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 Table of Contents  
BRIEF COMMUNICATION
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 86-89

What scares patients to get admitted in a psychiatry ward? An exploratory study


Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Web Publication29-Mar-2018

Correspondence Address:
Dr. Sushmita Bhattacharya
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_24_17

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  Abstract 


Background: There has been very little focus on understanding the experiences of people suffering from mental illness during their treatment in the outpatient and inpatient treatment facilities. Majority of the decisions regarding their treatment are taken by the mental health professionals in consultation with the caregivers, and the patient remains a passive recipient of the services. It is commonly seen that patients refuse admission in the psychiatry ward even when clinical needs warrant admission. Aim: The aim of the current study was to explore the perception of patients regarding admission in the psychiatry ward and the fears associated with indoor treatment facility. Methodology: A semistructured interview schedule was administered to 110 patients undergoing treatment from outpatient services to study their attitude toward treatment in psychiatry ward. Results: A large number of patients perceived psychiatry ward as a hostile place with unfriendly atmosphere and dark and unsupportive environment. However, the patients who had been admitted in the past found it less scary and appreciated good and friendly behavior of the staff in the ward. Conclusion: Negative perception of inpatient treatment and psychiatry wards is still highly prevalent among the patients. With growing focus on reducing stigma about psychiatric illnesses, dispelling the myths related to treatment in wards is the need of the hour.

Keywords: Admission, attitude, mental illness, ward


How to cite this article:
Bhattacharya S, Chavan BS. What scares patients to get admitted in a psychiatry ward? An exploratory study. Indian J Soc Psychiatry 2018;34:86-9

How to cite this URL:
Bhattacharya S, Chavan BS. What scares patients to get admitted in a psychiatry ward? An exploratory study. Indian J Soc Psychiatry [serial online] 2018 [cited 2021 Jan 21];34:86-9. Available from: https://www.indjsp.org/text.asp?2018/34/1/86/228792




  Introduction Top


Mental disorders are on rise and contribute to significant morbidity and disability.[1] The recently conducted National Mental Health Survey revealed that, excluding tobacco-use disorders, the mental morbidity of individuals above 18 years was 10.6%.[2] The study also revealed that huge treatment gap still exists and nearly 150 million persons in India are in need of active intervention.

Although the focus has shifted from hospitals to community, short-term inpatient treatment is considered an essential part of acute care for mental disorders. The need of inpatient treatment arises in cases with risk to self, others, and property, and lack of support to supervise the community-based treatment. Despite increased demands, there is a dearth of facilities for inpatient treatment with the number of psychiatric beds in India being about 0.2/1,00,000 population.[3]

However, it is frequently seen that patients express strong reluctance for admission in psychiatry ward. Although lack of insight into illness might be a deterrent to admission, there are other unwarranted fears which require recognition and intervention. The negative portrayal of mental hospitals in media might be maintaining such an attitude.

In today's time, when individuals' autonomy and rights hold utmost importance and with the advent of advance directives in the new Mental Health Care Bill, 2016,[4] it is extremely important that the perspective of individual with mental illness be understood and adequate steps be taken to depict a picture close to reality than based on false media coverage or misconceptions prevalent in society. Hence, a closer look at the patients' perception about psychiatry ward is required to identify the factors influencing their refusal for admission. The present study is an effort in that direction.


  Methodology Top


A cross-sectional study was conducted in the Department of Psychiatry, Government Medical College and Hospital, Chandigarh between September 2015 and April 2016 on 110 consecutive patients diagnosed to have mental illness as per International Statistical Classification of Diseases-10 criteria [5] and coming for follow-up to psychiatry outpatient services.

Patients recruited for the study included patients who had been previously admitted in any inpatient psychiatry treatment facility as well as those who had never been admitted. Patients in acute phase of illness, those with severe neurocognitive deficits, and those with intellectual disability and substance use disorder were excluded. After taking informed consent from patient and caregivers, interviews were conducted with the help of a semistructured questionnaire.

For preparation of the questionnaire, the authors searched the literature for the reasons that could possibly influence the patient's decision of getting admitted or experiences of patients during indoor treatment in the past. Additional items were added from in-house discussions among the residents and faculty working in the department. Another source of items was the focused group discussion with the caregivers of the patients coming to the department. The items were sent to two senior psychiatry consultants for face validity of each item. There were two sets of questionnaires. Set 1 had 18 items and was administered to the patients who had been admitted in the ward in any mental health facility and Set 2 had 15 items and was administered to the patients who had never been admitted in any psychiatry ward. Both the sets of questionnaires were administered by the investigator (SB). The replies were recorded by ticking the options provided in the questionnaire.

The analysis of the answers given by the patients was done qualitatively by framework method.


  Results and Discussion Top


Of the 110 patients, fifty patients belonged to the first group, i.e., those who had been previously admitted in a psychiatry ward and sixty patients belonged to the second group (never been admitted). Majority of the patients were males (60%) and belonged to the middle-age group. Forty-five percent of patients had diagnosis of schizophrenia, schizotypal, or delusional disorders (F20–F29) and 36% patients had diagnosis of mood (affective) disorders (F30–F39). The clinical profile of the patients is presented in [Table 1]. Among the patients who were previously admitted, the average number of admissions and duration of ward stay were 1.3 and 16.21 days, respectively.
Table 1: Clinical and demographic profile of patients

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The findings from the interview of patients who had never been admitted are mentioned in [Table 2]. Approximately two-thirds of patients believed that psychiatry ward might be a hostile place with negative and unwelcoming atmosphere, 72% patients expressed unwillingness to get admitted because of fear of neighbors or employers who may come to know about their illness due to admission, and approximately 50% of the patients thought that they may have negative influence after staying with other patients. Since these patients were never admitted in the ward, these findings might resonate with what many authors have previously reported regarding stigma of “madness,” and negative image related to psychiatry as a discipline.[6],[7] In the absence of any personal experience, their opinions are most likely based on media portrayal of patients as violent and displaying unpredictable behavior.[8],[9]
Table 2: Why patients don't want to get admitted in a psychiatry ward if admission is ever required in future

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Other perceptions about the psychiatry ward were as follows: the ward would be dull and frightful (37%), administration of medicines against their wish (28%), restraint and forceful seclusion (33%), giving electroconvulsive therapy (ECT) or “shock treatment” (22%), and painful treatment (23%). However, many of these patients could not mention any specific source of pain but mentioned about medication side effects, shock therapy, and injectables as probable sources of pain and discomfort.

As our study showed, many patients expressed their reservations regarding ECT. Few Indian studies on patients who have never received ECT have revealed that a high proportion of patients had a negative perception about ECT.[10],[11],[12] Similarly, the lack of appropriate education and fear regarding side effects of medications can impede the development of therapeutic collaboration and hence needs to be addressed as a priority.

Another reason for not getting admitted that was reported by 15% of patients was denial of any illness. This is somewhat unexpected as insight has been studied as an important independent predictor of therapeutic alliance.[13] This may be because in our study, the interviews were conducted after the acute phase of illness had resolved. Nonetheless, it is an important finding as it highlights that the major reasons for noncompliance with treatment are more related to the perceived stigma, the misconceptions, and myths related to treatment rather than only absence of insight.

[Table 3] and [Table 4] depict the responses of patients who had been previously admitted in the psychiatry ward. Interestingly, the majority (68%) of patients who had been admitted held a positive perception and opined that hospital staff was very supportive and cooperative. This finding is similar to an earlier study on inpatients in which most patients expressed relatively favorable attitude toward psychiatry, hospitalization, and treatment upon admission.[14]
Table 3: Level of satisfaction of patients (who have been previously admitted in the psychiatry wards) regarding overall ward stay (n=50)

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Table 4: Difficulties experienced by patients during their ward stay (n=50)

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Minority of patients (18%) reported witnessing incidents of violence, both verbal and physical aggression, on a frequent basis by other admitted patients, and this was perceived as an unpleasant experience. This is in keeping with findings from a recent meta-analysis suggesting that almost one in five patients admitted in acute psychiatric units may commit an act of violence.[15] Another 14% of our patients reported being scared most of the times due to unpredictability of other aggressive patients, or the uncertainty of what is going to happen further during ward stay. Illness-related factors such as auditory hallucinations, persecutory and referential thinking, or depressed mood were other factors which contributed to them being scared. Other difficulties experienced by varying number of patients included sleep disturbance due to excessive noise in the ward, missing family members, and not being able to visit outside.

Twelve patients (24%) reported that they were given some injections without their consent, and six patients (12%) reported that they were physically restrained at some point during their ward stay. Regarding physical restraint, all but one patient opined that physical restraint was unnecessary and expressed resentment about the situation. The practice of seclusion and/or restraint of a psychiatric patient for therapeutic purposes is still widely prevalent in India, with a study reporting that nearly 80% psychiatrists have used physical restraint at some time.[16]. A recent literature review revealed that the prevalence of perceived coercion ranged from 16% to 90%.[17] Various studies have found that patients' views on coercive treatment have been mostly but not always negative.[18],[19],[20]

Five patients (10%) reported having major altercations with staff/doctors or other patients during their ward stay. Other difficulties which were faced by the patients which negatively affected their perspective were: Unclean washrooms (28%) and delay in getting discharged (42%).


  Conclusion Top


The present study is one of its own kind which collected data from service users directly to find out their experiences and expectations in case they required admission in future. However, there were several limitations in this study. The study was carried out at one treatment facility on a small and nonrandomized sample on a nonstandardized questionnaire, thereby limiting its generalization to other settings. The duration of illness, past treatment, associated comorbid disorders, and psychosocial stressors were not taken into account.

Despite these limitations, the study highlights the major deterrents to seek indoor treatment, and there is a wide scope of intervention as majority of these misconceptions are learnt from the negative depiction of psychiatry in Hindi cinema and electronic media. There is an urgent need to include patients' and caregivers' treatment decisions, avoidance of physical restraining, and admission of acutely ill and violent patients in a separate room.

Acknowledgment

We thank all the mental health service users who agreed to be interviewed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86.  Back to cited text no. 1
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2.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health Survey of India, 2015-2016: Summary. NIMHANS Publication No. 128. Bengaluru: National Institute of Mental Health and Neuro Sciences; 2016.  Back to cited text no. 2
    
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Mohandas E. Roadmap to Indian psychiatry. Indian J Psychiatry 2009;51:173-9.  Back to cited text no. 3
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4.
Mental Health Care Bill. Available from: http://www.prsindia.org/uploads/media/Mental%20Health/Mental%20health%20care%20as%20passed%20by%20RS.pdf. [Last accessed on 2017 Mar 16].  Back to cited text no. 4
    
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World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization; 1992.  Back to cited text no. 5
    
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Choudhry FR, Mani V, Ming LC, Khan TM. Beliefs and perception about mental health issues: A meta-synthesis. Neuropsychiatr Dis Treat 2016;12:2807-18.  Back to cited text no. 6
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Bhugra D, Sartorius N, Fiorillo A, Evans-Lacko S, Ventriglio A, Hermans MH, et al. EPA guidance on how to improve the image of psychiatry and of the psychiatrist. Eur Psychiatry 2015;30:423-30.  Back to cited text no. 7
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Stuart H, Sartorius N, Liinamaa T, Images Study Group. Images of psychiatry and psychiatrists. Acta Psychiatr Scand 2015;131:21-8.  Back to cited text no. 8
    
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Babu RS. Media and psychiatry. AP J Psychol Med 2011;12:55-8.  Back to cited text no. 9
    
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Dan A, Grover S, Chakrabarti S. Knowledge and attitude of patients with psychiatric disorders and their relatives toward electroconvulsive therapy. Indian J Psychol Med 2014;36:264-9.  Back to cited text no. 10
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Grover SK, Chakrabarti S, Khehra N, Rajagopal R. Does the experience of electroconvulsive therapy improve awareness and perceptions of treatment among relatives of patients? J ECT 2011;27:67-72.  Back to cited text no. 11
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Chavan BS, Kumar S, Arun P, Bala C, Singh T. ECT: Knowledge and attitude among patients and their relatives. Indian J Psychiatsry 2006;48:34-8.  Back to cited text no. 12
    
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Kvrgic S, Cavelti M, Beck EM, Rüsch N, Vauth R. Therapeutic alliance in schizophrenia: The role of recovery orientation, self-stigma, and insight. Psychiatry Res 2013;209:15-20.  Back to cited text no. 13
    
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Gynther MD, Reznikoff M, Fishman M. Attitudes of psychiatric patients toward treatment, psychiatrists and mental hospitals. J Nerv Ment Dis 1963;136:68-71.  Back to cited text no. 14
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Iozzino L, Ferrari C, Large M, Nielssen O, de Girolamo G. Prevalence and risk factors of violence by psychiatric acute inpatients: A systematic review and meta-analysis. PLoS One 2015;10:e0128536.  Back to cited text no. 15
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Khastgir U, Kala A, Goswami U, Kumar S, Behera D. The nature and extent of the use of physical restraint and seclusion in psychiatric practice: Report of a survey. Indian J Psychiatry 2003;45:155-7.  Back to cited text no. 16
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Newton-Howes G, Stanley J. Prevalence of perceived coercion among psychiatric patients: Literature review and meta-regression modelling. Psychiatrist 2012;36:335-40.  Back to cited text no. 17
    
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Eriksson KI, Westrin CG. Coercive measures in psychiatric care. Reports and reactions of patients and other people involved. Acta Psychiatr Scand 1995;92:225-30.  Back to cited text no. 18
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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