by- Anirudh Kala

‘Covert medication’ is the practice of mixing medication in food or beverages by the family because the patient refuses to take it since he does not believe he is ill.

The person is usually suffering from schizophrenia, or mania. Tablets are crushed, or liquid forms of medication used by distraught and optionless family members, in the absence of adequate mental health resources in the country. It has questionable legality and for that reason it is not talked about much and there are hardly any 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 a 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. However the act permits involuntary admission only if he is a danger to himself or to others even he 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 sense.

However if side effects occur when patient is out and alone, it can cause 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.

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 patiently convince his son. One valid reason of course is that if patient finds out, he can become even more paranoid.

I had forgotten all about them till four years later when the father 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 years old daughter and now a son, hence the sweets (daughters do not merit either ‘lohri’ or sweets).
And, almost as an aside, told me that the medicine I prescribed four years back for two weeks, 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 risperidone. 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 boy looked hurt, insisted he felt fine and 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 system , in its own way 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 guidelines, I could have advised the family accordingly and outcome for every one 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 illness five years back and have recovered since. 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’.