Covert Medication- The Worst Kept Secret of India Psychiatry
Of Hard Choices and Omelettes laced with Anti-psychotic medication.
‘Covert medication’ is the practice of mixing medicines in food or beverages by the family because the patient refuses to take it, since he does not believe he is ill to start with. The person is usually suffering from schizophrenia, or bipolar disorder. Tablets are crushed, or liquid forms used by distraught and optionless family members, in the absence of adequate mental health resources in the country. It has questionable legality, hence not talked about much and there are very few clinical studies on its usefulness versus harms. For the same reason, no case notes in patients’ file ever mention covert medication. It is Indian Psychiatry’s worst kept secret, in fact of all low- and middle-income countries. It is not that an adult mentally ill person cannot be treated against his wishes but it can be done only after he is admitted to a psychiatric hospital under the Mental Health Care Act. This is difficult for most families for reasons of limited number of psychiatric beds available at affordable cost. Moreover, the Act permits involuntary admission only if the person is a danger to himself or to others even he or she is otherwise floridly psychotic. Home to 15% of mentally ill persons in the world India has an abysmally low number of psychiatric beds. Admissions to psychiatric hospital is also highly stigmatizing. Most psychiatrists have written prescriptions for families knowing well these are going to be used covertly. A large number of taste- less liquid preparations are conveniently available. Families swear that covert medication improves the patient to a point where he is willing to take treatment and this reduces the need for a forced admission, and that covert medication is less cruel than physical restraint. All of this makes some sense. However, if side effects occur when patient is out and alone, it can cause serious problems since neither the patient, nor the new doctor would know that he is on medication. Right activists also point towards the fact that personal autonomy is an in-alienable right and cannot be breached for convenience of families. This is met with the argument that with-holding medication may in fact amount to denying patient’s right to prompt treatment and a life with dignity. Many years back, I saw a young engineering student brought by his father, an ex-army officer. I prescribed some anti-psychotics for his aggressive- paranoid behaviour. A few days later, the father rang up to say the patient had refused to take any medicine (“Shove it yourself,” it seems, he said). He wanted to know if he could mix the medicines in food. I dissuaded him, citing the reasons I knew against it and advised him to try to patiently convince his son and nurture consent. One valid reason against the practice is that if patient finds out, he can become even more paranoid and suspect family of poisoning him ‘since he has no illness needing a medicine’. I had forgotten all about the father and the son, till four years later when the former came to my clinic (‘for a courtesy call’, he told the receptionist out-side) and presented me a box of sweets (it was ‘Lohri’ time). He informed me that his son was now an engineer, had a good job, was married, had a two year old daughter and now a son, hence the sweets (daughters do not merit either ‘lohri’ or distribution of sweets). And, almost as an aside, he told me that the medicine I prescribed four years back for ten days, was a miracle and that his son was still taking it albeit unknowingly, laced into his breakfast. Whenever it was not put it in food, he would look ‘strange and suspicious’. Buying medicines without a prescription had never been a problem. After he got married, the father took his wife into confidence who improvised things and became an expert in making an omelette with onions, tomatoes, and a dash of tasteless haloperidol after the omelette was made. Since she found her husband quite nice and caring while on just a dropperful a day, she did it happily. I sat him down and lectured him about his having been too paternalistic (he kept saying, ‘but I am the father’) about him 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 up to him, but it was legally and ethically wrong. I presume that the father went home and told his son 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 son looked hurt and insisted he felt fine to which father replied, “Of course you do, you are on medication. He looked at his father coldly and from next day, switched over to boiled eggs. I do know that by month end, the wife had left him 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 he were together in so many conspiracies. He stopped going for work because ‘people followed him on motor-cycles’. After six months 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 and legal defects (an over-bearing and lying father, crooked chemists, secret conspiracies of medicating the patient etc), the community had found a workable solution to a difficult problem 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 the practice been legal with a set of strict guidelines, I could have advised the family accordingly and outcome for everyone would have been happier.
But be under no illusion. The practice can be and often is misused. Husbands use it to tame assertive wives, who had a short-lasting mental illness years back and no longer need medicines. Wives do it too, to alcoholic husbands by mixing disulfiram in food so that if they take even a sip , the face get flushed and one feels like throwing up. (It can get serious too). Vernacular press and hoardings on bus stands carry ads, ‘Treat your alcoholic husband without telling him’. For those interested in exploring more:- journals.lww.com/indianjpsychia…
(This is a repost from last year)