GUIDELINES FOR

MARRIAGE & MENTAL

HEALTH ISSUES IN
WOMEN

PRELIMINARY DRAFT FOR

CONSENSUS
SPECIALITY SECTION - WOMENS MENTAL HEALTH
INDIAN PSYCHIATRIC SOCIETY
Dr. U. C. Garg
Thirunavukarasu

Prof. M.

Hon. General Secretary

Indian Psychiatric Society
Society

President
Indian Psychiatry

Dr. Bharathi Visveswaran

Convener

Dr. Sonia Parial

Chair person

CORE COMMITTEE
Prof. M. Thirunavukarasu
President, Indian Psychiatric Society
Prof. & HOD, Dept of Psychiatry
SRM Medical College and Research Centre Chennai
Dr. U. C. Garg
Hon. General Secretary
Indian Association Of Biological Psychiatry (IABP)
Past Treasurer, SAARC Psychiatric
Federation (SAF)
Past President, Central Zone, Indian
Psychiatric Society (IPS)
Dr. Sonia Parial
Chair person
SPECIALITY SECTION ON WOMENS MENTAL HEALTH
Indian Psychiatric Society
Dr. Bharathi Visveswaran
Convener
SPECIALITY SECTION ON WOMENS MENTAL HEALTH
Indian Psychiatric Society
Prof. G. Bhagya Rao
President elect, South zone IPS, Vizag,
Retd Director of Medical Education, A.P.
Retd superintendant, Government Hospital For Mental Care
Vizag, A.P.

Prof. P. K. Dalal
Professor & Head, Department of Psychiatry
C.S.M. Medical University, Lucknow, U.P
Prof. Indira Sharma
Head of the Department of Psychiatry
Institute of Medical Sciences,
Banaras Hindu University,Varanasi,UP
Chairperson - IPS. Speciality section on Forensic Psychiatry
Prof. S. Nambi
Past president
of the Indian Psychiatric Society
Prof & head, Dept of Psychiatry
Sree Balaji Medical College & Hospital Chennai
Prof.Prabha S. Chandra
Professor of Psychiatry, NIMHANS, Bangalore, India
Prof. Prakash B. Behere ,
Dr.B. C.ROY Award Recipient
Director, Professor & Head
Department of Psychiatry,
Mahatma Gandhi Institute of Medical
Sciences,Sevagram,
Wardha,(Maharashtra)
Chairman, Publication Division,Indian Psychiatric Society
Honble judge
Mr.T. C. S. Raja Chockalingam
Principal Judge, Family court
Chennai High Court Campus

Dr. C. Ramasubramanian
Consultant Psychiatrist
Founder, Chellamuthu Trust For Psycho Social Rehabilitation
Nodal Officer, District Mental Health Program,
Madurai
Dr. T.S.Sathyanarayana Rao
Editor, Indian Journal of Psychiatry
Prof. & Head, Department of Psychiatry,
JSS University, JSS Medical College & Hospital
3

Mysore
Mrs. Sharada Devi
Addl. District & Sessions Judge
Fast Track Court, Vizianagaram District, A.P

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

Methods used to develop these guidelines

The speciality section on womens 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 July10, 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
Honble
Judge
Mr.T.
C.
S.
Raja
Chockalingam,
Dr.
C.
Ramasubramanian, Dr. T. S. Sathyanarayana Rao and Honble Judge
Mrs. Sharada Devi.
A seminar was organized by the chairperson and convener of this
speciality section at Chennai on the 10 th 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.

Future Plans
6

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

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 prefinal 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.

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.

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, doesnt 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 husbands
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?

GUIDELINES
SECTION 1
SECTION 2
SECTION 3

SECTION 1
Before Marriage
Common Scenarios
1. Family plans for marriage and asks for suggestions
2. 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
`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.

10

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

11

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 womans
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 familys 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.
12

 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).

13

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 patients 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 familys concepts and belief systems and expectations on

marriage.
Elicit reasons as to why the family wants the woman to get
married?
Elicit familys awareness of patients 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 familys 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.

14

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 husbands 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.

15

 May decrease disability and enhance functioning if the family

of origin had high expressed emotions and the husbands family
is more understanding.
May ensure social and financial security.
Having children may further enhance above security.

Medication and marriage

Address familys 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 psychiatrists duty to give factual information

The psychiatrist should put the facts in front of patient/familythe assets and liabilities, the abilities and disabilities.
16

The psychiatrist should disclose the above points in a

generalised form as well as specific to the patient, taking in to
consideration her illness
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.
17

Avoid directive messages do this, dont do this.

Avoid moral preaching and do not be judgemental
Do not certify `fitness for marriage.
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
18

 Discuss contraception with the patient. Clarify her

doubts and fears.
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.

19

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
20

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 womans side and the husbands
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
husbands 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
21

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
womans 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.

22

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

23

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 husbands 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 illnesss 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.
24

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
courts duty to go in to the truth behind allegations by both
parties.
Stick to only a clinical opinion.
Discuss with peers

25

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 patients and
the spouses 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.
Patients 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
MYTHS RELATING TO MARRIAGE AND MI
26

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.
MYTH: Patients with mental illness are violent and dangerous.
27

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 patients 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 disorders
developed by the Rehabilitation Committee of Indian Psychiatric
Society,
December 2000.
Items :
I. Self Care : Includes taking care of body hygiene, grooming, health

28

including bathing, toileting, dressing, eating, taking care of ones

health.
II. Interpersonal Activities (Social Relationships) : Includes initiating
and
maintaining interactions with others in contextual and social
appropriate manner.
III. Communication and Understanding : Includes communication and
conversation with others by producing and comprehending spoken/
written/non-verbal messages.
IV. Work : Three areas are Employment/Housework/Education
Meaures
on 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 items
0 - 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 Score
Add scores of the four items and obtain a total score
Weightage for duration of illness (DOI) :
<2 years : score to be added is 1
2-5 years : add 2
6-10 years : add 3
>10 years : add 4
Global Disability
Total disability score + DOI score = Global Disability score
percentages:
0 No Disability = 0%
1-6 Mild Disability = <40%
7-13 Moderate Disability = 40 - 70%
14-19 Severe Disability = 71-99%
20 Profound Disability = 100%
Cut off for welfare measures
MANUAL FOR IDEAS
29

In order to score this instrument, information from all possible

sources should be obtained. This will include interview of patient,
the care giver and
case notes when available.
I. Self Care
This 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 and
brush 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
standard
of cleanliness and orderliness ?
Scoring
0 = No disability
Patients level and pattern of self-care and normal, within the social
cultural and economic context.
1 = Mild
Mild 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 = Moderate
Lack of concern for self-care should be clearly established such as
mild deterioration of physical health, obesity, tooth decay and body
odors.
3 = Severe
Decline 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).
4 = Profound
Total or near total lack of self-care (Example : risk to physical
survival, needs feeding, washing, putting on clothes, etc. Constant
supervision necessary).
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II. Inter-personal Activities

Includes patients 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 Questions
a. 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 ?
Scoring
0 = No
Patients gets along reasonably well with people personal
relationships.
No friction in inter-personal relationships
1 = Mild
Some friction on isolated occasions. Patient known to be nervous or
irritable but generally tolerated by others.
2 = Moderate
Factual evidence that pattern of response to people is unhealthy.
May
be seen on more than few occasions. Could isolate himself from
others
and avoid company.
3 = Severe
Behaviour in social situations is undesirable and generalized.
Causes
serious problem in daily living/or work. Patient is socially ostracized.
4 = Profound
Patient in serious and lasting conflict, serious danger to problems or
other. Family afraid of potential consequences.
III. Communication and Understanding
Understanding spoken messages as well as written and non-verbal
messages and ability to reduce messages in order to communicate
with others.
Questions
a. Does he avoid talking to people ?
b. When people come home what does he do ?
31

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 ?

32

Scoring
0 = No disability
Patient mixes, talks and generally interacts with people as much as
can be expected in his socio-cultural context. No evidence of
avoiding
people.
1 = Mild
Patient described as uncommunicative or solitary in social
situations.
Signs of social anxiety might be reported.
2 = Moderate
A very narrow range of social contact, evidence of active avoidance
of
people on some occasions and interference with performance of
social
rules, causes concern to family.
3 = Severe
Evidence of more generalized, active avoidance of contact with
people
(leave the room when visitors arrive and would not answer the door
or phone).
4 = Profound
Hardly has contacts and actively avoids people nearly all the time,
for
example, may lock himself inside the room. Verbal communication is
nil or a bare minimum.
IV. Work
This includes employment, housework and educational performance.
Score
only one category in case of an overlap.
Employment
Guiding Questions
a. 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 ?
Scoring
0 = No disability
Patient goes to work regularly and his output and quality of work
performance are within acceptable levels for the job.
33

1 = Mild
Noticeable decline patients ability to work, to cope with it and meet
the demands of work. May threaten to quit.
2 = Moderate
Declining work performance, frequent absences, lack of concern
about
all this. Financial difficulties foreseen.
3 = Severe
Marked decline in work performance, disruptive at work, unwilling
to adhere to disciplines of work. Threat of losing his job.
4 = Profound
Has been largely absent from work, termination imminent.
Unemployed
and making no efforts to find jobs.
Housewives
In similar ways, housewives should be rated on the amount,
regularity
and efficiency in which tasks in the following areas are completed.
Consider
the amount of help required completing these. Acquiring daily
necessities,
making, storing and serving of food, cleaning the house, working
with those
helping with domestic duties such as maids, cooks, etc., looking
after
possessions and valuable in the house.
Student
Assess an score on performance in school/college, regularity,
discipline,
interest in future studies, behaviour at educational institutions.
Those who
had to discontinue education on account of mental disability and
unable to
continue further should be given a score of 4.
Ideas Scoring Sheet
Items 0 1 2 3 4 5
Self
care,
Inter-personal
Understanding, Work
A. Total Score + B. DOI Score

Activities,

Communication

&

- Global Score (A+B)

APPENDIX -4

LEGAL ASPECTS THAT A MENTAL HEALTH PROFESSIONAL SHOULD BE

AWARE OF.
34

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 MARRIAGE

1. The Special Marriage Act 1954
2. 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
6. The Christian Marriage Act 1872
7. The Indian Divorce Act 1869
8. The Family Courts Act 1984
HINDU MARRIAGE ACT, 1955 [HMA]
35

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

36

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 Act

Parsi 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.

37

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
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APPENDIX 5
LEGAL CASE VIGNETTES COURT JUDGEMENTS
SYNOPSIS OF THE JUDGMENTS ON MENTAL HEALTH OF MARRIED
WOMAN & CHILDREN
N
O
1

PARTIES , CITATION & COURT

OBSERVATIONS / FINDINGS
Ajitrai Shivprasad Mehta vs. Bai Vasumati
AIR 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.

39

Rita Roy vs. Sitesh Chandra Bhadra Roy

AIR 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.

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.
Hema Reddy vs. Rakesh Reddy
2002 (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.
While arriving at such conclusion, regard must be had to the
40

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.
5

Dissolution of marriage rejected.

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.
The Court was considering whether a party to a divorce
proceeding can be compelled to undergo a medical
41

examination. Held yes.

6

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

&
Neelu Kohli vs. Naveen Kohli
A.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.
N.Senthi Nath vs - Karthigai Selvi
H.M.O.P.No.470 of 2006
Family 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
Vinita Saxena vs - Pankaj Pandit
2006(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.
Sujadata Uday Patil vs Uday Madhukar Patil
2007 (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
atmosphere at home for upbringing of their off springs.
Divorce granted.
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10

Samira Kohli vs- Dr.Prabha Manchananda & Another

(2008) 2 SCC 1 Supreme Court
Held 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.

43