Surreptitious Practices in the Management of Persons with Serious Mental Illnesses - Perspectives from the Schizophrenia Research Foundation

Article excerpt

Byline: Padmavati. Ramachandran, Thara. Rangaswamy

The aim of this communication is to briefly describe the surreptitious practices and management of non-adherence, observed at the services offered by the Schizophrenia Research Foundation. Screening of records at our services for documentations of this practice and the efforts made to deal with non-adherence and concealed treatment was done. Surreptitious practices in SCARF's out-patient services and in community outreach programs have been documented. Efforts to manage non-adherence include educating families on pharmacotherapy and strategies of dealing with non-adherence. At the level the patient, individualised and group strategies deal with the issues addressing lack of insight, acceptance of the disorder, or dealing with perceived side effects are held. Ethical principles of autonomy, justice, beneficence, and respect are adopted in implementing these strategies. There are potential advantages and disadvantages of adopting surreptitious treatment strategies in persons with serious mental illnesses. There is a need to formulate rigorous guidelines for the management of non-adherence.

Introduction

On of the greatest challenges in the management of persons with mental illnesses is non-adherence to treatment. Treatment non-adherence is associated with poor outcomes in schizophrenia.

While surreptitious administration of medication to the schizophrenia patient is fairly universal, there is a lot of secrecy and little public debate on the practice. Scientific literature on the subject has been sporadic. [sup][1],[2],[3],[4] In clinical practice, most of us come across difficult-to-treat patients refusing treatment, who are in danger of being violent to themselves or others. Some in remote areas are seen in a state of dehydration as a result of poor intake of food and fluids, and run the risk of many health hazards. While the ideal management is to admit them in a treatment facility, this may not always be possible in some cases.

Ten years ago, an urban survey [sup][2] of family members of outpatients with schizophrenia identified that 50% of the non-compliant patients treated as out-patients had received medication at least once without their knowledge. This was after all other methods like waiting, coercing, pleading, and threatening were used. The concealed medications were given from a few days (majority) to months. The study found that 91% of this group of patients had improved considerably. In 19 (26%) cases, the families reported that the patient became aware of being given the medication, at a later date. Caregivers of 74% of the patients were not sure of the patient's state of awareness about receiving medications without their knowledge and did not want to explore it with the patient. In the patients who were aware of the treatment, anger and resentment toward the family was common while some were said to have accepted it without any reaction. However, a recent scrutiny of 400 case records of out-patients at SCARF showed that majority were adherent and only 12 of the 400 were receiving surreptitious treatment.

Surreptitious practices in SCARF's community outreach programs, in predominantly rural areas, have also been documented. Interviews with the caregivers of patients receiving surreptitious treatment in one such program indicated that almost all them were giving the medication as advised by the doctor. They were willing to use this method. Only one caregiver, the spouse of a male patient, was unwilling to conceal the medication in food as she was afraid of the responses of her in-laws, if they ever found out. In at least half the respondents, almost all immediate family members knew that the medicines were being administered without the knowledge of the patient. One has to exercise a lot more caution when recommending surreptitious medicines in rural communities since the frequency of contact with the psychiatrist can be much less. …