Covert medication – Multiple situations, varied options

Abstract

Mental health interventions in low and middle income countries, with limited resources of human and other resources, requires that they be viewed from multiple viewpoints. This applies to the issue of covert medication, which on the face should not be practiced at all, in an ideal care situation. In India, it would be better to consider the use of covert medication, in differing situations and with the varying levels of involvement of patients and their families in a planned manner and with an open approach. Such an approach could meet the care needs of patients as well as protect the rights of the patients.

There are two aspects to the issue of covert medication, namely, (i) necessity in the Indian condition and (ii) the guidelines for the use of covert medication.

The lead paper and the responses of the commentators address the first issue well. I would like to add only one additional point often missed by the advocates of absolute legal capacity of the persons with mental disorders. There are a very small percentage of persons with mental disorders who, as part of their illness, temporarily are not able to exercise their legal right. It is for this reason that there are mental health legislations in a number of countries to both address the situation and protect the rights of the involved person. The use of covert medication is not just because of the lack of adequate care facilities, though this aspect adds to the need, in addition to that mentioned above.

I would like to focus on the guidelines for use of covert medication.

During the last four decades of my work as a psychiatrist, the request for covert medication has come in the following situations.

Level 1: A colleague/neighbor reports that an individual is behaving abnormally and disturbing others and requests for medication to “control” the behavior of his colleague/neighbor, without the patient coming to see the psychiatrist. A definite no situation.

Level 2: A family member reports that an individual is behaving abnormally/suspicious of family members/disturbing other family members, or drinking excessively and requests for medication to “control” the behavior of his family member without the patient coming to see the psychiatrist. A definite no situation.

Level 3: A family member of a former patient of the psychiatrist (not seen for over 6 months) reports that there is a relapse of the illness with stopping of the medication. Patient is unwilling to come to see the psychiatrist. The request is for medication that can be given to the patient to control the behavior of the patient so that he can be brought for assessment and care. The relative has not been seen by the psychiatrist during the earlier episode of illness, but the relative brings the earlier treatment records. The psychiatrist has no earlier contact with the relative and no way of knowing the relationship of the informant and his earlier patient. This is a no situation for the covert medication, but the psychiatrist could request the relative to bring someone who has been part of the earlier treatment contact.

If such a relative provides reliable information, covert medication could be considered for the shortest possible period of time.

Level 4: Husband/wife/father/mother/brother/sister/or other family member of a former patient of the psychiatrist (not seen for over 6 months) reports that there is a relapse of the illness with stopping of the medication. Patient is unwilling to come to see the psychiatrist. The request is for medication that can be given to the patient to control the behavior of the patient so that he can be brought for assessment and care. The relative has been seen by the psychiatrist during the earlier episode of illness, has been part of the treatment process, and the psychiatrist knows the relative as part of the earlier treatment records. This is a situation where the psychiatrist could consider the request for a few days, and request that the patient be brought for assessment to the outpatient or admitted for assessment, where the decision for continuing the treatment can be made.

Level 5: Patient with acute symptoms of disturbance thought/mood/awareness of the surroundings (e.g. paranoid schizophrenia, severe mania, severe depression, delirium, etc.) is examined in the clinic and advised medicines for care. Patient is unwilling to take medicines, as part of the psychopathology. It is not possible to admit the patient for observation and care. In this situation, it is good to get a second opinion and attempt by another colleague to persuade the patient to take the medication. In this situation, the psychiatrist could consider covert medication by taking a responsible family member into confidence and use covert medication for a short period of time to control the disturbance of thought/mood/awareness of the surroundings, which is leading to impaired judgment of the patient. The duration should be limited, and as soon as the patient accepts the need for treatment, covert medication should be changed to treatment with willing cooperation of the patient.

Level 6: Patient with acute symptoms of disturbance thought/mood/awareness of the surroundings (e.g. paranoid schizophrenia, severe mania, severe depression, delirium, etc.) is examined in the clinic and advised medicines for care. Patient is unwilling to take medicines, as part of the psychopathology. He/she is admitted for observation and care using the provisions of the Mental Health Act. In this situation, the psychiatrist can use covert medication by taking a responsible family member into confidence to control the disturbance of thought/mood/awareness of the surroundings, which is leading to impaired judgment of the patient. The duration should be limited, and as soon as the patient accepts the need for treatment, covert medication should be changed to treatment with willing cooperation of the patient.

Level 7: Psychiatrist is caring for patient with recurrent psychiatric illness (e.g. paranoid schizophrenia, recurrent mania, recurrent depression, alcoholic withdrawal states, psychosis with epilepsy, etc.). In the past episodes of “psychoses,” the patient has reached symptom levels with disturbance of thought/mood/awareness of the surroundings that impairs his judgment about medication. Psychiatrist has worked with the patient in the past and recognizes the need for treatment during these acute episodes for “forced” medication to control the episodes. Knowing the likelihood of the recurrence of episodes and the difficulties of medication, psychiatrist discusses with the patient during the phase of “normalcy” to give written advanced consent for short periods of covert medication. On the basis of the written advance consent, the treating psychiatrist uses covert medication for a short period of time.

Of the above seven situations, I would not use covert medication in situations at levels 1 and 2. From levels 3-7, there will be gradations of steps taken to decrease the decision taking to be not in the interest of the ill person.

My suggestion to professional colleagues is to think of developing a sequential approach (along the lines outlined above) to a decision of covert medication and inclusion of safety measures, totally aimed toward protecting the health and rights of the ill person.