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Marriage and rehabilitation of persons with severe mental illness
* Corresponding author: Dr. Indira Sharma, Professor Emeritus, Psychiatry, National Academy of Medical Science, New Delhi, India. indira_06@rediffmail.com
Presented for the ‘Dr. Shridhar Sharma Oration Award’ of National Academy of Medical Sciences. New Delhi (India), on 21 April 2023
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Received: ,
Accepted: ,
How to cite this article: Sharma I. Marriage and rehabilitation of persons with severe mental illness. Ann Natl Acad Med Sci (India). doi: 10.25259/ANAMS-2023-5-14-(937)
Abstract
Psychiatric illness is associated with disability, which is responsible for the major part of the global burden of disease. Despite the fact that, all persons with mental disorder (s) do not qualify for marriage, as per the legislations on marriage, recent court judgments have disallowed nullity/ divorce on the ground of mental illness (MI)/ schizophrenia. It may noted that the right to marriage and to have a family is a universal human right and most persons with mental disorders do get married. In India, the institution of marriage is strong. Rehabilitation via marriage is feasible and desirable. It meets all the rehabilitation needs of people with severe mental disorders, provides a dignified life with a family and children in a natural setting, is economical, and associated with least stigma. It decreases the burden on the State for providing formal rehabilitation services.
Keywords
Marriage
Rehabilitation
Severe mental illness
INTRODUCTION
A sizable proportion of persons with severe mental disorders have disability, which is responsible for the major part of the global burden of disease. Psychosocial rehabilitation (PSR) of PwMI (person with mental illness) is needed to improve functioning, integrate them into the society and improve their quality of life. Current rehabilitation programs of PwSMI (person with severe mental illness) have limitations. The author has almost 5 decades of clinical experience in psychiatry of working in the general hospital (University Hospital, Banaras Hindu University) setting and private practice. No patients were ever referred to rehabilitation centers. Most patients with severe mental illness (SMI) have been married, integrated well into society and are having a fairly good quality of life. This paper will discuss rehabilitation of SMI via the institution of marriage. The discussion will focus on the situation in India.
UNDERSTANDING SERIOUS MENTAL ILLNESS
Serious mental illness is a mental, behavioral or emotional disorder, associated with functional impairment of serious nature leading to interference or limitation in major activities of life.1
Generally, serious mental illness includes bipolar disorder (BPD), psychotic disorders, including depression with psychotic symptoms; and resistant depression. Anxiety, personality and eating disorders, are considered as Serious mental illness when associated with severe functional impairment.2 The main contribution of the burden of mental illnesses is by persons with SMI experiencing disability.1
SEVERE MENTAL ILLNESS: MAGNITUDE OF PROBLEM
One in seven Indians are afflicted with psychiatric disorders.3 In India, the disease burden (non-fatal) can be attributed largely to mental disorders. Since 1990 the proportional contribution by mental disorders to the disease burden (total) in India has almost doubled from 2.5% to 4.7% in 2017. Depressive disorders have contributed maximally (depressive disorders 33.8% (major depressive disorders 26.7%)) to disability-adjusted life years (DALYs). Other disorders such as, idiopathic developmental intellectual disability (10.8%), schizophrenia (9.8%), BPD (6·9%), and anxiety disorders (19%), have also contributed significantly to DALYs.3
OUTCOME OF MENTAL DISORDERS
In a follow up study4 involving 3 centers in India (Vellore, Madras and Lucknow), patients with schizophrenia were studied with respect to factors related to the course and outcome of the disease. 287 patients out of 386 patients completed the follow up. The majority of active symptoms had subsided at 2 years, and a good outcome was noted in 67% patients at 5 years follow up.4 In two studies by WHO (the International Pilot Study of Schizophrenia5 and the Determinants of Outcome of Severe Mental Disorders),6 the patients with schizophrenia, in the centers located in India, had a better outcome.6 All the patients achieved remission at one year follow up; only half of them had residual symptoms.7 Thus schizophrenia has a good outcome in India.
SEVERE MENTAL ILLNESS AND DISABILITY
It is difficult to define disability as a single definition may not cover all its aspects. Nevertheless, it has been defined as, ‘any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.’8
The International Classification of Impairment, Disability and Handicap (ICIDH) 1980.8 has categorized disabilities into behavior, personal care, locomotor, body disposition, communication, dexterity, particular skill disabilities, situational, and other activity restrictions.
The ICIDH has been developed by WHO. It has evolved a unifying framework for describing under the term "disablement," disability, handicap, impairment and the consequences of disease.8
For measuring disability in mental disorders, the Indian Psychiatric Society developed the Indian Disability Evaluation and Assessment Scale (IDEAS). It classifies disabilities into 4 major domains: Self-care, Interpersonal Activities, Communication and Understanding, and Work.9
Significant disability (>40%) is accepted with a diagnosis of schizophrenia, obsessive compulsive disorder (OCD), BPD, or depression (mild-to-moderate), with a duration of 3 years or more, which has been treated on a regular basis.10
In a study, from July 2003 to June 2004, involving 228 outpatients, from the Psychiatry Department of Assam Medical College, Dibrugarh, disability was assessed by IDEAS in 228 out patients with 7 major disorders, BPD, schizophrenia, OCD, depressive episodes (major depressive disorder), anxiety disorder, dementia and alcohol use disorder (AUD). Notably, all the 7 disorders were found to be associated with significant disability; schizophrenia was found to be most disabling. Further, disability associated with OCD was comparable to disability due to AUD and anxiety disorder.11
ASSESSMENT OF PSYCHIATRIC DISABILITY AND REHABILITATION NEEDS
Major areas of functioning are adversely affected by disability such as care of one-self, understanding and communication, relations with others, and work performance.
Several instruments are available for assessment on one or more domains specially designed for specific populations. It can be assessed clinically with a structured pro forma or formally with the help of instruments like IDEAS 2000 or the ICIDH 1980. Certain instruments (The Maryland Assessment of Social Competence, Time Sample Behavior Checklist, Clinical frequencies recording system, Staff Resident Interaction Chronograph and Independent Living Skills Inventory) have been recommended for patients in long-term residential settings.12 Out patients and higher functioning in-patients have been assessed by sets of other instruments (Client Assessment for Strengths, Interests and Goals).
Apart from this, there are tools to assess specific domains such as cognition (Schizophrenia Cognition Rating Scale), and learning (Micromodule Learning Test (MLT)).
The key components of skills training are responsiveness to verbal instruction, modeling and role play; all these are measured by MLT.12
CURRENT METHODS OF REHABILITATION IN INDIA
Rehabilitation of PwSMI involves a wide range of interventions, usually by a multidisciplinary team to integrate the patients into the mainstream of society. Most rehabilitation programs of PwSMI have been initiated by hospitals, non-governmental organizations (NGOs), community and consumers. Eg family care-givers have established day-care centers; Asha Deep in Assam, and Asha in Tamil Nadu.13 Besides, community based rehabilitation programs are being operated by public-private partnership, wherein the services of Accredited Social Health Activists (ASHAs) are utilized for identification, referral and treatment of PwSMI.14 Richmond Fellowship, with branches all over India, and The Schizophrenia Research Foundation in Chennai provides for residential facilities, half-way homes and Day Centers for PwSMI.13 The Medico Pastoral Association-Rehabilitation Centre provides for ‘House parents’, a novel approach to rehabilitation.13 Going a step further in Kerala from 1993, the homeless wandering mentally ill are picked from the streets, provided food, shelter and medical care, and then, wherever possible, united with their families.13
Concern has been expressed by Murali and Tibrewal regarding the availability of PSR services both in the government and private (NGO) sectors.13 In Ranchi, at the Central Institute of Psychiatry (CIP), and in many other centers, a steady decline in PSR services has been reported.13 Earlier, CIP, Ranchi provided excellent PSR of psychiatric patients.13 In these statements the authors do not appreciate: 1) that family and marriage have a role in health care (which includes mental health care) of PwMI; 2) that the formal rehabilitation declined because it was replaced by better rehabilitation at homes by families; and 3) also that many of the problems of patients, such as food, clothing, housing, employment, education, socialization, etc are not psychiatric problems per se, but are social problems which are being also faced by a vast majority of persons without mental illness. It is the responsibility of the family, and also of the State to ensure that no citizen be deprived of these basic amenities; and 4) Every citizen has a right to work and have a ‘living wage’ (Article 43 Constitution of India).15
LIMITATIONS OF CURRENT METHODS OF REHABILITATION
Rehabilitation services in the form admission into a hospital; residential facility, both short and long-stay; day care centers (sheltered workshops) and homes for the homeless generally focus on occupational therapy relating to the hospital/ centre’s needs with no income generation; where payments are made the remunerations are very low. Besides, many rehabilitation centers are expensive. Eg city-based rehab centers have been charging between Rs 60,000 to Rs 3 lakhs for a three to four month program.16 Then the long stay ones (eg Cadabams in Bangalore) take a hefty one-time payment. Sadly, the latter are in great demand probably because they provide the rich with the means to abandon the mentally sick relative. A major criticism is that they have become mental asylums. Apart from this, care at the rehabilitation centers maintains ‘stigma for mental illness’, which seriously comprises the dignity of the PwSMI in the real world.
Maslow has proposed a 5-tier hierarchy of human needs. Sex is a basic human need in the first tier (physiological needs). This tier also includes other basic survival needs, such as air, water, food, shelter, clothing, warmth, sleep.17 Rehabilitation centers do not provide for the avenue for meeting the sexual needs of patients. In India, live-in-relations are a taboo and arranging marriage of PwMI is not on the agenda rehabilitation centers. Notably, unmarried women, more so those with SMI, are at great risk for sexual harassment by people, both in rehabilitations centers and outside by others when they move out.
MARRIAGE, MENTAL ILLNESS AND REHABILITATION
Marriage is the basis for the family. It is a union between two persons for a stable and enduring relationship, which is socially supported. The six key functions of marriage are: regulation of sexual behavior and reproduction, nurturance and care of children, production, consumption, socialization, and passing on of race and other ascribed statuses.18
For Hindus and Christians marriage is a sacrosanct permanent union, which is indissoluble.
As per the law cited in the Hindu Shastras,19 marriage is one of the essential sanskaras (sacraments). The Veda mandates marriage for every Hindu, “To be mothers were women created and to be fathers men.” “Dharma must be practiced by man together with his wife and offspring.” “He is only perfect who consists of his wife and offspring.”19
The relationship between marriage and mental illness is complex. A stressful marriage can precipitate or exacerbate mental illness (MI) in a vulnerable person. On the other hand, a stable marriage provides for all the needs of a PwMI, including sexual needs. Marriage has been a dominant institution in life of Indians, so it plays a vital role in the care and management of PwMI.20
In Eastern countries, including India, high marriage rates in PwSMI have been reported.21 Marriage of PwSMI improves social support and prevents against the stigma of an unmarried status,21 Apart from this, it provides for a dignified life with children and a family; also provides for adoption when there are no children from the marriage, all of which have a protective role; and rehabilitates the PwMI in a natural setting, with minimum costs and stigma.
In a pilot study, 783 PwMI, registered at Schizophrenia Research Foundation (SCARF), were investigated for marriage and marital outcome. Although more women could be married; more had a poor marital outcome in terms of being divorced, abandoned or deserted. Despite this, the responsibility of looking after the women and their children was thrust on their parents as the husbands failed to provide maintenance or any financial assistance. On the other hand, more men had a good marital outcome as their wives continued to live with them and took up the responsibility to earn and support the family. It is thus evident that patriarchy significantly influenced the marital outcome in PwMI.22
The relationship between mental illness and marital outcome was investigated in 76 patients with schizophrenia (first episode) in a follow up study over a 10-year period. Interestingly, about 70% were married before the start of illness. Gender differences were evident; more men could not marry, while more women faced broken marriages. Good marital outcome was found to be associated with several clinical variables such as having children, a short duration of illness, type of onset, hallucinations (auditory), simple depression when recruited into the study, etc.23 Gender issues were further examined in an in-depth study of 76 women with schizophrenia and with broken marriages, hailing from 3 centers. Surprisingly, many had separated from their husbands, but not legally. The stigma of marital separation was acutely felt by them, which was not less than that for being mentally ill. On the positive, even after several years, many were still very hopeful that one day they would unite with their husbands.24
The suicide rate in never married/ single has been reported to be double of the rate in married persons (11 per 100,000);18 suggesting that marriage reinforced by children has a protective role in that it is associated with lesser suicidal risk. These studies highlight the fact that mental illness does not adversely affect the marital outcome in majority of PwMI.18 A subsequent study from Chennai, the Institute of Mental Health, examined the outcome of marriage in 275 patients with major mental illness. Interestingly, only 10% of the patients faced poor outcome of marriage (widowhood, separation or divorce). Poor outcome of marriage was 13 times more in patients with schizophrenia than in those with BPD.18 Even more intriguing is the fact that in the cases filed for nullity or dissolution of marriage in the Family Court at Chennai over a period of one year, in only a small proportion of cases (45/5000), the ground was mental illness.18
In conclusion, having children has some protective role in preventing mental illness, women with mental illness are discriminated against and the restoration of marriage is vastly important even for women with schizophrenia.
SHOULD PERSONS WITH MENTAL ILLNESS GET MARRIED?
Social perspective on marriage
The social dictum is that everyone must marry. It is the primary responsibility of parents to get their children married. In order to have a dignified status one must marry. Sexual needs are to be met only via the institution of marriage. However, in the setting of mental illness, society has double standards because of the social stigma for mental illness. Parents generally believe their child should get married, irrespective whether the child has a MI, and would always look for a partner without mental illness. In the vast majority of cases, the history of mental illness is concealed at the time of solemnization of marriage else it would be difficult to get the child married. In real life setting most PwMI get married. In India, as most marriages are arranged, this is not very difficult.
Legal perspective on marriage of persons with mental illness
The Universal Declaration of Human Rights (UDHRs) mentions under article 16 about the right to marriage. All adults have a right to get married and have a family, which is without any limitation due to race, religion or Nationality.25 Thus, mental illness by itself cannot be a ground for denial of the basic right to marriage. The Mental Healthcare Act, 201726 has endeavored to uphold the rights of PwMI. 11 Rights are enlisted, but the ‘Right to marriage’ is glaringly absent. This omission is understandable as the Act is essentially based on western norms wherein marriage is not mandatory, and a live-in-relationship is not a great taboo as in India. There is, however, mention in Art 19 (1) of the ‘Right to live in, be part of, and not be segregated from society and in Art 20 (1) of the ‘Right to live with dignity.’ The ‘Right to marriage’ under Art 16 of UDHRs takes care of these rights.
The legislations on marriage, The Hindu Marriage Act (HMA)27 1955 and Special Marriage Act (SMA), 1954,28 have enlisted the conditions which must be met for a valid marriage. Thus, marriage of PwMI is restricted when: 1) the person cannot give a valid consent because of mental illness, or 2) has a mental disorder because which he is unable to fulfill the obligations of marriage and beget children, or 3) has been getting repeated episodes psychosis (insanity), or 4) has committed fraud by not revealing the history of mental disorder. Such a marriage would be and void as per SMA28 and voidable as per HMA.27
These marriage laws were enacted almost seven decades back when good treatment for mental illness did not exist. The outdated laws are the cause of continuing stigma for mental illness and create problems for persons with mental illness who are married without disclosing the history of mental illness to the other party at the time of marriage. Thus many cases land up in courts for matrimonial reliefs such as nullity, restitution of conjugal rights, divorce, and judicial separation. Considering the plight of PwMI, the Indian Psychiatric Society brought forward a Position statement on ‘Marriage mental illness and law.’29 The amendments suggested to the HMA are: 1) removal of mental illness under the conditions of a Hindu marriage, and 2) a statement that not disclosing a history of psychiatric illness would not amount to fraud. Further, the SMA may be amended on the same lines.29
An important question is whether there is any obligation to disclose the fact of past illness, and whether failure to disclose the same amounts to ‘fraud’ within the meaning of the word ‘fraud’ used in Section 12 (1) (c). Whether fraud has been committed can be determined by applying the ‘doctrine of caveat emptor,’ which is explained. It is not the duty of the parties intending to marry to themselves speak of their virtues and vices. If a party is interested in a particular quality of the other party, eg, no history of MI, the party should make specific inquiries. On inquiry if wrong information is given, or there is deliberate concealment of relevant facts, it is to be reckoned as fraud committed.30 If on inquiry, there is no concealment and the petitioner himself fails to verify all the facts because of his own lethargy, carelessness or difficulties, then it is not fraud. This is well been illustrated in the NG Dastane v. S Dastane, 1975 case. The bridegroom and his parents had been told that due to a stroke of heat, the mental condition of the bride was adversely affected, and she was treated in a mental hospital, and that they could themselves enquire about it from there. The bridegroom failed to make inquiries about the case. Applying the doctrine of caveat emptor, the court did not pass a decree of nullity.31
The happy news is that over the years the judiciary has been able to appreciate the beneficial effects of modern psychiatric treatment and has not granted decree of divorce merely on the ground of mental illness. It has always been the intention of the court to protect the marriage.
An important point that deserves mention is that the petitioner has the responsibility to prove mental illness in the respondent. This provision, by itself, may be self-defeating as the respondent may deny MI even when present. A better provision would be to order for a psychiatric assessment (to conform mental illness) and treatment (if MI is present). This would improve marital relations and chances of survival of the marriage.
There have been a few landmark judgments. In R N Gupta v. R Gupta 1988,32 the Supreme Court observed that “mere branding of a person as schizophrenic will not suffice”, “Schizophrenia is what schizophrenia does”, and that outcome of schizophrenia depends on psychosocial stimuli and therapeutic activity. The Punjab-Haryana High Court observed in Mst Lakshmi v. Dr Ajay Kumar 2005, that the disease is curable, once treated, it may not recur.33 Likewise, in Kollam Chandrasekhar v. Kollam Padmalatha 2013, the Supreme Court ruled, “Man can’t dump wife on grounds of schizophrenia. It is a treatable, manageable disease, on par with hypertension and diabetes.”34 Recently, in Pawan Kumar Pandey v. Sudha, the Allahabad High Court ruled that the existence of a mental disorder, by itself, is legally an insufficient ground law for dissolution of marriage.35
PROBLEMS IN MARRIAGE OF PwSMI
Problems arise in marriage of PwSMI when psychotic symptoms arise during, soon after or within a couple of years after marriage. In such cases the patient has a high likelihood of being rejected by the spouse/ family. The risks are much less if the patent had a past episode from which there was full recovery for about 2 years or the MI develops 2 years after marriage.36
Cessation of psychotropic medication around the time of marriage, along with the stress of marriage can precipitate the illness. The thumb rule is that marriage of the PwSMI should take place only when the patient has recovered well from the acute phase of MI and is either off medication or is maintained on a low dose for about 1–2 years prior to marriage.36 In women, switch to a non-prolactin elevating drug (eg, aripiprazole, asenapine, clozapine, lurasidone, olanzapine, quetiapine, or ziprasidone); else, addition of aripiprazole 3–6 mg/day, is recommended.37 In men sexual function and potency issues need to be sorted by making appropriate changes in the medication. Medication should be continued during marriage and thereafter to prevent emergence of symptoms.
SEVERE MENTAL ILLNESS, MARRIAGE AND REHABILITATION: ROLE OF PSYCHIATRIST
The major challenges are: 1) to ensure that the PwSMI receives uninterrupted psychiatric treatment (including rehabilitation) of optimal quality; 2) to help the patient/ spouse/ families (natal and of in-laws) to cope with various marital problems that may emerge during the course of treatment; and 3) to engage spouse/ family (s) as co-partner (s) in the care of the patient.
The role of the psychiatrist/ psychiatric team is vital at all stages, much before, around, soon after, and much after marriage. Before marriage the psychiatrist has the important duty to guide the patient/ family about selecting the partner, the timing of marriage, and selecting the right medication, to ensure the safety for both the mother and the foetus/ baby when the women with SMI plans pregnancy. The prospective partner should preferably not have a SMI (eg schizophrenia, schizoaffective disorder, BPD or AUD) in a first degree relative, as this would result high morbidity (almost 50%) in offspring of the couple.36
The rehabilitation needs of the patient should be assessed. The rehabilitation plan should be made in consultation with family and executed. The spouse/ family has a major role to play in ensuring a healthy life style, which is essentially a balance routine with time slots for personal care, exercise, work/ study/ and vocational training. Family and marital problems are dealt with by a wide range of family-based Intervention techniques. While addressing problems relating to marriage, the psychiatrist must ensure that due attention is given to social norms and legal provisions. For details the reader may refer to articles: ‘Clinical practice guidelines: Management of issues relating to marriage, mental illness, and Indian legislation’36 and ‘Preserve and strengthen family to promote mental health.’20
Models of marriage, mental illness and psychosocial rehabilitation
Generally, presence of SMI in a son/daughter does not deter a family from getting him/ her married.
In clinical practice several models are seen. Some are mentioned below:
First marriage
MI is present in only one partner, husband or wife, and the couple lives with the children at the husband’s place. This is the most common and the ideal model. Occasionally, both partners may have a SMI/MI or one has a SMI and the other has physical illness like epilepsy/ physical disability. Partners accept each other’s deficiencies and adjust.
It is not uncommon to see couples wherein one partner has SMI at the time of marriage, and the other develops a SMI a few years after marriage. There have also been cases wherein the woman with SMI after marriage continues to live with her parents, along with her husband (as ghar jamai) and children. Parents provide all the support needed to the patient and her family; especially to the husband to find a job or to start a business. The husband in generally cooperates and adjusts.
Second marriage
A sizable number of marriages of PwMI end up in divorce. When divorce takes place, parents generally remarry the son/ daughter with SMI, to a person with/ without MI. When there are children from the 1st marriage, custody issues may come up. Sometimes the children of a woman with MI, may be retained by her parents, to facilitate her 2nd marriage.
Divorced status
Second marriage of PwMI may not take place because several reasons. In such situations, the divorced PwSMI lives with the children (if any, from first marriage) or with parents/ brother’s family.
Unmarried status
Occasionally one comes across PwSMI who could not be married. All their needs are generally taken care of by their parents, and after their death, by their brothers.
In all the models described above it has been seen that the families from both sides are very helpful by way of providing continuity of medical care, housing, economic and social support. They also provide education, vocational training, employment and other needs of the PwMI. When children of the PwSMI grow up, they take up the responsibility of providing care to meet the needs of their parents.
CONCLUSION
All PwSMI have a right to marry and most of them do get married. Rehabilitation via the institution of marriage is recommended. Marriage provides for all the rehabilitation needs, a dignified life with children and a family in the natural setting, and rehabilitates the PwSMI with minimum costs and stigma. It also decreases the burden on the State for providing formal rehabilitation services.
Ethical approval
Institutional Review Board approval is not required.
Declaration of patient consent
Patient's consent not required as there are no patients in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of Artificial Intelligence (AI)-Assisted Technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Reference
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