East Asian Arch Psychiatry 2012;22:141-5

ORIGINAL ARTICLE

从受害者角度分析精神病住院患者的暴力行为

Dr Dhanya Raveendranathan, MD, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
Prof. Prabha S. Chandra, MD, FRCPsych, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
Prof. Santosh K. Chaturvedi, MD, FRCPsych, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.

Address for correspondence: Dr Dhanya Raveendranathan, Department of Psychiatry, National Institute of Mental Health And Neurosciences, Bangalore 560029, India.
Tel: (91-80) 26995250; Fax: (91-80) 26564822; Email: dhanya.ravi@gmail.com

An earlier version of this paper was presented at The Second Joint International Conference of the Hong Kong College of Psychiatrists and the Royal College of Psychiatrists (UK) — Brain, Behaviour and Mind 2010 (poster).

Submitted: 12 December 2011; Accepted: 26 January 2012

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Introduction

In India, for more than 50 years, there was a practice of involving family members in the caretaking process for inpatients by asking them to stay with the patient during the period of hospitalisation. This practice is believed to enable faster recovery than patients admitted without accompanying family members.¹ By custom, families assume the role of principal caregivers for their ill relatives because of strong family relationships resulting in mutual interdependence and concern for relatives during adversity. An earlier study from India assessing the role of caregivers in patients with chronic schizophrenia found that in the majority of cases, family members were responsible for looking after their relative during inpatient stay and at home.² India has a huge population of subjects with psychiatric disorders and faces a severe shortage of mental health professionals.³ Hence, a system of utilising the services of the family members has multiple advantages. These include assisting the limited staff available so as to facilitate a greater degree of personalised and better care for patients.⁴ Thus, having adequate support from the family is of great benefit to the patient, the clinician, and health care administrators.

Violent patients in a psychiatric hospital pose a considerable challenge to psychiatric staff and health planners, because of the risks to the individuals involved and the implications for the organisation of services. These include longer hospitalisation, greater need for tranquilising medications, and more frequent medication changes, all of which have serious cost implications. Studies of inpatient violence are hard to compare because of differing definitions of violence and hospital settings in which the studies took place. A few western studies only focused on violence from the perspective of the staff and patients. It is important to recognise that the family members pay a huge price in the form of emotional, financial, psychological, and social burdens in the process of caring for relatives with psychiatric disorders, according to the western studies^5-8 and those from India.^9-11

Although there have been studies looking at the caregiver burden on family members in a variety of domains, there have been none from the perspective of family members as victims of violence in a psychiatric setting where they stay with the patients during inpatient care. Hence, this study set out to examine this issue in an Indian setting.

Methods

The study was conducted in the adult psychiatric wards of National Institute of Mental Health and Neurosciences, a tertiary care psychiatric teaching hospital of Bangalore in southern India. The study was approved by the institutional ethics committee. A total of 100 consecutive incidents involving male and female inpatients exhibiting violent behaviour during the period April 2008 to July 2009 were included. Violence was defined as the use of physical force the National Institute of Clinical Excellence guidelines.¹² It includes physical violence (which required physical contact with victims) and non-physical violence (including difficulty reporting verbal aggression in crowded wards and the possibility of underreporting, it was excluded from the study unless concomitant threatening or physical aggression took place. The definition of violence used for the study also and to other objects. In other words, violent incidents committed only against other people were included. Sexual violence including inappropriate physical contact made by the patient against any other person was also not included as this was considered outside the purview of this study. Besides, repeated episodes of violence by the same patient were excluded. Diagnosis was made by 2 independent trained psychiatrists based on the ICD-10 criteria.¹³ Patients with an exclusive diagnosis of substance dependence in the absence of any other co-morbid psychiatric illness like induced psychosis were excluded. Information regarding violent incidents in the adult psychiatric wards occurring in the previous 24 hours was obtained from the staff nurse twice daily (in the morning and the evening). The clinical and socio-demographic details of the patients were collected partly using the information available in the patient treatment file and partly from interviews with a family member. The family member (who was present at the time of the incident) was interviewed within 24 hours of the incident, using the semi-structured interview schedule devised for this study after obtaining written informed consent. The semi-structured interview schedule contained open-ended questions to gather information regarding the behaviour of the patient prior to the incident, perceived causes, and suggestions regarding further preventive measures from family members. The semi-structured interview schedule contained the following questions — “How was the patient behaving a day prior / 2 hours prior / immediately prior to the incident?”, “What do you think are the possible causes that led to the incident?”, “How satisfied are you with the way it was managed?”, “What help was available?”, “What help was required?”, “How much time did it take for adequate help to arrive?”, and “Any possible ways to prevent this incident from recurring or minimising the damage?”

The responses were recorded verbatim after face-to- face interviews with the respondents. All interviews were conducted by the principal investigator (the first author).

Results

Table 1 shows the socio-demographic and clinical profile of the patients who were responsible for the 100 episodes of violence. 

The mean (standard deviation) age of the study sample was 29 (11) years. Their psychiatric diagnoses were divided into 3 major groups: affective disorder, non- affective psychotic disorder, and other diagnosis. Non- affective psychotic disorder included various subtypes of schizophrenia, psychosis not otherwise specified, acute psychosis, and substance-induced psychosis. Affective disorder included the first episode of mania and bipolar affective disorder. Other diagnoses included personality disorders, obsessive compulsive disorders, organic conditions, and mental retardation. Bipolar spectrum disorders were noted in 52 patients, while the schizophrenia spectrum was present in 25 and other diagnoses in 23 patients. Bipolar affective disorder, with a current episode of mania with psychotic symptoms (31 cases), was the most common diagnosis.

For 78% of the patients, there was a history of violence in the previous month. About 70% of incidents were preceded by a clear threat made by the patient, which comprised verbal threats (72%) and physical threats (28%). The characteristics of the violent incidents are described in Table 2. 

In 70%, a family member was the target of the violence. In 81 incidents, a clear provocation for the violence was identified. In this study, provocation was defined as clearly identifiable external provocation by the victims. In 63 (78%) of the incidents, the provocation was identified 7 by the patient’s family member. Of the 75 (38 male and 5 37 female) family members of patients interviewed, 54 5 were parents, 13 were siblings, 6 were spouses, and 2 were 3 children. All the questions in the interview schedule were to each question varied. The behaviour of the patient at 51 time points 1 day, 2 hours, and just before the incident 27 were obtained from the family member as shown in Table 3.

One day prior to the incident, 50 (67%) were identified 10 as irritable by the family member. Two hours prior to the incident, 57 (76%) of the family members identified the patients as being irritable. The causes of the violent incident as perceived by the family member are shown in Table 3; of which the patient being prevented from leaving the hospital ward (57%) was the commonest reason.

The recommendations made by family members regarding the means to prevent similar incidents could be divided into 3 themes (Table 4).

Numerous recommendations were made on changes in hospital administration and policy, including issues related to staffing and restricting patient access to sharp objects (glass and knives) that could be used as weapons. The most common recommendation (52%) was to retain more staff on duty in the ward in the form of nurses and security personnel. There were a few treatment recommendations, such as frequent administration of sedating medication (19%) and recourse to isolation wards (4%). There were also a few recommendations to improve communication with patients, including the need to listen carefully to their initial pleas and respond appropriately without an outright immediate refusal. In all, 12 (16%) family members offered no recommendations.

Discussion

A family member is an untrained individual who, as per the hospital policy, accompanies the patient during a hospital stay and has the closest contact with him or her. In this study, the most common victim of violence was the family member. Violent episodes were noted in patients with a wide variety of disorders. A majority had a history of violence in the previous month and most incidents were preceded by a clear threat made by the patient. There is a consensus that a history of aggressive behaviour is the best predictor of future violence.^14-19 These findings underscore the need to carefully monitor patients who have a history of violence.

Among the 81 provoked episodes, more than 75% were by a family member. The causes included their patient being prevented from leaving the ward, getting upset over the family member who reported to staff about their violent behaviour, and strict ward rules enforced by the staff. These were in fact highly modifiable causes for violence and could have been prevented by negotiating with the patient by practising a form of pre-incident verbal de-escalation. The staff’s perspective of possible causes for violence was comparable to that perceived by the family members, except that the former identified the patient’s disoriented state as a cause (in about 5% of instances). This finding was consistent with several studies^20-22 showing that external provocations, involving problematic interpersonal interactions, are the most common situations leading to inpatient violence. In the majority of incidents, the family members could identify specific patient behaviour patterns prior to the violent incident, which could be used as warning signals and might have helped involved individuals identify the impending incident. Lee et al²³ concluded that behaviour patterns of patients immediately before incidents might have better predictive value than the diagnosis per se. Since violence is unpredictable in many situations, rather than preventing it, these behaviour patterns could help in taking precautionary measures so as to decrease the severity and consequences of violent incidents.

Family members made several recommendations to prevent future episodes of violence. They included administrative steps (increased staffing and treatment changes) and the increased use of sedative medications. The latter was often perceived as the most practical form of prevention to mitigate inpatient violence due to its rapid onset of action. Chemical restraint is usually achieved by resorting to parenteral antipsychotic medication and / or benzodiazepines. Frequent use of many of these medications increases the risk of extrapyramidal side-effects like acute dystonia. Family members should be made aware of these side-effects and the importance of alerting staff on duty at the earliest manifestation of such features.

Three large-scale international collaborative studies conducted by the World Health Organization — the International Pilot Study on Schizophrenia,²⁴ the Determinants of Outcome of Severe Mental Disorders,²⁵ and the International Study of Schizophrenia²⁶ — convincingly demonstrated that persons with schizophrenia had a better clinical outcome in India and other developing countries, compared with their western counterparts and that much of this was attributed to good family support in these countries. Family members in India assume a multitude of roles in the caregiving of patients as shown by an earlier study from our centre.² Such care ranged from accompanying the patient during inpatient stays to ensuring medication adherence. Hence, the role of family members in the care of patients in a country like India cannot be ignored due to important cultural and logistic reasons.

Several studies conducted in India^27-29 demonstrated the importance of culture-specific and flexible psycho- educational programmes, which included identifying relapse symptoms and treatment-related information. This may also improve patient compliance, resulting in better illness outcomes and caregiver satisfaction. In a country facing significant shortage of mental health professionals, the capability of family members in identifying behaviour patterns of the patient prior to the episode could help to prevent or ease the management of such incidents.

It is necessary to identify the distress of family members while they face inpatient violence. Including this aspect of patient care as part of the psycho-education for family members makes it more culture-specific and provides them with the skills in handling such patients during their admissions and post-discharge. It may also go a long way towards relieving an important aspect of the caregiver burden in managing a psychiatrically ill relative because even after they are discharged from the hospital, their family members continue to remain the main source of patient care in the community. Ultimately, prevention of a violent incident ensures the safety of both the victim and the patient.

One of the limitations of this study was its relatively small sample size. As the study was undertaken in a hospital, its generalisability to other settings like the community is limited. In the absence of a control group, definitive predictors of inpatient violence could not be made. Lack of a structured evaluation for clinical factors like severity of psychotic symptoms and premorbid personality is also acknowledged. Nevertheless, this study highlights a very important, though poorly examined aspect of psychiatric practice and care.

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