ORIGINAL ARTICLE ABSTRACT

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1 222 ORIGINAL ARTICLE Discharge of patients with mental illness back into the community following involuntary admission versus voluntary admission: factor analysis Srinivas Kandrakonda, 1,MD, MPH, Hareesh Angothu, 2,MD, DPM, Vara Prasad Vanapalli, 3,MD, Rajender Soorinedu, 4,MD 1 Consultant Psychiatrist; Manager, Medical Scientific Affairs in Clinical Research, Hyderabad, India; 2 Assistant Professor of Psychiatry, Department of Psychiatry, Kakatiya Medical College, Warangal, India; 3 Consultant Psychiatrist, Kakinada, India; 4 Consultant Psychiatrist, Kakinada, India ABSTRACT Background: At times, there is even a need for community involuntary treatment which may help in reducing the hospital admissions of patients with mentally illness. In India, there are very few State run psychiatric hospitals where patients get admitted and treated under section 20 of MHA There should be provisions for treating mentally ill in the community, if needed involuntarily. Detention of mentally ill for treatment during the time of florid psychosis is not a permanent solution for mental illness treatment. With the existing medicines these illnesses cannot be cured but can be controlled. So it leaves us with the option of using such detention only when no other method to treat is practicable. Such detention should best in the interest of the patient and the community. Aims: This study was an attempt to explore the practical problems in reintegrating the mentally ill back in to the community after their involuntary admission in comparison with the voluntary admission. Methods: This is a cross sectional study and data was collected from the medical records of 113 patients who were admitted in this hospital during the period of January 2010 to June Nearly 470 voluntary patients records were analysed during the above said period but by randomization they were limited to nearly 113 to equate with the involuntary admission. Results: Median duration of total hospitalization period in involuntary admission group of patients is 108 days with a minimum of 15 days and maximum of 460 days of admission. Median duration of involuntary stay at hospital is 91 days in some patients in whose reception orders there was a clear mention of what should be done after their treatment and recovery. In comparison to this group median duration of involuntary stay in others is 113 days as there was no clear mention in their reception orders about what should be done after their treatment and recovery. Conclusion: Most of the hospitals do not have any community social worker who can liaise with the family members to address their fears and to facilitate their early reintegration back in to home. There is a need for a review board consisting judiciary and medical personnel which can revoke the reception order at any point of time to minimize through duration of involuntary hospitalization in closed wards. Key message: Mentally ill patient rights need to be protected. Key words: Mental illness; community; involuntary; Mental Health Act 1987 Date of first submission: 23/9/14 Date of initial decision: 10/10/14 Date of acceptance: 31/12/14 INTRODUCTION: Apart from many other drawbacks, one of the important drawbacks of the current mental health legislation of India is that it is silent about community psychiatry. This act assumes mental illnesses as events that happen in human life rather as chronic illnesses which require both inpatient and outpatient treatment for prolonged periods. At times there is even need for community involuntary treatment which may help in reducing the hospital admissions of mentally ill. There should be provisions for treating mentally ill in the community if needed involuntarily. Detention of mentally ill for treatment during the time of florid psychosis is not a Address for correspondence: Dr Srinivas Kandrakonda, Address: Plot Number 457, HMT Hills, Opposite JNTUC, Kukatpally, Hyderabad Phone number: dr. srinivaskandrakonda@gmail.com How to cite this article: Kandrakonda S, Angothu H, Vanapalli VP, Soorinedu R. Discharge of patients with mental illness back into the community following involuntary admission versus voluntary admission: factor analysis. AP J Psychol Med 2014; 15(2) : permanent solution for mental illness treatment. With the existing medicines these illnesses cannot be cured but can be controlled. So it leaves us with the option of using such detention only when no other method to treat is practicable and such detention should be best in the interest of the patient and the community. The concepts of detaining the mentally ill patient only in the interests of the community based on the parameter of dangerousness or detaining the patient in the interest of the patient where there is no imminent threat to patient him or herself, both have limitations. It has to balance on both factors and also such decisions should be based on the diagnosis and other medical reports. The purpose of involuntary admission or detention is clear in some country legislations with the terms like for treatment, to prevent from deterioration, to protect from harm, for reintegration, for improving skills but in many cases Indian reception orders are being issued with main intention that mentally ill are danger to the community. Though laws as per the constitution differs in different countries the freedom and the right to choose among different choices is considered as human right even when it matters to life and death. In the medical context the right to refuse treatment remained controversial especially if the person suffers from mental disorder. People can refuse blood

2 Kandrakonda, et al: Discharge of patients with mental illness 223 transfusion based on their religion even when the life is at stake. In Afghanistan women refused to consult male obstetrician even in the absence of women obstetricians. People may have their own opinions and decisions to make choices regarding treatment of medical conditions, how much critical illness it may be. Often patients may differ in their opinions with doctors regarding the need for treatment and choice of treatment. Involuntary admission for observation and or for treatment of mentally ill patient can be made under special circumstances as described under section 19 of chapter IV or according to section 20 of chapter IV of Mental Health Act (MHA) 1987 by a reception order issued by First class judicial magistrate or above rank. [1] There are only few state run psychiatric hospitals where patients admitted under section 20 of MHA There is scarcity of literature in this connection regarding patient s perspectives of involuntary admission, mean duration of hospitalization, refusal of family members and community to integrate patient back in the society after treatment, undue delay in sending patient back in to the community because of poor liaison between different departments of State, unavoidable delay in reintegrating them back in to community. With this background there is a need to look in to such factors influencing the process of reintegration of mentally ill patients back in to the community after their involuntary admission in a psychiatric hospital. Identifying such factors might help in making better plans to reintegrate them back in to community as early as possible after their treatment. Early reintegration in to the community reduces the burden on psychiatric hospitals in terms of conserving financial and human resources of the State. This also helps in improving the overall productivity of the community as a whole, once the recovered patients start attending their work. The process of reintegration of mentally ill patients admitted by a reception order back in to the community is more difficult compared to other mentally ill patients with similar illnesses as refusal by family members is significant factor delaying their reintegration. All the efforts to persuade and educate and to accept these patients back in to their homes sometimes takes few months during which patient has to stay in the hospital under supervision in spite of being declared fit for discharge. At times lack of clarity and ambiguity in judicial orders concerning the involuntary admission may itself cause the delay or further delay in addition to delay due family refusal to accept patient back. In contrast to medical diseases it is often observed that persons with severe mental illness fail to recognize the need of treatment for their mental illness. People belonging to religious group of Jehovah s witnesses refuse to accept blood transfusions for them and for their children even when their life is endangered based on their religious conviction that Jehovah will turn his back on anyone who receives blood transfusions. [2] However such refusal for treatment with lack of understanding about the consequences may not be acceptable and such personnel are often forced to receive treatment either in the community or in the hospital. Treatment of any illness particularly a mental illness when a patient refuses treatment has legal implications hence such admissions and treatments are made according to mental health laws of the land. There is a wide variation in the legislations in the process and methodology of involuntary admission across countries. In a review of outcomes of involuntarily admitted patients a substantial number of involuntary patients do retrospectively not feel that their admission was justified and beneficial. Patients with more marked clinical improvement tend to have more positive retrospective judgments. [3] In this regard to sending patients, back in to the community after closed ward treatment problems arising were conveyed to the Judiciary department. Among them one important suggestion to the magistrates was to use the terminology provided in the MHA 1987, [1] rather than the terminology given in the Indian lunacy act 1912 while issuing a reception order. More importantly this order also highlighted that mentally ill person who is fit for discharge after treatment and who is not discharged in time for want of police escort or defective reception orders would amount to violation to human right of such person [2]. In this back ground this study was carried out with primary objective of exploring the poor terminology in the reception order and whether they were in accordance to the instructions issued by the Honourable High Court. In contrast to medical diseases patients with severe mental disorders often fails to recognize the need for treatment due to lack of insight, stigma, poor awareness and understanding about mental disorders. Also in sharp contrast to medical diseases severe mental disorders often impair their reasoning and judgment at personal and social level. It is at this juncture severe conflict arises between the wishes of mentally ill patient and their neighbourhood community regarding the need and choice of treatment of mental disorder. Also severe mental disorders often interfere with interests and rights of neighbourhood personnel living around the mentally ill patient. A person with paranoid schizophrenia may have significant problems in interactions with his family members with false beliefs about persecution and infidelity. A mere functional impairment and distress to the individual may not be sufficient justification for considering any involuntary treatment in mentally ill. But when the false beliefs and actions of the individual because of the mental disorder starts interfering the rights of others and harmonious living within same home, the demand for involuntary treatment arises. But the concept of involuntary treatment has widespread implications considering the potential for abuse for such law. History also suggests many incidents of abuse political and military. The laws concerning the procedures and duration of involuntary admission of mentally ill are different in different countries.

3 224 Widely criticized aspect of current Indian mental health legislation is the appeal process of mentally person against his detention. A person who is under detention for the treatment of mental illness can appeal his challenge to the district judge of that hospital s Jurisdiction. However once if the patient is detained he has limited access to the judiciary. This study was an attempt to explore the practical problems in reintegrating mentally ill back in to the community after their involuntary admission in comparison with the voluntary admission. MATERIALS AND METHODS: Study design: This is a cross sectional study and data was collected from the medical records of 113 patients who were admitted in this hospital during the period of January 2010 to June Nearly 470 voluntary patients records were analyzed during the above said period but by randomization they were limited to nearly 113 to equate with the involuntary admission. This study was carried out at Institute of Mental Health, department of psychiatry, Osmania Medical College, which is 800 bedded psychiatric care hospital in Hyderabad, India. Selection of the patient population: All the involuntarily admitted patients during this period were included in this study. A separately designed questionnaire was used to collect the socio demographic details, illness related details and details regarding hospitalization periods. Appropriate permissions were obtained from the concerned authorities before the start of the study. As the data collection by reviewing the charts and no direct patient interviewing was carried out no separate informed consent was obtained for the involuntary admission patients whereas for the one who got admitted for above said period proper consenting along with the duration of the stay is calculated. All the results analyzed using SPSS RESULTS Table 1 shows the socio demographic details of the subjects. All the 113 patients who got admitted under reception order during this period were included in this study which is compared to the voluntary group of 113 after randomization. Of these 83(73.5%) were males and 30 (26.5%) were females in involuntary group whereas 79 (71.2%) were males and 34 (28.8%) were females in voluntary group. Their mean age was 31 and 31.5 years respectively in both groups. Nearly half of these patients are from rural areas which may imply that patients from rural areas might have high risk of involuntary admission requirement similar to voluntary admission. This may be also be due to poor access to mental healthcare facilities which can cause delay in initiation of early treatment to these patients from rural areas. Nearly two thirds of these are either unmarried or separated from their spouse. Their single status might be related to their chronic mental illness or their poor social support network system or due to poor functional ability due to mental illness. Kandrakonda, et al: Discharge of patients with mental illness Table 1- Socio demographic details of patients admitted involuntarily and voluntarily (n=113) Variables Involuntarily Voluntarily Sex (%) (%) Males 83 (73.5) 79 (71.2) Females 30 (26.5) 34 (28.8) Marital status Unmarried 50 (44.2) 44 (41.3) Married and living together 42 (37.2) 48 (39.2) Bereaved 2 (1.8) 5 (3.7) Divorced 3 (3.5) 2 (2.9) Left by spouse due to illness 15 (13.3) 13 (12.3) Residence Urban 28 (24.8) 19 (18.8) Semi Urban 29 (25.7) 38 (29.7) Rural 56 (49.6) 56 (49.6) Educational status Illiterate 48 (42.5) 53 (44.9) Primary School 27 (23.9) 32 (27.9) High School 24 (21.2) 27 (23.2) Intermediate 6 (5.3) 4 (4.9) Graduate or above 8 (7.1) 7 (6.9) Diagnosis Organic psychosis 1 (0.9) 3 (1.4) Substance related disorders 3 (2.7) 11 (7.7) Schizophrenia 69 (61.1) 49 (51.5) Psychosis NOS 16 (14.2) 25 (19.2) Mania 6 (5.3) 3 (4.3) BPAD 14 (12.4) 11 (10.9) Others 4 (3.5) 11 (8.5) Co morbid Mental retardation Yes 3 (2.7) 0 No 110 (97.3) 113 (100) However it appears that from this sample unmarried or separated people from their spouse are likely to have high risk of involuntary admission compared to those are having stable marital relationships. Nearly two thirds are either illiterate or having just primary level of education which implies that people with less formal education are at higher risk of requiring both involuntary or voluntary admission. About seventy five percent patients are schizophrenic or psychotic compared to about twenty percent of mood related disorders. This study also implies that schizophrenic patients are at high risk of requiring involuntary/voluntary admission than patients with mood related disorders. A minority of these patients were also diagnosed as having co morbid mental retardation apart from their psychotic excitation which was the cause for their involuntary admission with no cases of mental retardation in voluntary group. The analysis of the correlation matrix indicates that the strongest positive correlation between type of admission and the total duration of stay in the hospital by the mentally ill before joining the community for normal functioning (r= 0.89, p=0.0001) which shows most of the patients who were voluntarily admitted stayed for shorter duration in the hospital. The negative correlation between the co morbidity and the psychiatric diagnosis (r= -.16, p=0.017) which indicated severity of the medical complications widely

4 prevalent along with psychiatric burden which is delaying the reintegration process. When we analyzed the reception order phrasing which was used while referring these patients to psychiatric tertiary care centres for involuntary admission, we found that only in 58% of judicial reception orders it was clearly mentioned that those mentally ill patients were being referred as per the existing mental health act 1987 (Table 2). In about 30% reception orders there was no mention any such law. Simply it was stated that patient should be admitted and treated for their mental illness. In about 16% of reception orders it was mentioned that those patients were referred as per the Indian lunacy act In about 82% of case these patients were not evaluated by qualified psychiatrists before their admission to determine whether or not they require involuntary admission. This may be due to low availability or non availability of government psychiatrists at periphery level for formal evaluation of patients about their illness severity or requirement for involuntary admission. This may be also due to the difficult process involving such referral from magistrate to local doctor then again back to magistrate and then to involuntary admission. But in about 40 % cases either they were seen by local government general practitioner or psychiatrist before they were ordered for involuntary treatment. One more important finding in our study was that mention of how should be patient handled once his or her treatment finishes for their acuteness of mental illness, i.e. how a patient should be sent back to the community after their recovery and what process should be adopted for that? In about two thirds it was mentioned that they should be handed over to their family members. In about 15% there was no such any mention. In rest it was mentioned that either they should be produced before the same magistrate for revaluation or they should be allowed to go home on their own as a free citizen without any further restrictions. In our study we found that such phrases have significance in either prolonging or restricting the patient s hospital stay even after their improvement and declaration as fit for discharge by the hospital board. Table 2- Reception order process adopted and the act that was mentioned to detain the mentally ill patients (n=113) Mention of mental health act in order Mental health act (51.3%) Indian lunacy act (16.3%) No act mentioned in the order 36 (31.9%) What to do after treatment of patient (mention in the order) Hand over the patient to family 72 (63.7%) To produce the patient before magistrate 10 (8.8%) To leave the hospital as a free citizen 14 (12.3%) No mention of any such thing 17 (15.2%) Was the Patient seen by psychiatrist before order Yes 20 (17.7 %) No 93 (82.3%) Was the Patient seen by general practitioner before issuance of order? Yes 42 (37.2%) No 71 (62.8%) Kandrakonda, et al: Discharge of patients with mental illness 225 It was observed in this study that there are huge variations in the period of hospitalization (Table 3). Hence median duration and the range were chosen to describe the duration of hospitalization. Median duration of total involuntary hospitalization period in these patients is 108 days with a minimum of 15 days and maximum of 460 days. It is the illness severity on which usually the hospitalization either voluntary or involuntary period depends. However we have observed that apart from the severity there are certain other factors which were contributing to their prolonged stay at hospital. One factor was that, a phrase used in the reception order by the magistrate has implication in prolonging or restricting the duration of hospital stay. So we have analyzed the reception orders issued by the judicial magistrates particularly about the mentioning of what should be done with patient once the treatment of patient finished and patient improves clinically where he or she will be in a position to take care of self. Median duration of hospitalization is only 91 days when there is mention of the status of the patient after treatment in comparison to 113 days when there is no mention of any post discharge status of the patient. Table 3- Hospitalization period and its relation to post discharge status of patient Mean S.D Median Range Total Duration of hospitalization Involuntary admission Voluntary admission Total Duration of hospitalization If PDS mentioned in order If order lacks clarity about PDS Detention after being declared as fit for discharge If PDS is mentioned in order If order lacks clarity about PDS Total What to be done with the patient after being declared as fit for discharge To leave as free citizen as mentioned in reception order To hand over to family as mentioned in the reception order To produce before magistrate as mentioned in the reception order Total SD= Standard Deviation, PDS= Post discharge status of the patient as mentioned by the magistrate in the reception order

5 226 DISCUSSION: In our study we found that some patients were kept involuntarily even for more than a year because of various factors where as some required only as few as 15 days of involuntary admission. As we discussed earlier when we analyzed the phrasing related to patient handling after their recovery from mental illness median duration of hospitalization was only 91 days in patients with reception order containing their post discharge status compared to 113 days of hospital stay in whose orders as there was no such mention. We looked in to other reasons of why there was delay in sending these patients back in to the community after their declaration as fit for discharge by the board. It was difficulty and delay in communicating and liaising with the local law enforcement agencies to take patient back to their home or to be produced before court. Often we noticed that in more than half of the families after patients involuntary admission family members were reluctant and hesitant to accept them back. Family members behaved some times as if they are more comfortable when their patient is detained in ward than at home. Over all these patients are kept in closed wards even after their discharge for a median duration of 35 days with a minimum of 0 days to maximum of 400 days. However it was observed that these patients were detained for a maximum of 230 days even when there was mention of the post discharge status of the patient in the reception order of the patient. When it was mentioned that patients should be produced before magistrate after treatment patients were detained for a median duration of 22 days with a maximum of 140 days. This is mainly because the patient has to produce before the same magistrate by the concerned police station from which he was brought to the hospital. So after declaring the patient as fit for discharge it has to be communicated to the in charge police officer of the corresponding police station that patient is recovered from mental illness and he may be produced before magistrate as per the reception order. In certain cases it was observed that police were reluctant to take patient back complaining lack of adequate staff. When it was mentioned in the order that patient should be handed over to the family member s patients were detained for a median duration of 43 days with a maximum of 140 days. This is mainly because patient s family members were not ready to accept patient back to their home. But our study shows quite good social functioning in the ward after 35 days of admission in line with Cochrane data base. [5] Main reason they were citing was patient s assaultive behaviour in their past. Sometimes finally patients were handed over to the family members by the hospital staff. In some cases hospital staff has travelled for hundreds of kilometres and took the local police help to hand over the patient back in Kandrakonda, et al: Discharge of patients with mental illness their home. This hospital does not have any community social worker who cans liaise with the family members to address their fears and to facilitate their early reintegration back in to home. In certain orders it was mentioned that after treatment patient may leave the hospital as a free citizen. However such order is difficult to implement in practical. Most of the time patient s residence remained hundreds of kilometres away from this tertiary care hospital. Often these patients will be admitted by the law enforcement personnel in dishevelled state without any money in their pockets. So the question arises without any financial support how the patient can travel back to his home. Again in such cases it will be informed to the patient s family members that patient has recovered and may be taken back to home. Often resistance from family members was observed. In this study the median duration of detention of some patients in whose it was mentioned as free citizen is 14 days with a maximum of 171 days. Significant finding in our study which will have future implication are when there is mention that patient can leave the hospital as a free citizen after his or her treatment the median duration of involuntary hospitalization is only 14 days, in comparison to 11 days in voluntary group, whereas 43 days and 22 days when there is a mention of handing over the patient to respective family members or producing the patient before the same magistrate. This is very significant in our opinion that if there is a clear mention that patient can leave the hospital as a free citizen after their treatment a patient is less likely to spend in hospital for about one month compared to other options. This reduces the cost on State care facility both in terms of financial and medical resource expenditure. This also has implication as the person leaves early back in to the community he or she is more likely to return to work thus improving the overall productivity at the community. In our study we noticed that this particular prolongation in this group is only because of certain phrasings of orders rather anything to do with their illness severity or type of illness. Such studies should be carried out in other state run psychiatric hospitals to understand the current practice of issue of reception orders. Especially studies require looking for the differences in admission rates and duration hospitalization if reception orders are enclosed with medical certificates in a format described in the MHA There is a need for a review board consisting judiciary and medical personnel which can revoke the reception order at any point of time to minimize the duration of involuntary hospitalization in closed wards. Such proposals are in the draft prepared for the new mental health act which may take years to come in to existence. However there is every chance that mentally ill people might be detained for reasons and periods which may not be sufficient for detention in the point of view of a psychiatrist. Whether or not this is a rights

6 Kandrakonda, et al: Discharge of patients with mental illness 227 violation of mentally ill needs a debate as it is often argued that every such detention is done only with good faith and best interest of the patient. Limitations of the study This study was carried out in one particular state and hence generalizability is questionable, whether or not such reception orders being issued in other states needs further studies. Also this study represents the existing problem only as there is a chance for betterment in the terminology of reception orders if judiciary personnel are sensitized to mental health terms and problems. CONCLUSIONS: The views expressed in this article are solely of the authors. It does not reflect its endorsement by the journal, the editor, the editorial board, the publisher, or the society The effects of hospital care and the length of hospitalization is important for mental health policy. Outcomes of the present study do suggest there is a need for a review board consisting judiciary and medical personnel which can revoke the reception order at any point of time to minimize the duration of involuntary hospitalization in closed wards to protect the violation of mentally ill patient rights. Finally, there was a significant difference favouring short-stay hospitalization for good social functioning and improved personal hygiene. Early discharge and reintegration back in to community reduces the financial and medical resource expenditure of the State as illness severity is the not only the reason for prolonged hospitalization as in this study. Authors contribution: Harish Angothu (HA) and Srinivas Kandrakonda (SK) conceptualized and designed the study and were the major contributors in preparing and writing the manuscript. HA and SK acquired the data and performed all the assessments. All the authors analyzed and interpreted the data; were involved in revising and editing the manuscript critically for important intellectual content; and read and gave approval for the final version of the manuscript to be published. All the authors made substantial intellectual contributions to this study and participated sufficiently in the work. All authors take public responsibility for appropriate portions of the content and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. HA and SK are the guarantors for this study. Acknowledgements: Nil References 1. The Mental Health Act, 1987, Stat. Act no 14 of 1987 (1987). 2. Thompson HA. Blood transfusions and Jehovah s Witnesses. Texas Medicine. 1989; 85(4): Circular-Languishing of mental illness persons in the Institute of Mental Health -Certain instructions to the Judicial Magistrates by the High court of Andhra Pradesh, R.O.C.No.3204/O.P.CELL-E/2010 (2010). 4. Somasundaram O. The Indian lunacy act, 1912: The historic background. Indian J Psychiatry 1987; 29: Babalola O, Gormez V, Alwan NA, Johnstone P. Length of hospitalization for people with severe mental illness. Cochrane Database Syst Rev 2014; 1:CD Conflict of interest: None declared Source(s) of support: Nil