GUIDELINES FOR MARRIAGE & MENTAL

HEALTH ISSUES IN WOMEN

PRELIMINARY DRAFT FOR CONSENSUS

SPECIALITY SECTION - WOMEN’S MENTAL HEALTHINDIAN PSYCHIATRIC SOCIETY

Dr. U. C. Garg Prof. M. ThirunavukarasuHon. General Secretary PresidentIndian Psychiatric Society Indian Psychiatry Society

.Dr. Bharathi Visveswaran Dr. Sonia Parial Convener Chair person

CORE COMMITTEE

Prof. M. ThirunavukarasuPresident, Indian Psychiatric SocietyProf. & HOD, Dept of PsychiatrySRM Medical College and Research Centre –Chennai

Dr. U. C. GargHon. General SecretaryIndian Association Of Biological Psychiatry (IABP)Past Treasurer, SAARC PsychiatricFederation (SAF)Past President, Central Zone, IndianPsychiatric Society (IPS)

Dr. Sonia Parial Chair person SPECIALITY SECTION ON WOMEN’S MENTAL HEALTH Indian Psychiatric Society

Dr. Bharathi VisveswaranConvenerSPECIALITY SECTION ON WOMEN’S MENTAL HEALTHIndian Psychiatric Society

Prof. G. Bhagya RaoPresident elect, South zone IPS, Vizag,Retd Director of Medical Education, A.P.Retd superintendant, Government Hospital For Mental CareVizag, A.P.

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Prof. P. K. Dalal Professor & Head, Department of PsychiatryC.S.M. Medical University, Lucknow, U.P

Prof. Indira Sharma Head of the Department of PsychiatryInstitute of Medical Sciences,Banaras Hindu University,Varanasi,UPChairperson - IPS. Speciality section on Forensic Psychiatry

Prof. S. NambiPast president of the Indian Psychiatric SocietyProf & head, Dept of PsychiatrySree Balaji Medical College & Hospital – Chennai

Prof.Prabha S. Chandra Professor of Psychiatry, NIMHANS, Bangalore, India

Prof. Prakash B. Behere ,Dr.B. C.ROY Award RecipientDirector, Professor & HeadDepartment of Psychiatry,Mahatma Gandhi Institute of MedicalSciences,Sevagram,Wardha,(Maharashtra)Chairman, Publication Division,Indian Psychiatric Society

Hon’ble judgeMr.T. C. S. Raja ChockalingamPrincipal Judge, Family court Chennai High Court Campus

Dr. C. Ramasubramanian Consultant PsychiatristFounder, Chellamuthu Trust For Psycho Social RehabilitationNodal Officer, District Mental Health Program,Madurai

Dr. T.S.Sathyanarayana Rao Editor, Indian Journal of PsychiatryProf. & Head, Department of Psychiatry,

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JSS University, JSS Medical College & HospitalMysore

Mrs. Sharada DeviAddl. District & Sessions JudgeFast Track Court, Vizianagaram District, A.P

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INDEX

Development of clinical guidelines

Preamble on clinical guidelines

FAQs by Patients and Families

Guidelines: Section – 1

Section - 2

Section – 3

Section – 1:

Before Marriage – Common Scenarios with Guidelines.

Section – 2:

After Marriage – Guidelines

Section – 3:

Issues of Separation and Divorce

Section – 4

Appearance in Court

Appendices: 1 – 5

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Methods used to develop these guidelines

The speciality section on women’s mental health of the Indian Psychiatric Society [‘IPS’]was given the task of developing guidelines on marriage and mental health issues under the auspices of Prof. M. Thirunavukarasu, President of the IPS.

A symposium was convened by Prof. Indira Sharma, at the ANCIPS 2011 held at New Delhi. The speakers were Prof. S. Nambi, Prof. T. S. S. Rao, Prof. P. K. Dalal, Prof. Saritha Shah and Dr. Shanthi Nambi.

The inputs obtained during the symposium were taken into account. A thorough literature search was done.

In July’10, a core committee was formed who were to give guidance in development of the draft. The core committee comprises of Prof. M. Thirunavukarasu, Dr.U. C. Garg, Dr. Sonia Parial , Dr. Bharathi Visveswaran, Prof..G.Bhagya Rao, Prof. P. K. Dalal & Prof.Indira Sharma ,Prof.. S. Nambi, Prof. Prabha S. Chandra, Prof. Prakash B. Behere Hon’ble Judge Mr.T. C. S. Raja Chockalingam, Dr. C. Ramasubramanian, Dr. T. S. Sathyanarayana Rao and Hon’ble Judge Mrs. Sharada Devi.

A seminar was organized by the chairperson and convener of this speciality section at Chennai on the 10th of September, 2010. During this seminar, guidelines for psychiatrists, families and the judiciary were presented by Prof. Prabha .S. Chandra, Prof. P. K. Dalal and Prof. S. Nambi. After the seminar there was a session where the audience interacted and gave their inputs. Stakeholders like patients, family members, NGOs, mental health professionals namely psychiatrists, psychologists and psychiatric social workers participated in this discussion. After this, a workshop was conducted which was attended only by the core committee members. All inputs derived from the previous sessions were incorporated. Controversial points were discussed, opposing views were exchanged and amendments were made to the draft.The views of other psychiatrists which were expressed on the e_ips forum were also incorporated into these guidelines.

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Future Plans

A review panel was constituted, comprising of senior and

experienced psychiatrists from all over the country. These

panellists will take part and give their recommendations in a

workshop organized at the ANCIPS 2012 to be held at Cochin

on the 19th of January, 2012.

Suitable recommendations and corrections will be incorporated

into the draft.

This revised draft will be sent to stakeholders with a

representative sample comprising of patients, families, legal

professionals, NGOs, psychiatrists working in different setups

(Acute care, General hospitals, Rehabilitation, Community,

Etc).

After incorporating the inputs from the above sources, a pre-

final draft will be put up in the IPS website and e_ips forum for

a period of a month.

Formation of the final draft, publication and release.

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What are clinical guidelines?

Clinical guidelines are ‘systematically developed statements that assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ (Mann, 1996). They are derived from research evidence, using predetermined and systematic methods to identify and evaluate all the evidence relating to the specific condition in question.

Where evidence is lacking, the guidelines will incorporate statements and recommendations based upon the consensus statements developed by the Guideline Development committee.

Why are guidelines needed

• Marriage is a social issue with medical and legal connotations. There is no data on consensus on this subject.

• The purpose of guidelines is to give direction and facilitate decision making.

• To assist mentally ill women and their family in making informed decisions regarding marriage by providing appropriate information about their illnesses and their implications in marriage.

• Guidelines are likely to bring uniform, comprehensive set of practices in the information given on this issue by mental health professionals.

Limitations of clinical guidelines

• Guidelines are not a substitute for professional knowledge and clinical judgment.

• Guidelines are not law and do not have statutory status.• The lack of research evidence, the quality of methodology used

in the development of the guidelines, the generality of research findings and the uniqueness of individual patients.

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FAQs by patients / families

Will marriage `cure’ mental illness? Will marriage decrease the symptoms? Since patient is demanding sex / marriage, by getting the

patient married, are we not fulfilling his/her needs and reducing frustration?

Will not the responsibilities involved in marital life quicken the recovery and make patient more responsible and `normal’?

If we disclose the illness and treatment, doesn’t it become impossible to get the patient married?

Is the marriage a valid one? Is it possible for her to have a normal social and sexual life? Will medication interfere in her sexual life, household

obligations, pregnancy, child birth? Do medicines have long term side effects? Is it not possible to `complete’ the treatment and THEN get her

married? Can the husband divorce / desert her on the grounds of mental

illness? Is it an offence to conceal the fact and get her married? Is it possible to continue medicines without husband’s

knowledge? What do we tell if he finds out? Are there any legal provisions for her upkeep (financial) if the

husband leaves her or divorces her? Will you treat her if she is not able to come but we parents

report her condition to you periodically? (Treatment by proxy?) If we do not get her married, what happens to her after us?

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GUIDELINES

SECTION – 1SECTION – 2SECTION – 3

SECTION – 1

Before Marriage

Common Scenarios

1. Family plans for marriage and asks for suggestions2. Family has confirmed the date of marriage and asks for

advice.3. Family gives you the invitation and the marriage is within a

few weeks.4. Family brings the patient in a state of active psychotic

symptoms and informs that the marriage is fixed to take place within the next few days or weeks and asks you to treat

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`quickly’ and make the patient `ready’ for the marriage `function’.

5. Family has informed the prospective groom and he wants to discuss issues about the illness.

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SCENARIO -1

Guidelines for the psychiatrist when family discusses marriage

1. Be aware of and acknowledge culture specific issues

2. Be aware of and acknowledge the nature of the illness

and its effects on marriage

3. Assessment

4. Discussion

5. Give factual information (Psycho education).

6. Recommendations

7. Know your own limitations.

8. Avoid

9. Document

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1. Be aware of & acknowledge the socio cultural issues in the Indian context

Marriage has been, since ancient times, one of the most important social institutions.

Marriage is considered the most important aspect of a woman’s life – at any cost.

Not being married is a stigma. Social status of woman is higher if she is married. Vulnerability of women in society and having to depend on others

enhances the family’s need for getting her married. If the woman remains unmarried, the prospects of siblings’

marriage are also affected. Families often resort to giving more dowries or selecting a

husband who needs economic help to facilitate marriage. Pressure for a child within a year or two after marriage. Contraception not in control of the woman. Marriage demands a sustained level of adaptation and induces

more stress in women than in men. It may be because of multiple factors: more responsibilities in

taking care of the family, adjusting to a new family, pregnancy, childbirth, motherhood, - All these can induce more stress through bio-psychosocial means.

Studies show greater distress among married women as compared to married men.

Women in the Indian community are less likely to get mental health care, because having a mentally ill woman in the family, by itself, is stigmatized and ridiculed.

After separation, almost all these women live with their parents who are already aged.

Social isolation and stigma is caused by this double disorganization of chronic illness and a personal tragedy is stigmatized even now by the society.

It has been brought to the fore, the plight of Indian women, who in addition to be affected by a serious mental illness have also been abandoned by their spouses and left to fend for themselves in a world, where very few options are open to them

Married mentally ill women are more likely to be sent back to their natal homes, abandoned, deserted or divorced.

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Clinical experience is that the responsibility of care for the mentally ill women is often left to her own family than to her husband or his family.

In addition to the stress of mental illness, hostility from family members and rejection from society in general, these women are ridiculed and ostracized for their divorced / separated status.

For families (primarily aging parents) the emotional, financial and physical burden of caring for a severely mentally ill woman is extremely high.

The caregivers of these women suffer much more than the patients themselves. Feelings of disruption, loss, guilt, frustration, grief, disappointment and a fear about the future of their daughter all make them miserable.

The other family members such as the sibling who often, anticipating their role as future caregivers, distance themselves from the patients.

Often, families conceal mental illness in the woman and get them married.

When found out by the husband and his family, the parental family often counter attacks by making false allegations about dowry demands, domestic violence and cruelty in an attempt to `save’ the marriage.

The woman, her children and the husband are the worst sufferers in this scenario.

2. Be aware of & acknowledge the nature of the illness & its effect on marriage

Make a thorough clinical diagnosis of the illness A acknowledge that those with major or chronic mental illness

tend to be poor intellectual partners in a relationship. Their adaptive skills may be compromised. Acknowledge that some patients do not tolerate intimacy or

close relationships while doing quite well in sheltered environments and relationships with no major expectations. (As such of that in half way homes).

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3. Assessment

A thorough physical and psychiatric examination of the patient

Current medication and adverse effects, if any. Assess the response to treatment and if there is a substantial

improvement. Do the assessment in a private, safe environment. Speak to the woman alone. Be firm about excluding others whose presence could

interfere with or influence the assessment. Assess the patient’s concepts on marriage. Assess current level of functioning in social, emotional and

functional domains. Assess adaptive skills. Assess the strengths and support systems –Family and

community. Invite key family members for further discussions.

4. Elicit and discuss

Elicit family’s concepts and belief systems and expectations on marriage.

Elicit reasons as to why the family wants the woman to get married?

Elicit family’s awareness of patient’s readiness for marriage in terms of duties and responsibilities of marriage.

Discuss multiple social, emotional and occupational demands of marriage

Discuss compromised adaptive skills of the patient in the context of the recent challenges the patient has faced.

Discuss multiple demands of parenting. Discuss support systems – financial, emotional and

social.Discuss family’s readiness to disclose. Allow family to talk about positive and negative effects of

disclosure of mental illness. Re elicit their opinion about disclosure after you provide them

with factual information.

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5. Give Factual Information (PSYCHO EDUCATION)

Address the myths associated with mental illness, medication, dependence potential, stigma, etc. And clarify.

(Refer appendix-2 for details).

Different issues in different psychiatric disorders:

Severe mental illnesses – Medication, disability,Chronicity, recurrence.

Depression and OCD –Chronicity, impact on daily life, childbirth, medication.

Personality disorders – interpersonal issues. The impact of unpredictable/impulsive/controlling behaviour/anger dyscontrol on marriage..

Positive and negative effects of marriage on the patient Can marriage be a stress?

It is a major life event Marriage demands a sustained level of adaptation and may

induce more stress. Stress is likely to increase the risk of relapse and worsen the

course of illness. Attitudes of husband’s family following marriage may not be

very congenial. Expressed emotions may be high. Separation from existing support networks may add to stress. Migration Impact of childbirth on mental illness Unrealistic expectations.

Can marriage bring about positive changes ?

Adds to social status and may decrease stigma. Support of husband may facilitate and maintain remission. May decrease disability and enhance functioning if the family of origin had high expressed emotions and the husband’s family is more understanding.

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May ensure social and financial security. Having children may further enhance above security.

Medication and marriage

Address family’s desire to stop medicines, adverse effects (dullness, sedation, amenorrhoea,) effects on sexual life, pregnancy and childbirth, ability to perform household chores.

Educate about the need to continue medication before, during and after marriage and the risk of relapse if medicines are stopped. Explain the implications of relapse just before, during or immediately after marriage.

Address their concerns regarding adverse effects of medication and make appropriate changes when required.

Educate about the need for a regular follow up after marriage.

Information on disclosure

A) Advantages of disclosure of mental illness

Honesty builds trust and ensures a stronger bonding Medication adherence will be better Pregnancies can be planned Husband becomes a partner in the treatment May lower expressed emotions May be more aware of side effects and hence more tolerant

B) Disadvantages of disclosure of mental illness

May have difficulty in getting married Stigma as the society may come to know about mental

illness in the girl The groom who is willing to get married may have problems

which could be concealed by his family.

6. Recommendations

It is the psychiatrist’s duty to give factual information The psychiatrist should put the facts in front of patient/family-

the assets and liabilities, the abilities and disabilities. The psychiatrist should disclose the above points in a

generalised form as well as specific to the patient, taking in to consideration her illness

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He should base his information on his knowledge of psychiatry and law, clinical experience, textbooks, research studies and other sources.

The psychiatrist should motivate the patient/family make their own informed decision and should never decide for them.

The psychiatrist should stress the importance of continuation of treatment and the risk of relapse if treatment is discontinued. He should suggest that a close family member be assigned the duty of monitoring medication intake.

If the patient shows considerable improvement, we should suggest that she takes up a job or continue her current job. A consistent work record will be a protecting factor economically, socially and legally.

The psychiatrist may give salient legal points to the family pertaining to the patient.

7. The Limitations Of The Psychiatrist

Acknowledge the uncertainty surrounding the decision making regarding marriage.

People want categorical answers. They are not comfortable when the responsibility of decision making is thrust upon them.

The psychiatrist cannot predict future episodes. A psychiatrist cannot `certify’ whether a patient is `fit’ for

marriage or not. A psychiatrist sometimes cannot even `certify’ if the patient

can give the consent for marriage. (Even some patients with schizophrenia with persistent delusions or hallucinations get married and have children, and continue to live with the spouse).

Relying on laws on marriage to give guidance is not always possible. For example, The HMA and the Special Marriage Act do not mention anything about treatment or treatability.

8. Avoid

Psychiatrists are only doctors, and they should limit their advice within the boundaries of their profession.

Avoid making decisions for families. Avoid directive messages – do this, don’t do this. Avoid moral preaching and do not be judgemental Do not certify `fitness’ for marriage.

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Avoid getting over involved with family and stick to your role as a doctor.

Do not break confidentiality. Do not see or discuss the patient with the prospective groom

or his relatives without a written consent from patient and her family members.

9. Document

Refer to appendix-1

SCENARIOS -2 & 3

When family fixes the marriage and asks for your advice.

Follow the appropriate points of Scenario -1 guidelines Special issues: Relapse

Stress the need for continuation of treatment and explain the higher risk of relapse during stress.

Amenorrhoea When the patient has amenorrhoea which is a common

adverse effect of medication, address this issue which is of great concern to the family due to its high socio biological significance.

Decide on switching over to medication which has lesser propensity to cause amenorrhoea.

Contraception

Discuss contraception with the patient. Clarify her doubts and fears.

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Educate her about contraception methods. Encourage her to discuss contraception with her husband

till they decide to start a family. Stress the importance of a later discussion about

medication during pregnancy and relapse issues and their implications on pregnancy.

Decide on switching over to medication which has lesser propensity to cause amenorrhoea.

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SCENARIO - 4

Family brings the patient in a state of active psychotic symptoms and informs that the marriage is fixed to take place within the next few days or weeks and asks you to treat `quickly’ and make the patient `ready’ for the marriage `function’

Clarify to the family about your inability to play god. Treat the patient. Educate the family about the clinical reality. Do not get judgemental. Let the family decide the future course of action.

SCENARIO - 5

Family has informed the prospective groom & he wants to discuss issues about the illness

Acknowledge that it is a tricky situation. He may opt out of marriage after knowing the issues. If he is willing to discuss, give an objective account and

information Highlight the strengths and weaknesses of the patient. Do not take sides. You can quote cases of other patients to clarify your opinion. Always get a written consent from the patient and family

member before talking to anyone about the patient.

SECTION -2

AFTER MARRIAGE

SCENARIO -1

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The newly married woman is brought by her parents or husband with mental illness.

The psychiatrist must handle this situation with utmost care because most marriages break at this point because bonding may not have yet developed between the couple so early.

Psychiatrist must avoid an attacking/ demeaning/authoritarian attitude. Adapt a supportive attitude.

Treatment of current relapse and symptom reduction takes utmost priority than settling family issues.

Make a strengths- based assessment which will be useful later. It may help in saving the marriage.

The spouse experiences anger and distrust that disclosure of the illness was not done. Acknowledge it.

Treat every patient as new patient and examine in an unbiased manner even if the patient has received prior treatment from psychiatrist.

Do not acknowledge that you have treated the patient before if the patient or family requests you so.

Elicit information from the woman’s side and the husband’s side separately.

Examine the patient in privacy. If the patient is in a hostile environment, move the patient to

a safe environment (hospital, maternal home). Document case details thoroughly and objectively. Take a written consent from patient before you talk to

husband’s family or any other agency. Do not issue any certificate about the illness to the husband

or his family. Many families start counter threatening behaviours like

implicating husband and his family and lodge complaints under prohibition of dowry act or domestic violence act. The psychiatrist should point out that it may work against the marriage and explain the repercussions of allegations which may eventually be disproved. The bonding between the woman and husband may get permanently damaged.

Encourage the family to have transparent discussions with the husband.

Highlight the good prognostic factors to the husband and family.

Refer to common points given at the end of scenario-2

SCENARIO -2

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The woman develops mental illness after marriage

Make a thorough clinical assessment of patient. Elicit history of possible sexual abuse or domestic violence. Listen to both sides without bias. Concentrate on symptom management strategies. Husband is likely to ask many questions. Clarify Involve spouse early in treatment. Treat the patient and ensure that she is in a safe environment

which will facilitate treatment compliance.

Interventions with spouse and his family

Get a written consent from patient before discussing. Listen to the spouse without bias and acknowledge the issues

which are stressful to him. Educate him/family about the illness, its nature, course,

prognosis, importance of treatment, etc Point out the positive effects of a supportive environment in

the recovery from illness. Highlight good prognostic factors. Do not blame or alienate the spouse. Often there are problems between the spouse and the

woman’s parents – address and intervene.

Specific issues to be addressed to the husband

Involve the husband early in treatment. The importance of treatment compliance and rehabilitation. Clarify his doubts about the adverse effects of medication. If there are major issues like violence, suicide, etc., educate. Contraception. Pregnancy and lactation. Discuss in detail about the effects of

medication in pregnancy. Use a standard international guideline regarding medication in

preganancy and post partum. (eg. NICE guidelines or Maudsley prescribing guidelines).

If the woman has children, discuss the impact of mental illness on children. Clarify and guide.

If the children are to be removed from her, discuss with patient, her caregiver and husband. Educate them about the clinical condition and their rights.

If legal issues of child custody are beyond your purview, suggest that they obtain a legal opinion.

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Work in a multi disciplinary team – Use services of psychologists, trained social workers.

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SECTION-3

ISSUES OF SEPARATION / DIVORCE

Do not hand over any written document to the husband which may be used against the patient.

If the husband expresses his wish to separate from her or divorce her in the early phases of her treatment, acknowledge that it is the husband’s decision but suggest that he does not decide to make such a major decision in haste. The patient is to be given a fair chance to be observed for her response to treatment.

Convey to the husband your willingness to discuss this issue later, after the illness’s response to treatment becomes clear.

If necessary, educate about some legal aspects

Mental illness by itself is not a ground for nullity or divorce.

Concealment of illness may or may not be a ground for nullity.

It may go against divorce if the woman improves substantially and is able to meet social, familial and occupational demands.

If husband approaches you after a considerable period of treatment, give your clinical opinion in the most unbiased manner in order to help him make an informed decision.

If separation or divorce is inevitable

Assess suicide risk. Supportive psychotherapy for the patient and family to deal

with the consequences of separation. Encourage patient and family to utilise their social support

system. Focus on coping issues and promote self reliance as much as it

is possible. Educate the patient about her rights. Help patient to develop a vocational plan. Educate about and ensure treatment compliance and relapse

prevention. Rehabilitation.

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SECTION-4

APPEARANCE IN COURT

The court may ask your opinion regarding many marriage related issues- divorce, cruelty, domestic violence, abetment of suicide, child custody, etc.

Always maintain a thorough documentation on the patient and her illness.

Do not succumb to social pressures. Do not recommend living together or divorce. Do not give

predictive opinions. Neither favour nor be biased against the patient. Psychiatrist is not trained in investigating skills. It is the

court’s duty to go in to the truth behind allegations by both parties.

Stick to only a clinical opinion. Discuss with peers

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APPENDIX-1

DOCUMENTATION,

• Client records should be factual – clear, accurate and an objective recording of information, history, diagnosis, observations and treatment plan.

• Be aware that records can be subpoenaed to Court Where professional opinion is recorded.

• All contacts of patient or family with the medical health service to be documented

• Records are confidential and should be kept in a safe place.• Confidentiality is subject to constraint and is overridden where

the record is later subpoenaed for court.• Clients have a right to access their personal health records. • Do not give the records to ANYONE other than the patient.

The following information is to be documented.• The date and time of every contact with the patient.• An accurate and concise history as told by the patient’s and

the spouse’s side• All relevant medical history• The status of the family system where the patient lives.• A thorough examination of the mental status• A provisional diagnosis/diagnostic formulation• All communication with the family• Strengths and weaknesses in the current scenario.• Patient’s behaviour and reactions towards other family

members and spouse.• The outcome of consultations with the other members of the

mental health service team• If police are involved, the name and contact details of the

police officer • Intervention plans discussed with patient, husband and family.• Regular follow up notes• Details of medication and adverse effects noted if any.

APPENDIX -2

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MYTHS RELATING TO MARRIAGE AND MI

There are certain myths existing in society regarding marriage and MI. They are:

MYTH: Marriage can cure mental illness.

CLARIFICATION: Marriage does not cure MI. It may worsen MI, especially if the partner or his family is unsupportive and hostile and this in turn would affect the outcome of the disease, interfere with treatment compliance and affect marital life.

MYTH: Once a person has MI, one does not have a future in terms of career and marriage.

CLARIFICATION: Most patients with MI with appropriate psychiatric treatment improve to the extent that they can pursue their studies and have a career, get married and continue with their marriage with an acceptable degree of functioning.

MYTH : All MIs are the same.

CLARIFICATION: All MIs are not the same. Majority of MIs are minor illnesses (non-psychotic illnesses) eg., anxiety disorders, depression, adjustment disorders, somatoform disorders, etc. A person afflicted with such a disorder can usually manage himself/ herself. They do not have a tendency for aggression or violence. Their behaviour is not socially embarrassing or inappropriate. Psychotic illnesses like schizophrenia, bipolar disorder etc. can be considered as major illnesses because the person with these illnesses may not be able to take care of himself/herself, manage her routine affairs, studies and work, may not know how to behave appropriately with others, and may sometimes become suicidal or violent and become unmanageable.

MYTH: Patient can come out of MI if they want to.

CLARIFICATION: MIs are not figments of imagination nor are they brought upon themselves by patients deliberately. They are diseases like diabetes, malaria etc. They requires specific treatment. Patients cannot snap out of these illnesses at their will.

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MYTH: Patients with mental illness are violent and dangerous.

CLARIFICATION: Patients with mental illness are generally not dangerous or always violent except in a severe phase.(mainly psychotic illnesses.) The incidence of violence in persons with MI during the non-acute phase is equal to that in the general population or that in persons supposedly without MI.

MYTH: MI is due to bad parenting.

CLARIFICATION: MI is not due to bad parenting. For most MIs there are multiple causes, including biological and psychosocial factors which act together to cause the illness. Biological factors include heredity, personality characteristics and imbalance of chemical substances in brain. Psychosocial factors include stressful factors and adverse life situations.

MYTH: MI can be detected by CT scan, MRI Scan or X-Ray.

CLARIFICATION: MIs are diagnosed after taking a detailed history about patient’s behaviour and examination of the physical and mental status by the doctor. In the vast majority of MIs, unless the mental illness has an organic cause, CT-scan and MRI-scan or X-Ray of the brain is normal.

MYTH: Mental retardation is curable.

CLARIFICATION: Mental retardation is not curable. However, substantial improvement can occur with training and special education especially if the mental retardation is not severe or profound.

APPENDIX – 3

INDIAN DISABILITY EVALUATION AND ASSESSMENT SCALE (IDEAS)

A scale for measuring and quantifying disability in mental disordersdeveloped by the Rehabilitation Committee of Indian Psychiatric Society,

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December 2000.Items :I. Self Care : Includes taking care of body hygiene, grooming, healthincluding bathing, toileting, dressing, eating, taking care of one’s health.II. Interpersonal Activities (Social Relationships) : Includes initiating andmaintaining interactions with others in contextual and socialappropriate manner.III. Communication and Understanding : Includes communication andconversation with others by producing and comprehending spoken/written/non-verbal messages.IV. Work : Three areas are Employment/Housework/Education Meaureson any aspect.1. Performing in Work/Job : Performing in work/ employment (paid)employment/self-employment/family concern or otherwise.Measure ability to perform tasks at employment completely and efficiently and in proper time includes seeking employment.2. Performing in Housework : Maintaining household including cooking, caring for other people at home, taking care of belongings,etc. Measures ability to take responsibility for and perform household tasks completely and efficiently and in proper time.3. Performing in school/college : Measures performance education related tasks.Scores for each items0 - NO disability (none, absent, negligible)1 - MILD disability (slight, low)2 - MODERATE disability (medium, fair)3 - SEVERE disability (high, extreme)4 - PROFOUND disability (total, cannot do)Total ScoreAdd scores of the four items and obtain a total scoreWeightage for duration of illness (DOI) :<2 years : score to be added is 12-5 years : add 26-10 years : add 3>10 years : add 4Global DisabilityTotal disability score + DOI score = Global Disability score percentages:0 No Disability = 0%1-6 Mild Disability = <40%7-13 Moderate Disability = 40 - 70%

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14-19 Severe Disability = 71-99%20 Profound Disability = 100%Cut off for welfare measuresMANUAL FOR “IDEAS”In order to score this instrument, information from all possible sources should be obtained. This will include interview of patient, the care giver andcase notes when available.I. Self CareThis should be regarded as activity guided by social norms and conventions.The broad areas covered are:(a) Maintenance of personal hygiene and physical health.(b) Eating habits.170(c) Maintenance of perosnal belongings and living space.(d) Does he look after himself, wash his clothes regularly, take a bath andbrush his teeth ?(e) Does he have regular meals ?(f) Does he take food of right quality and quantity ?(g) What about his table manners ?(h) Does he take care of his personal belongings with reasonable standardof cleanliness and orderliness ?

Scoring0 = No disabilityPatient’s level and pattern of self-care and normal, within the socialcultural and economic context.1 = MildMild deterioration in self-care and appearance (not bathing, shaving, changing clothes for the occasion as expected). Does not have adverse consequences such as hazards to his health to his health. No embarrassment to family.2 = ModerateLack of concern for self-care should be clearly established such as mild deterioration of physical health, obesity, tooth decay and body odors.3 = SevereDecline in self-care, should be marked in all areas. Patient wearing torn clothes, would only wash if made to and would only eat if told. Evidence of serious hazards to physical health. (Malnutrition, infection,patient unacceptable in public).

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4 = ProfoundTotal or near total lack of self-care (Example : risk to physical survival, needs feeding, washing, putting on clothes, etc. Constant supervision necessary).

II. Inter-personal ActivitiesIncludes patient’s response to questions, requests and demands of others. Activities of regulating emotions. Activities of initiating, maintaining and terminating interactions and activities of engaging in physical intimacy.Guiding Questionsa. What is his behaviour with others?b. Is he polite ?c. Does he respond to questions ?d. Is he able to regulate verbal and physical aggression?e. Is he able to act independently in social interactions ?f. How does he behave with strangers ?g. Is he able to maintain friendship?h. Does he show physical expression of affection and desire ?Scoring0 = NoPatients gets along reasonably well with people personal relationships.No friction in inter-personal relationships1 = MildSome friction on isolated occasions. Patient known to be nervous orirritable but generally tolerated by others.

2 = ModerateFactual evidence that pattern of response to people is unhealthy. Maybe seen on more than few occasions. Could isolate himself from othersand avoid company.

3 = SevereBehaviour in social situations is undesirable and generalized. Causesserious problem in daily living/or work. Patient is socially ostracized.

4 = ProfoundPatient in serious and lasting conflict, serious danger to problems orother. Family afraid of potential consequences.III. Communication and Understanding

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Understanding spoken messages as well as written and non-verbal messages and ability to reduce messages in order to communicate with others.

Questionsa. Does he avoid talking to people ?b. When people come home what does he do ?c. Does he ever visit others ?d. Is he able to start, maintain and end a conversation ?e. Does he understand body language and emotions of others, such as,crying, screaming, etc.f. Does he indulge in reading and writing ?g. Do you encourage him to be more sociable ?

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Scoring0 = No disabilityPatient mixes, talks and generally interacts with people as much as can be expected in his socio-cultural context. No evidence of avoidingpeople.

1 = MildPatient described as uncommunicative or solitary in social situations.Signs of social anxiety might be reported.2 = ModerateA very narrow range of social contact, evidence of active avoidance ofpeople on some occasions and interference with performance of socialrules, causes concern to family.3 = SevereEvidence of more generalized, active avoidance of contact with people(leave the room when visitors arrive and would not answer the dooror phone).4 = ProfoundHardly has contacts and actively avoids people nearly all the time, forexample, may lock himself inside the room. Verbal communication isnil or a bare minimum.IV. WorkThis includes employment, housework and educational performance. Scoreonly one category in case of an overlap.EmploymentGuiding Questionsa. Is he employed/unemployed ?b. If employed, does he go to work regularly ?c. Does he like his job and coping will with it ?d. Can you rely on him financially ?e. If unemployed does he make any efforts to find a job ?

Scoring0 = No disabilityPatient goes to work regularly and his output and quality of work

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performance are within acceptable levels for the job.1 = MildNoticeable decline patient’s ability to work, to cope with it and meetthe demands of work. May threaten to quit.2 = ModerateDeclining work performance, frequent absences, lack of concern aboutall this. Financial difficulties foreseen.3 = SevereMarked decline in work performance, disruptive at work, unwillingto adhere to disciplines of work. Threat of losing his job.4 = ProfoundHas been largely absent from work, termination imminent. Unemployedand making no efforts to find jobs.HousewivesIn similar ways, housewives should be rated on the amount, regularityand efficiency in which tasks in the following areas are completed. Considerthe amount of help required completing these. Acquiring daily necessities,making, storing and serving of food, cleaning the house, working with thosehelping with domestic duties such as maids, cooks, etc., looking afterpossessions and valuable in the house.StudentAssess an score on performance in school/college, regularity, discipline,interest in future studies, behaviour at educational institutions. Those whohad to discontinue education on account of mental disability and unable tocontinue further should be given a score of 4.

Ideas Scoring SheetItems 0 1 2 3 4 5Self care, Inter-personal Activities, Communication & Understanding, WorkA. Total Score + B. DOI Score - Global Score (A+B)

APPENDIX -4

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LEGAL ASPECTS THAT A MENTAL HEALTH PROFESSIONAL SHOULD BE AWARE OF.

MARRIAGE IS A CONTRACT

• “Marriage is a contractual agreement” which formalizes & stabilizes the social relationship which comprises the family.

• Any transaction, be it a contract, a marriage or a will has both physical & mental components. The written document or oral declaration is the physical component; the intention to perform the transaction with requisite comprehension constitutes the mental component.

• Both these should be present for a valid transaction. LEGAL ISSUES IN MARRIAGE

Questions with reference to marriage:-• Is the marriage a valid one?• Is it possible for the relationship to continue?• An individual who is not capable of comprehending what is

happening to him or her, cannot give valid consent for marriage.

• Nullity of marriage means that the marriage is held null and void i.e., a valid marriage did not take place at all.

• Divorce means the marriage was a valid one: but the marital status cannot be continued.

• Institutions of suit: Nullity – within one year / divorce after 1 year / custody of child < 6 years mother / > 6 years child welfare.

VALIDITY OF MARRIAGE• Conditions prevailing at the time of marriage decides its

validity.• The individual who is not capable of comprehending what is

happening to him / her cannot give consent for marriage.• The capacity to procreate and the relationship that are

prohibited by Religious codes are other factors. Such situations lay open to question the validity of marriage.

• NULLITY OF MARRIAGE means that the marriage is held null & void by a court. In other words, a valid marriage did not take place at all

INDIAN LAWS RELATED TO MARRIAGE1. The Special Marriage Act – 19542. The Hindu Marriage Act – 1955 [as amended in 1976].3. The Dissolution of Muslim Marriage Act – 1939.4. The Muslim Women Protection of Rights on Divorce – 1986.5. The Parsi Marriage and Divorce Act – 1936

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6. The Christian Marriage Act – 18727. The Indian Divorce Act – 18698. The Family Courts Act – 1984

HINDU MARRIAGE ACT, 1955 [HMA]

• A Hindu Marriage is voidable if either party is incapable of giving a valid consent as a consequence of unsoundness of mind, or though capable of giving a valid consent as a consequence of unsoundness of mind, or though capable of giving a valid consent has been suffering from mental disorder of such a kind or to such an extent as to be unfit for marriage and the procreation of children.

• Has been subject to recurrent attacks of insanity. THE SPECIAL MARRIAGE ACT 1954 [SMA] • Applicable to persons from any religion undergoing a civil

marriage• Has provisions similar to the HMA

INDIAN DIVORCE ACT 1869 A Christian marriage is voidable if either party was a “Lunatic” or “Idiot”.

PARSI MARRIAGE AND DIVORCE ACT 1936.

Unsoundness of mind is not a Ground for annulment.MUSLIM LAW A person of unsound mind cannot contract a marriage and such a marriage if contracted is void. However, if the guardian of the person of unsound mind considers such marriage to be in his interest and in the interest of society and is willing to take up all the monetary obligations of the marriage, then such a marriage can be performed

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HMA & DIVORCE

HMA 1955 – Unsoundness of mind for a continuous period of not less than 3 years, immediately preceding presentation of the petition for divorce.

• HMA 1976 – Incurably of unsound mind or continuous or intermittent mental disorder of such a kind & to such an extent that one spouse cannot reasonably be expected to live with the affected spouse.

• Definition of Mental disorder as per HMA – mental disorder is mental illness, arrested or incomplete development of the mind, psychopathic disorder or any other disorder or disability of the mind and includes schizophrenia.

MARRIAGE & DIVORCE LAWS

Hindu Marriage Act - Special Marriage ActParsi Marriage & Divorce Act

Spouse is incurably of unsound mind or has been suffering continuously or intermittently from mental disorder of such a kind & to such an extent that the other spouse cannot reasonably be expected to live with the affected spouse.

Dissolution of Muslim Marriage Act 1939

A Muslim woman can seek divorce on the ground that her husband has been insane for a period of two years.Indian Divorce Act 1869 [applicable to Christians]

Unsoundness of mind is a ground of divorce on two conditions that is it must be incurable and it must be at least for two years immediately before the filing of the petition.

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FAMILY COURTS ACT, 1984

• To promote conciliation in & secure speedy settlement of disputes related to marriage and family affairs.

• Jurisdiction - validity / nullity of marriage / divorce/ maintenance, custody of children property, adoption etc.,

• Informal proceedings, in camera, to maintain confidentiality.• Assistance of legal expert if required.• Assistance of counselors for reconciliation .• Free legal aid for weaker sections. MEDICAL INSANITY

• In medicine, insanity is a disorder of the mind that impairs the mental facilities of a man

• Insanity is another name for mental abnormalities due to various factors & exists in various degrees

• Insanity is popularly denoted by idiocy, madness, lunacy, mental derangement, mental disorder & all other forms of mental abnormalities known to medical science.

• Insanity in medical terms encompasses a much broader concept than insanity in legal terms.

LEGAL INSANITY

• Disorder of the mind, which impairs the cognitive faculty.• Mental capacity is impaired to such an extent as to render a

person incapable of understanding the consequences of actions, the nature of the act or that the act is wrong or contrary to law.

• Excludes from its purview insanity which might be caused or engendered by emotional or volitional factors.

• 4 kinds of persons who may be said to be non compos mentis [not of sound mind]

•  An idiot – is one who from birth has perpetual defective mental capacity without lucid intervals

• Non compos mentis due to illness & therefore excused from consequences of acts are committed under such influence

• A lunatic or madman – are those who become insane & whose incapacity might be or was temporary or intermittent & afflicted by mental disorder at certain periods & vicissitudes, with lucid intervals

• One who is drunk 39

APPENDIX – 5

LEGAL CASE VIGNETTES – COURT JUDGEMENTS

SYNOPSIS OF THE JUDGMENTS ON MENTAL HEALTH OF MARRIED WOMAN & CHILDREN

NO

PARTIES , CITATION & COURT

OBSERVATIONS / FINDINGS

1 Ajitrai Shivprasad Mehta vs. Bai VasumatiAIR 1969 Guj 48 [Gujarat High Court]

The Court held that Section 13(1)(iii) of the Hindu Marriage Act, 1956 [‘HMA’] provides that a marriage solemnised, whether before or after the commencement of the Act, could, on a petition presented by the spouse, be dissolved by a decree of divorce on the ground that the other spouse "has been incurably of unsound mind for a continuous period of not less than three years immediately preceding the presentation of the petition".

"Unsoundness of mind may be occasioned either by perversion of intellect, manifesting itself in delusions, antipathies, or the like; or it may arise from a defect of the mind. The mind may be originally so deficient as to be incapable of directing the person in any matter which requires thought or judgment, which is ordinarily called idiocy or the defect may arise from the weakening of a mind, originally strong by disease or some accident of a physical nature, by which memory is lost & the faculties are paralysed, although there is no perversion of the mind, nor any species of that insanity which is ordinarily called mania.”

Whether the congenital insanity, lunacy or unsoundness of mind, the mental infirmity satisfies the test of legal insanity only when it is to such a degree that a person is unable to understand the nature & consequences of his acts & would, therefore, be considered not responsible for his acts or his acts in the eye of law could not be regarded as his acts at all. It also held that a slight mental disorder, which a person is suffering intermittently, cannot be termed “legal insanity”.Petition for divorce rejected.

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2 Rita Roy vs. Sitesh Chandra Bhadra RoyAIR 1982 Cal 138 [Calcutta High Court]

The Court held that each case of schizophrenia has to be considered on its own merits. Schizophrenia is an illness of slow insidious onset developing over years. There may be reports of strange, odd inappropriate behaviour. There will be progressive deterioration in the level of performance at work & socially; school report, examination results & the employment record will provide objective & usually reliable indices of intellectual performance, its maintenance or decline. It will always be wise, even for the consultant psychiatrist to see the patient on several occasions before ruling out schizophrenia, & his relatives, employers & friends should be interviewed, A single interview may not disclose any abnormalities. But if he can be observed in hospital, quite blatant signs may be recognized.

Petition for divorce rejected.3 R.D. Upadhyay vs. State of A.P. & others

(2001) 1 SCC 437 [Supreme Court]

An under trial prisoner was a lunatic & not fit to stand trial. The Court held that there had been a complete violation of the statutory provisions in dealing with the prisoner. The Court also suggested to the lawyer appearing for the State to file a submission/suggestion note for assistance of the Court to issue such guidelines & directions that may be necessary for ensuring that such prisoners do not suffer in the same way.

4 Hema Reddy vs. Rakesh Reddy2002 (2) ALT 16 [Andhra Pradesh High Court]

Mental cruelty can broadly be defined as that conduct which inflicts upon the other party such mental pain & suffering as would make it not possible for that party to live with the other. In other words, mental cruelty must be of such a nature that the parties cannot reasonably be expressed to live together. The situation must be such that the wronged party cannot reasonably be asked to put up with such conduct & continue to live with the other party. It is not necessary to prove that the mental cruelty is such as to cause injury to the health of the petitioner.

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While arriving at such conclusion, regard must be had to the social status, educational level of the parties, the society they move in, the possibility or otherwise of the parties ever living together in case they are already living apart & all other relevant facts & circumstances which it is neither possible nor desirable to set out exhaustively. What is cruelty in one case may not amount to cruelty in another case. It is a matter to be determined in each case having regard to the facts & circumstances of that case. If it is a case of accusations & allegations, regard must also be had to the context in which they were made.

The Court made a finding that “mental disorder” has to be proved by leading medical evidence. It does not mean that we are proposed to lay down that mental disorder cannot be proved by any other type of evidence.” –

Dissolution of marriage rejected.5 Sharda v. Dharmapal

(2003) 4 SCC 493 [Supreme Court]The Court held that a decree for divorce in terms of S.13 (1) (iii) of the HMA can be granted in the event the unsoundness of mind is held to be not curable. A party may behave strangely or oddly inappropriate & be progressive in deterioration in the level of work which may lead to a conclusion that he or she suffers from an illness of slow growing developing over the years. The disease, however, must be of such a kind that one spouse cannot reasonably be expected to live the affected spouse. A few strong instances indicating short temper & somewhat erratic behavior on the part of the spouse may not amount to suffering continuously or intermittently from mental disorder.

A matrimonial Court has the power to order a person to undergo medical test. Passing of such an order by the Court would not be in violation of the right to personal liberty under Art. 21 of the Constitution. However, the court should exercise such a power if the applicant has a strong prima facie case & there is sufficient material before the court. If despite the order of the Court the respondent refuses to submit to medical examination, the Court will be entitled to draw & adverse inference against him/her.

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The Court was considering whether a party to a divorce proceeding can be compelled to undergo a medical examination. Held yes.

6 V.Bhagat vs. D.Bhagat (Mrs.)&

Neelu Kohli vs. Naveen KohliA.I.R. 1994 S.C.710: (1994) S.C.C. 337 [Supreme Court]

Mental cruelty in S.13(1)(i-a) of HMA can broadly be defined as that conduct which inflicts upon the other party such mental pain & suffering as would make it not possible for that party to live with the other. In other words, mental cruelty must be of such a nature that the parties cannot reasonably be expected to live together.Marriage dissolved.

7 N.Senthi Nath – vs - Karthigai SelviH.M.O.P.No.470 of 2006Family Court, Chennai

The Court held that “In the case of people suffering from Schizophrenia, sexual dysfunction is one of the symptoms” & in this case held the a married woman had “sexual aversion due to psychotic illness Schizophrenia as well the state of being with full fantasies & loss of reality.” Divorce granted

8 Vinita Saxena – vs - Pankaj Pandit2006(3) SCC 778 [Supreme Court]

The Court held that for establishing “legal insanity” as a ground of divorce, the “Mental disorder is of such a kind & to such an extent that the petitioner cannot reasonably be expected to live with the respondent; that mental insanity/mental disorder should be looked into with regard to the medical disease, viz., schizophrenia, its causes, its psychotic symptoms, how it develops, how serious the disorder becomes when paranoia is combined with delusional symptoms & the nature of drugs which are administered, on the basis of medical publications in this regard.

9 Sujadata Uday Patil – vs – Uday Madhukar Patil2007 (1) CTC 266 [Supreme Court]

Held that that in case of matrimonial disputes, Courts should adopt a pragmatic approach in the matrimonial dispute & keep in mind ground realities. The Court should also bear in mind host of factors in such adjudication & the most important matter is whether the marriage can be saved & husband & wife can live together happily & maintain a proper

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atmosphere at home for upbringing of their off springs.

Divorce granted.10 Samira Kohli – vs- Dr.Prabha Manchananda & Another

(2008) 2 SCC 1 Supreme CourtHeld that consent of the patient is required for treatment. Consent, unless it can be clearly or obviously implied, held, should be express consent.

In India, the extent & nature of information required to be given by Doctors to the Patient in order to obtain a valid consent is governed by the “Bolam Test” & not by the reasonably prudential patient test.

It is for the Doctors to decide with reference to the condition of the patient, nature of illness & the prevailing established practices as to how much information regarding the risks & consequences should be given & how they should be couched in the best interest of the patient. It was held that by taking such a decision, the Doctor cannot be held to be negligent because another body of opinion takes a different view.

It was also held that mere consent for diagnostic procedure would not amount to authorization to perform therapeutic surgery in life threatening circumstances.

The court differentiated between “Consent”, Real Consent” & “Informed Consent” based on the Guidelines to Doctors issued by the General Medical Council if UK.

The court was considering whether informed consent of a patient was required for surgical procedure and if so, what should be the nature of such consent.

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