Surreptitious practices in the management of persons with serious mental illnesses - Perspectives from the schizophrenia research foundation.

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.[1-4]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[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. Community-level health workers should be well educated about this, especially with following up these cases and reporting any adverse events promptly. The duration of surreptitious medication should be kept at a minimum.

MANAGING THE USE OF SURREPTITIOUS TREATMENT

Ethical principles of autonomy, justice, beneficence, and respect have been discussed with reference to concealed treatment.[14] In India, the dominance of strong familial interdependence and the collective goals of family often ride over the autonomy of the individual patient. With sufficient evidence base for the effectiveness and safety of treatments for mentally ill persons, justice is not rendered if patients are not provided with adequate care and treatment. Beneficence can be viewed as offering care in the form of concealed medication in the “best medical interests” of the patient who would otherwise not take it. Respect for individuals is perhaps the sole factor which weighs against the use of concealed medications, which “denies them the right to know what is being done to their minds and bodies.”[1] All these principles are seen to operate in the strategies adopted at this facility to manage surreptitious treatment of patients.

Some of the strategies used at this facility include the following.

Efforts to educate families (in our regular Family Education Programs): The focus on pharmacotherapy includes the need for treatment, effects, and side effects. Methods of managing non-compliance are stressed on with the aim of getting the patient to comply with treatment. Some suggestions to caregivers include the following:

Persuasion is better than coercion and that perseverance will work. Forcing someone to take medication by threats is, at best, a temporary solution best left for acute (emergency) situations

Carers could perhaps identify a person who is most influential with the patient to do the talking

Focus should be on any possible day-to-day benefit of the drug rather than the long-term need approach. These may include sleep and anti-anxiety effects, instead of emphasis on psychotic symptoms

Caregivers could try to match the need to take medication to achieve one's life goals like getting to work, finishing school/education, etc

There has to be a uniform agreement about the need for medication within the greater family

Caregivers are advised to avoid direct confrontation about medicine, especially when the patient is acutely sick. Not only would it be counterproductive, a confrontational approach could also be dangerous

It is suggested to the caregivers that when side effects occur, they could use the presence of this event to reinforce the need for the patient to comply with treatment

It is frequently noted that once medications are administered for a sufficient period and the patient's psychosis reduces in intensity, many patients can be convinced to comply with the treatment prescription. Families are encouraged to maintain medication schedule diligently and watch for signs of improvement.

Patient issues such as addressing lack of insight and acceptance of the disorder, or dealing with perceived side effects, are dealt with in every review with the patient.

In the event the patient does not turn up for reviews, attempts are made to reach out to the patient either by telephone or by house visits

Group therapy sessions focusing on medications and the need for adherence are also held regularly for patient groups

Cognitive behavior therapy is undertaken in patients who are willing to participate in the therapy sessions. The patient-focus approach is oriented toward the goal of improving adherence.

Thus, while dealing with non-compliance at the level of clinical practice remains a controversy, there are potential advantages and disadvantages of adopting such a strategy in persons with serious mental illnesses. There is a need to formulate rigorous guidelines for the management of non-adherence.