Psychosocial and clinical profile of chronic long-stay psychiatric patients in teaching institution

Abstract

Background:

A good number of psychiatric patients continue to stay in psychiatric hospitals for longer period of time despite their recovery. Inevitably, they tend to experience limitations to their freedom, personal choice and social isolation, and loss of self. It is important to assess the characteristics of these patients and the challenges in social integration.

Materials and Methods:

A cross-sectional study was conducted at a mental health hospital from May 2018 to January 2023. The data were collected from a retrospective review of 101 case files of all the long-stay patients (LSPs) who were admitted to psychiatric closed wards. Furthermore, cases were utilized to analyze the psychosocial situations of LSP.

Results:

This study reveals that the majority of the subjects were unmarried, females, unemployed, and hailing from rural background. Nearly 50% of the patients’ families are untraceable. About three-fourths of those patients had the wrong address and lacked community psychiatric rehabilitation facilities and employment opportunities in their neighborhood. Caregivers’ burden and poverty are major causes for prolonged or long-term hospitalization of patients in the mental hospital and barriers to community reintegration.

Conclusion:

Facilitating the transition of patients from the psychiatric hospital to community care is the need of the hour.

Introduction

World Health Organization (WHO)[1] reports that mental health concern is one of the major contributors to the global burden of disease and disability. Globally, about 12.3% of disability-adjusted life years (DALYs) and 31% of all years lived with disabilities across age groups are accounted for by mental health and neurological conditions.[2] Though India has various policies and programs to protect the rights of people with mental health concerns, they continue to experience violation of civil, cultural, economic, political, and social rights.[3,4,5,6,7,8,9,10]

In psychiatric hospitals, a small percentage of psychiatric patients tend to spend their lifetime under continuous or prolonged hospitalization and these patients are regarded as long-stay patients (LSPs).[11,12] This is due to the severity of mental health concerns with poor symptom control, in addition to homelessness caused due to one or more factors such as abandonment and/or neglect by the patients’ immediate family, poverty, stigma in society, and lack of sustainable community care model and rehabilitation homes for the recovered patients in the community.[13,14,15,16,17]

Paton et al.[18] had highlighted that nearly 40% of elderly patients were hospitalized at an acute psychiatry unit for a longer duration primarily because no other alternatives were available. Furthermore, clinical and patient-oriented factors have been found to have an association with prolonged hospitalizations. Schizophrenia, non-affective psychosis,[19-21] chronic mental illness,[16,22] substance use disorders, and comorbid medical illness[23] predict the length of stay (LOS) of patients. Involuntary admissions of the patients and having a history of frequent hospitalizations also contribute to longer LOS.[21,24,25,26]

Despite the deinstitutionalization movement, progressive laws, policies, and programs to prevent human rights violations, stigma, and discrimination against person with mental illness, a small segment of patients continue to experience lengthy stays in psychiatric hospitals.

In low- and middle-income countries like India, the community mental healthcare model mainly focuses on reintegrating people with mental illness into their family. However, this model is unsuccessful for a set of population who have been abandoned in the hospital due to societal stigma, lack of family support, finical and caregivers’ burden, death of family primary caregivers, lack of psychiatric rehabilitation facilities in the community, and much more. There is also a need to involve psychiatrists at general hospital in addressing psychosocial issues to ensure treatment adherence and prevent long-term hospitalization of patients. This study explores the psychosocial profiles of LSP in a tertiary mental health hospital.

Materials and Methods

The study was conducted at a mental health hospital in Southern Bengaluru, India. A cross-sectional survey of all the LSPs (N = 101) using a retrospective review of the case files was conducted between May 2018 and January 2023. Those patients of age 18 and above with a definitive diagnosis of psychiatric illness as per the International Classification of Diseases, the tenth version (ICD-10), and residing in the closed ward for a minimum period of two months or more were included in the research. A file review datasheet was developed by the researchers and validated by six mental health professionals. The datasheet looked at obtaining the following aspects: socio-demographic profile of the patients, clinical profile of psychiatric illness, circumstances of admissions, length of admission, psychosocial reasons for long-term stay, and efforts made by the multidisciplinary team to reintegrate back to the family/community as secondary data from the case files of the LSP. Ethical clearance was obtained from the Institute Ethical Committee, Behavioral Science, National Institute of Mental Health (NIMHANS), Bengaluru.

Analysis

Descriptive statistics was used to analyze the socio-demographic data, while the case study method LSP[27,28] was used to explore the factors contributing toward homelessness and institutionalization of people living with mental illness. The data collection was performed upon obtaining permission from the Institute Ethical Committee.

Results

Characteristics of LSP

As shown in Table 1, the mean age of the LSP was 45.22 ± 13.03 years. Nearly half of the LSPs (45.5%) were unmarried. Three-fourths of the LSPs belonged to the Hindu religion (85.1%). More than half of the LSPs had some form of formal education (55.4%), and about one-fourth of them (34.7%) were unemployed before psychiatric admission. The majority of the LSPs were from rural areas (57.4%). Though 51.5% of LSPs’ family members were contactable, about 65.3% of them were not visited by a family upon admission to a psychiatric closed ward. The average LOS at the hospital was 5.70 ± 8.30 years, and the longest LOS is 45 years. About 88.1% of LSPs were admitted to the hospital under involuntary circumstances.

Table 1.

Personal, familial, and clinical aspects of LSP

Socio-demographic and familial variables of LSP	n=101 ((%))
Mean age (years and±SD)	45.22±13.03
Minimum and maximum age of LSP (range)	20 years–79 years
Mean number of children	0.48±1.02
Gender
Male	45 (45.5)
Female	55 (55.5)
Marital status
Married	36 (35.6)
Unmarried	46 (45.5)
Others (widows/separated/divorced)	29 (18.9)
Religion
Hindus	86 (85.1)
Muslims	6 (5.9)
Christians	9 (8.9)
Domicile
Urban	43 (42.6)
Rural	58 (57.4)
Education
Educated	56 (55.4)
Uneducated	45 (44.6)
Employment
Employed	35 (34.7)
Unemployed	26 (25.7)
Unknown	40 (39.6)
Current family information
Available	52 (51.5)
Unavailable	49 (48.5)
Family visit
Never	66 (65.3)
Rarely	13 (12.9)
Sometimes	12 (11.9)
Always	10 (9.9)
Clinical variables of LSP Patients
Place of stay before hospitalization
Own house	31 (30.7)
On the street and others	53 (52.4)
Rented	10 (9.9)
Relatives	7 (6.9)
Mode of admission
Involuntary	89 (88.1)
Voluntary	12 (11.9)
Mean duration of hospital stay (DoHS)	5.70±8.30
Minimum and maximum duration of stay	1 year–45 years
History of substance use
Yes	20 (19.8)
No	81 (80.2)
Categorization of LSP according to clinical diagnosis
Schizophrenia	42 (41.6)
Mood disorder	26 (25.7)
Psychosis NOS	14 (13.9)
IDD and others	13 (12.9)
Schizoaffective disorder	6 (5.9)

Clinical profile of LSP

The mean age of onset of psychiatric illness was 27.6 ± 7.00 years. The majority of the LPS had a diagnosis of schizophrenia (41.6%) followed by mood disorders (25.7%) and other conditions including intellectual developmental delay (IDD). Poor drug compliance, frequent relapse, tendency to wander away, aggression, and attempts to commit suicide were some of the common reasons stated for admission to a closed ward [Table 2]. Frequently reported Z codes under ICD-10 include problems related to the social environment, problem related to employment and unemployment, problems related to housing and economic circumstances, education and literacy, and other problems related to the primary support group including family circumstances [Table 3].

Table 2.

Reasons for admission of LSP

Details	Frequenciesa
Poor drug adherence and relapse	57 (46.5)
Wondering behavior	40 (39.6)
Violent and aggressive behavior	25 (24.7)
Suicidal attempts	20 (19)
Absconding behavior	10 (9.6)

^aNot mutually exclusive

Table 3.

Z category diagnosis of LSP

Z category codes	Frequenciesa
Z 60: Problems related to the social environment
(Z 60.4): Social exclusion and rejection	101
(Z60.2): Living alone	24
Z63: Other problems related to the primary support group, including family circumstances (Z63.2): Inadequate family support	35
(Z63.8): Other specified problems related to the primary support group	35
(Z63.3): Absence of family member	24
(Z63.4): Disappearance and death of the family member	24
(Z63.0): Problems in relationship with spouse or partner	12
Z63.1): Problems in relationship with parents and in-laws	12
(Z63.5): Disruption of family by separation and divorce	10
Z73: Problems related to life management difficult (Z 73.4): Inadequate social skills	75
(Z 56): Problem related to employment and unemployment	66
(Z 59): Problems related to housing and economic circumstances	53
(Z 55): Problem related to education and literacy	45
(Z 81.8): Family history of other mental and behavioral disorders	36
Z91: Personal history of risk factors, not elsewhere classified (Z 91.5): Personal history of self-harm	15

^aNot mutually exclusive

Psychosocial factors of LSP

While 48.5% of LSP stayed at the hospital as their families were non-traceable, the others stayed due to a culmination of factors including unemployment, scanty options for rehabilitation, limited understanding of mental illness, violence, death of the primary caregivers, and family members not keen on taking up the responsibility of caregiving owing to existing interpersonal relationship issues, and similar concerns [Table 4].

Table 4.

Reasons for prolonged duration of stay in hospital

Psychosocial factors	Frequenciesa
Unemployment	85 (84.1)
Lack of rehabilitation facility in the community	80 (79.2)
Family misconception about mental illness	77 (76.2)
Poverty	75 (74.2)
Client refusal to return home due to unsafe living environment	60 (59.4)
Homelessness	53 (52.5)
Caregiver burden	48 (47.5)
Diagnostic profile	40 (39.6)
Violence and stigma toward patients in society	38 (37.6)
Death of the parents (primary caregivers) and unwilling to take back by siblings and extended family members	24 (23.8)
Caregiver profile—elderly single parent	22 (121.7)
Unable to trace the family	18 (16.8)
Family abandonment	19 (18.9)
Marital discord	10 (9.9)

^aNot mutually exclusive

Case studies

Mr. P was a 40-year-old bachelor and a lawyer belonging to middle socioeconomic status and hailing from a rural district of Karnataka. Owing to a first information report (FIR) filed by the neighbors in the local police station about his abusive and inappropriate behavior, he was produced in front of the Magistrate. Since he continued to exhibit similar symptoms in the presence of the Magistrate, he was admitted to the closed ward of the hospital with a reception order (RO), as per the Mental Health Act, 1987. The patient was diagnosed with paranoid schizophrenia, and his symptoms were treated. Upon response to medication, the patient was able to provide his family history. He had been living alone in a rented apartment following his parents’ death for the past 15 years. His unmarried brother was living in an accommodation provided by his employer in a hospitality setting, which had minimum infrastructure. Owing to the treatment-resistant nature of the patient’s mental health condition, minimum wage, and the demanding nature of the job held by the brother, he was unwilling to visit the patient or cooperate with the treating team with regard to taking up the responsibility of caregiving for the patient. He continues to stay in the closed ward for about eight years.

S was a 34-year-old man, diagnosed with moderate IDD and behavioral problems, and he has been staying in the hospital for the last five years. His mother, an aging widow, was distressed as she was unable to bring him for regular follow-up or manage his behavioral problems at home. Upon evaluation of existing resources in the community for support from extended family members and mental health care facilities such as daycare or residential care in addition to the stigma and discrimination of the duo, she admitted him to the closed ward for long-term management. The mother had requested the treating team place him in an appropriate organization as no one else would take care of the patient after her death.

Mrs. B was a 48-year-old widow, diagnosed with bipolar affective disorder (BPAD), and has been staying in the hospital for twenty-four years. The patient has three female siblings who are not willing to take care of her in view of financial burden, social stigma in the community, and lack of support from their family for procreation. With the support of the multidisciplinary treating team, she had undergone vocational rehabilitation training and got employed at an organization. However, due to adjustment issues, she moved back to the hospital without informing the employers on multiple occasions. Therefore, the organizations were hesitant to offer her a job.

Mrs. R, 61 years old, was diagnosed with persistent delusional disorder. She had been staying in the closed ward for twelve years. Both of her daughters were also known cases of severe mental illness. The patient’s husband died in a road accident and following which she developed inappropriate behaviors. This was noticed by her neighbors in the village who had intimated the police station regarding the same. As a result, she was admitted through an RO from the Magistrate. Multidisciplinary team members had made several attempts to contact the extended family members to reintegrate back into the community. Relatives were unwilling to take her back.

Mr. H was a 61-year-old bachelor diagnosed with paranoid schizophrenia, residing in the closed ward for the last twenty years. The police was notified by the public about his wandering as a homeless person with mental illness. They organized an RO and admitted him to the closed ward. Family members are untraceable due to a lack of adequate information. He accounted that he had undergone significant psychosocial issues with his family in his childhood. Despite efforts to place the patient in various nonpsychiatric residential care facilities, he was sent back owing to adjustment difficulty, wandering tendency, and poor interpersonal relationship between the patient and care staff. The patient continued to stay in a closed ward for an indefinite period due to the limited availability of community care rehabilitation homes with trained mental health personnel by both government and nongovernmental organizations (NGOs).

Mr. M was 54 years old, diagnosed with moderate IDD, and had resided in at closed ward for the past 15 years. The patient was brought to the hospital by RO as an unknown patient. The family could not be traced due to inadequate information acquired from the patient and the police.

Discussion

The analysis of secondary data presented in the research describes a group of individuals who have experienced long stays in a tertiary care psychiatric hospital in India. The analysis of data clearly indicated that for the majority of psychiatric patients the factors that prevented discharge are not confined only to clinical profile or the psychiatric symptoms. However, a combination of individual, familial, structural, and functional inadequacies of mental healthcare delivery systems and a lack of affordable rehabilitation options necessitated continued prolonged hospitalization in psychiatric ward [Figure 1]. The socio-demographic data revealed that being female, unmarried, illiteracy, unemployment, lack of information about the family, poor engagement of family in the patient care, and lack of supported employment facilities for the recovered patients in the community contributed to the prolonged stay and resulted in institutionalization of patients in the psychiatric ward. Most of the patients who are symptomatically recovered aspiring for a normal life and wanting to reunite with families are unable to unite family due to stigma, elderly caregivers who are unable to care for them, death of primary caretakers, especially parents, reluctance of family members/relatives to take them back once they recovered, and nonavailability of correct address due to reasons as follows: (a) family furnished wrong address during the time of admission, (b) family members must have changed address over a period of time without intimating the hospital, (c) patients must have been homeless for a long period of time before admission and are unaware of their origin, and (d) patients admitted through court orders who have compromised intelligence or communication skills. These patients ended up staying in the mental hospital due to the lack of community care models in the country, which would help them lead a life with dignity in society. For them, continued stay in the mental hospital itself is a serious hindrance to recovery and violation of human rights. The findings are in concurrence with various studies where clinical factors, unavailable family members, family rejection, willful abandonment of patients, lack of rehabilitation measures, patients’ wandering tendencies, admission through RO, symptoms profiles, and financial constraints are the barriers to the discharge and prolonged stay in psychiatric hospitals.[16,29-32] Mental hospitals are not equipped to offer adequate support toward their road to recovery in the form of positive social role modeling, creating avenues to take up a career/studies, and fulfillment of social milestones such as marriage and financial independence.[33]

Figure 1.

Reasons for long stay in psychiatric hospital

Prolonged stay and abandonment of patients by family members were higher among female patients compared with male patients in the current research. Women who have a mental illness appeared to be at a particular limitation in India.[22,34,35] The duration of long stay ranged from 1 year to 45 years with a mean duration of 5.70 ± 8.30 years for the present study. Few patients in the current sample were chronic “old long-stay” patients who had already experienced a long hospitalization at the start of the deinstitutionalization process. Schizophrenia and mood disorders were the most common group of disorders among these patients. Poor drug compliance and wandering and absconding behaviors are the most commonly cited reasons for the admission.

In the Z category, all the patients experienced social exclusion and rejection followed by inadequate skills, and problems related to unemployment and housing and economic circumstances were common among patients. The findings of Angothu et al.[36] reported that the mean duration of long stay of 4869 patients from tertiary care psychiatric hospitals was 9.6 years (range 1–more than 25 years). The findings highlighted the need for facilitating the transition of patients from hospitals to community care. Apart from easily accessible low-cost rehabilitation facilities in the community facilitate family and community reintegration and prevent prolonged hospitalization and homelessness among psychiatric patients.[16,34,37]

Conclusion

This research is unique in exploring psychosocial reasons for long stay in psychiatric hospital. A good number of recovered patients are stuck in the psychiatric ward due to the lack of affordable rehabilitation homes in the community and family rejection. Institutionalization isolates patients from mainstream society. Progressive legislations to protect the rights of patients under the new Mental Health Care Act 2017[9] and the Rights of Person with Disabilities Act 2016[10] have been enforced. It is now time to create a supportive environment for the recovered patients waiting for social reintegration. Most of the mental health facilities continue to be urban centric and fragmented. The community-based model and services offered by NGOs tend to merely meet the basic needs of patients. In addition, many such facilities are expensive and unaffordable for poor patients and their families in India. It is imperative for the state to create and provide an affordable residential rehabilitation facility for recovered patients in the community.

Summary and conclusion

• There is also a need to have evidence-based research in the area of efficacy of providing viable, replicable, and affordable models of rehabilitation services for recovered patients in the community.

• Supported employment and supported living are relatively new and promising concepts that may bridge this gap between the LSP and the community.

Key Message

The physicians and general practitioners in the prevention and promotion of mental health are very significant as many psychiatric patients delay their treatment because of stigma, misinformation, and poor economic conditions. Physicians and general practitioners are the first contact people who can guide or refer them to the appropriate hospital. Timely referral and ensuring treatment adherence in follow-up visits of patients at primary health centers and general hospitals would avoid frequent readmission, prevent drug resistance, lower the treatment cost, and help in better prognosis and recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.