychosis to the individual and the society, till the time the country has resources like community mental health teams and legislative provisions like community mental health orders.

PRACTICE GUIDELINES

The Indian Psychiatric Society should accept the fact that because of ground realities, covert medication is used fairly commonly and should lay down the situations where it can be used and should prescribe safe guards, when it has to be used. Owning up the practice, discussing it openly in academic sessions, publishing research about the practice and regulating the practice is the only way to get out of the current atmosphere of denial and shared silence. This would also curb its misuse.

CONCLUSIONS

1. Covert treatment is widely used and rarely acknowledged. It probably needs to be used a little less commonly, as a last resort and under guidelines which need to be prescribed. It certainly needs to be discussed more openly, so that credible research can be done

2. Till community out-reach teams are in place and community treatment orders, a part of mental health legislation, covert medication by the families should be main-streamed into the Mental Health Act, under specific circumstances

3. The clinical situations in which it can be used in decreasing order of justification are:

   • i)
     Patients of dementia or severe mental sub normality who have no capacity
   • ii)
     Patients of Schizophrenia, Bipolar disorder, Psychotic Depression and other psychotic conditions, who have been examined in the past and who have now relapsed at home and are refusing to see a psychiatrist or to take medication and who are at risk of harm to self or others
   • iii)
     Patients of category ii) above but those who are at no risk of harm to self or others
   • iv)
     Patients of suspected psychosis who have never been examined and diagnosed and who refuse to come and see a psychiatrist.

CONFLICT OF INTEREST

The author is a member of Mental Health Policy Group constituted by Ministry of Health and Familiy Welfare, Government of India and Chair-person of “Task-Force On Mental Health Legislation” of the Indian Psychiatric Society. However, the views expressed in the article are personal.