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| Prolonged hospitalization of persons with mental disorders in state-funded tertiary care psychiatric hospitals and unaccounted public health implications |
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Hareesh Angothu1, Sharad Philip2, Deepak Jayarajan1, Arun Rachana3, Aarti Jagannathan4, M Krishna Prasad5
1 Associate Professor, Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
2 Senior Resident, Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
3 Associate Professor, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
4 Additional Professor, Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India
5 Additional Professor, Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
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| Date of Submission | 04-May-2022 |
| Date of Acceptance | 23-Sep-2022 |
| Date of Web Publication | 07-Dec-2022 |
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Introduction: National strategy for an inclusive and community-based living (NSCIL) for persons with mental health issues 2019 report informs us that the length of stay (LOS) of 36% of inpatients in 43 state-funded tertiary care psychiatric hospitals (TCPHs) is above one year. This is concerning and its public health implications are not studied.
Objectives: This study was carried out to estimate the average duration of hospitalization by persons with prolonged hospitalization (PPH) in TCPH and to estimate the number of additional inpatient admissions that could have been offered.
Methodology: We analyzed the data in NSICL for calculating cumulative hospitalization years and the mean duration of stay by all PPH under each state. Based on the presumption that each psychiatric bed could cater to at least four admissions, a prediction is made on the number of additional inpatient admissions that could have been offered.
Results: The mean duration LOS of 4869 people in these TCPHs is 9.6 years (range 1 – more than 25 years) with significant variation between the states. An additional 190,153 persons could have been offered inpatient care in these TCPHs over 25 years duration, and a minimum of 7606 additional admissions could be accommodated every year.
Conclusions: Our predictions suggest a need for research on the possibility of deferred inpatient care to others with acute mental health needs and the scope for inpatient care to as many as in need by unblocking these beds.
Keywords: Inpatient care, length of stay, mental illness, prolonged hospitalization, psychiatric hospital
How to cite this URL:
Angothu H, Philip S, Jayarajan D, Rachana A, Jagannathan A, Prasad M K. Prolonged hospitalization of persons with mental disorders in state-funded tertiary care psychiatric hospitals and unaccounted public health implications. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.amhonline.org/preprintarticle.asp?id=362908 |
| Introduction | |  |
Time spent by patients in hospitals – estimated as the length of stay (LOS) – has public health implications, as it influences the cost of care to the patient and the exchequer. The Organisation for Economic Co-operation and Development (OECD) in 2019 reports that the LOS of persons with schizophrenia and related disorders (SARD) is lowest in Belgium with 9.6 days and highest in South Korea with 216 days. However, it is noteworthy that except for Korea, LOS due to SARD in all other countries listed under OECD is <84 days.[1] It can be inferred that despite significant variations in the LOS of persons with SARD between OECD countries, it rarely exceeds 90 days or 3 months. Gender, age of the patient at the time of admission, chronicity of the illness, type of illness, homelessness and, a range of social, economic and, health-care access factors are observed to influence the LOS at psychiatric hospitals.[2],[3],[4] The World Health Organization (WHO) reports that there are only about 20 psychiatric beds per 1 million population in India, compared to a global average of 164 and 680 OECD member countries.[5] Only a few thousand psychiatric beds are available under state-funded tertiary care psychiatric hospitals (TCPHs), which may not exceed 20,000 in India.[6]
Treatment Advocacy Center of the United States of America estimates that for those requiring In patient (IP) care, 390 psychiatric beds per 1 million are needed to address their acute mental health need and to avoid their waiting period of more than 1 day with an estimated average hospitalization period as 20 days for each admission.[7] This implies that if psychiatric beds are fewer than 390 per 1 million, or if the LOS of persons with mental disorders (PMD) is beyond 20 days, it could lead to access barriers for PMD requiring IP care and highlights the importance of optimal utilization of available psychiatric beds.
According to the Government of India report in 2014, there are three central government-run TCPHs and 40 state government-run TCPHs are there in India, apart from 398 psychiatry departments attached to 398 medical colleges both in the private and public sector.[8] A report, titled “National strategy for inclusive and community-based living (NSICL) for persons with mental health issues 2019: The Hans Foundation,” hereinafter referred to as NSICL report, containing details on PMD with LOS of more than 1 year in 43 state-funded psychiatric hospitals (SFPH) spread across 24 states of India.[9]
This contains descriptive data on persons with prolonged hospitalization (PPH) in TCPH, and it is prepared with suggestions to advocate policymakers for creating a range of supportive systems to support PPH after their discharge. However, the authors have not examined if the psychiatric beds occupied by PPH could cater to others. Indian National Mental Health Survey 2016 reports that 150 million persons have one mental disorder and require active intervention in India.[10] Considering the psychiatric bed shortage as described above and the magnitude of people requiring mental health care, it becomes necessary to examine the NSICL report in depth to understand if more people could have received IP care in these TCPHs.
Aims and objectives
The aim of this study is to estimate the mean duration of hospitalization of PPH in each of the states and to estimate how many more persons with mental illness could have been provided inpatient care in these state hospitals if the admission duration of PPH is <1 year.
| Methodology | | |
We analyzed the NSICL report 2019 to understand the average duration of time spent by PPH under psychiatric hospitals in each of the 24 states and the variability concerning the states, which the authors of the NSICL report did not carry out. NSICL reports the data of PPH under time intervals such as 1–5 years, 6–10 years, and so on, with the last category being more than 25 years, without any clear information on the exact duration of LOS of each PMD. To estimate the cumulative duration of hospitalization years by all PPH, we used the mid-time point for each time interval against the number of PPH reported in that time interval. To illustrate this, 3 for 1–5 years, 8 for 6–10 years, 13 for 11–15 years, 18 for 16–20 years, and 23 for 21–25 years were used for measuring cumulative hospitalization years for PPH in that group. However, for PPH under more than 25 years group, only 25 was used due to the nonavailability of further data. The institutional ethical committee approval was not sought, as we used only the published data under the NSICL report. Descriptive statistics were used for estimating the average duration of stay by PPH under each state.
To estimate the number of additional IP admissions that could have been offered against the psychiatric beds occupied by PPH and in each state, we used the estimate that each psychiatric bed could cater to a minimum of four IP admissions every year. We have arrived at four numbers based on three reasons. The highest LOS of persons with schizophrenia-related disorders in all OECD countries was 84 days, except for Korea. The second reason was based on sections 89 and 90 of the Mental Health Care (MHC) Act 2017 of India, which states that admission of PMD admission beyond 30 days should be limited to 90 days in the first instance before deciding on the further need for the extension.[11] The third reason is our experiential account that, most if not all, PMD would not require inpatient care in a TCPH beyond 90 days continuously for reasonable control of symptoms.
| Results | | |
Sociodemographic variables, clinical diagnoses and the LOS details of PPH are summarised in [Table 1]. In [Table 2], all states in which this study was carried out are arranged in alphabetical order summarising the number of PPH in each state. We have estimated the projected number of additional PMDs who could have been offered inpatient care in TCPHs on a presumption that none of the psychiatric beds is blocked by PPH for more than one year, summarised in [Table 3]. States are categorised in [Table 4] according to the proportion of PPH occupying the psychiatric beds to understand the variability in this regard. | Table 1: Sociodemographic and clinical details of prolonged hospitalization
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 | Table 2: Categorization of prolonged hospitalization according to their length of stay and under each state (synthesized from Table 2.2 of the national strategy for an inclusive and community-based living report)
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 | Table 3: Estimated additional persons with mental disorders that could have been offered intellectual property care under each state, based on the assumption that beds occupied by prolonged hospitalization are available for others with acute mental health needs
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 | Table 4: Categorization of states based on the proportion of psychiatric beds occupied by the prolonged hospitalization
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| Discussion | | |
As summarized in [Table 1], the LOS of more than one-third of all inpatients is above 1 year, indicating that only two-thirds of psychiatric beds under SFPH are available for others requiring IP care. As summarised in [Table 4], the proportion of PPH with LOS above one year is more than 10% of all inpatients in 23 out of 24 states suggesting that this is a pan India phenomenon, with variation between states. However, a significant variation in this is observed across the states. Maharashtra, West Bengal, and Tamil Nadu, with 28%, 20%, and 12% of all inpatients with PPH, respectively, accounted for 60% of all PPH, whereas all other states accounted for the rest of 40% of PPH. While higher age at admission, psychoses diagnosis, involuntary admission, etc., were observed to increase the LOS of some PMD,[12],[13] it is unclear if those factors may have played a significant role in this population. More than 50% of available psychiatric beds in seven states, as described in [Table 2], are occupied by PPH, thus making only less than half of psychiatric beds in those states available for the public requiring IP care at any given point in time.
We estimate that 4869 people have spent 46,887 years as inpatients cumulatively, with each person spending an average of 9.6 years as an inpatient, ranging from 1 to 25 years. As described in [Table 3], six states, Jharkhand, Karnataka, Maharashtra, Nagaland, Punjab, and Tamil Nadu, have inpatients with a mean LOS of more than 9.6 years, and whether this reflects variations in the quantity and quality of community-based continuous care facilities between states need to be explored. A total of 555 are reported to be staying as inpatients for more than 25 years, out of which 444 (80%) PMD are in only the two states, Maharashtra and Tamil Nadu. Including this, 1706 among the total PPH are reported as inpatients for more than 10 years. Factors influencing LOS in acute psychiatric care settings such as symptom severity, need for medication adjustment, and discharge planning[14] may not explain this period of hospitalization in this group.
It is doubtful that most, if not all of 1706, require IP care for more than one decade in SFPH for their symptom control. Instead, a range of other factors such as homelessness, lack of family caregivers to receive them after their discharge, the stigma of family caregivers to receive them after their discharge, and lack of availability or accessibility to community-based shelter services could have contributed to the continuation of IP care of this group beyond one decade.[15],[16]
Based on the presumption that each psychiatric bed could cater to at least four persons in 1 year, potentially a total of 190,153 could have been offered IP care over the past 25 years. SFPH under Maharashtra, Tamil Nadu, and West Bengal alone account for 119,445 potential IP admissions that could have been accommodated. Every year an additional 7606 PMD may be provided IP admission for at least 90 days per person across the nation. Maharashtra alone can accommodate about 2395 additional admissions every year in addition to the number of admissions currently being carried out; Tamil Nadu and West Bengal each could accommodate more than 1000 additional admissions every year; states such as Goa, Gujarat, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Punjab, Rajasthan, and Uttar Pradesh too can accommodate few hundreds of additional admissions every year by making those psychiatric beds available for others. We believe these numbers are an underestimate, and many more thousands of PMD could have been offered IP care under these SFPH, as most PMD rarely require 90 days of IP care, and each bed could provide IP admission for more than four.
NSCIL authors report that 699 PPH have expressed a wish to remain in hospitals. We believe that they might have psychosocial reasons for such wish expression. Social hospitalization may be a better term to describe this extended or indefinite hospitalization process for offering a safe environment, shelter, food, continuous medical care, and psychosocial support under these SFPH to compensate for the inadequacies in community-based MHC systems. A similar phenomenon described as social hospitalization is observed in Japan for the elderly population.[17] However, it is debatable if TCPH should and could accommodate the admission of PMD for prolonged periods for possibly fulfilling the psychosocial needs, but by blocking the psychiatric beds meant for offering inpatient clinical care.
Another observation that partially could explain the prolonged hospitalization of some is, as reported in [Table 1], more than 20% of PPH have intellectual disability (ID) as either a primary or comorbid diagnosis. Their discharge from SFPH becomes more complex in the absence of family caregivers or well-established community-based support systems for continued MHC. Samarth and Gharaunda centers offer long stay for persons with ID under the Ministry of Social Justice and Empowerment through the National Trust Act 1999.[18],[19] These centers are few with poor or no connectivity to SFPH for facilitating the transition of persons with ID, with lesser awareness about their existence to many mental health professionals for facilitating a transition. The National Trust report that only 435 persons have used group home facilities in 2020–21 across India[20] highlights the need for better connectedness between TCPH and group homes for persons with ID. Strengthening public health systems for facilitating a transfer between TCPH and group homes is essential in preventing the prolonged hospitalization of persons with ID, making those psychiatric beds available for others with acute mental health needs. We could not come across any data on the available number of social workers in these TPCHs who would often play a significant role in discharge planning and the transition of recovered patients back into the community.
NSICL report did not have data on whether any PMD were turned down admission at any of these SFPH due to the nonavailability of beds. We feel that the mental health treatment gap reported by the WHO as about 32% for mental disorders[21] has not considered the number needing inpatient care at SFPH and who could not access it due to bed nonavailability. The nonavailability of beds in state-funded TCPHs offering free or subsidized treatment could delay quality MHC or force the service seekers to approach the private sector or faith healers. Establishing systems for recording the number of patients seeking inpatient care, the number of PMD kept in waiting for admission, and measuring the time delay before admission at each of these TCPHs would clarify further whether our hypothesis of prolonged (social) hospitalization is acting as a barrier for quality MHC to others and essential from a public health perspective. Establishing such systems at all of these TCPHs with a periodic audit on PPH and cost-effective analysis of continuing the prolonged hospitalization could offer broader insights in this regard for better planning.
Limitations
Predictions we have made about the number of additional admissions offered in these TCPHs are speculative and based on the 100% occupancy of psychiatric beds at these hospitals. However, a lower bed occupancy estimate could reduce the number of admissions predicted.
Strengths
We analyze the prolonged hospitalization of PMD at TCPH from a different viewpoint which has not been researched well in the Indian context, i.e., public mental health implications, by avoiding a prolonged hospitalization somehow many additional PMD could have been offered inpatient care, and the need for the creation of systems to monitor the waiting list, admission period of PMD at state-funded TCPH. Our estimation of the mean duration of hospital stay across states could help estimate the economic impact on respective health systems.
| Conclusions | | |
More than one-third of inpatients in 43 state-funded TCPHs are admitted to psychiatric hospitals for over 1 year is concerning and has several public health, mental health, and policy implications. Prolonged hospitalization extending over decades in some, as reported in this report, could cause significant access barriers to others who require inpatient care. Significant variations in the number of PPH across the states necessitate more methodical research to understand the existence of community-based psychiatric and rehabilitation facilities across the states. Prolonged inpatient care for some while depriving their right to the least restrictive MHC guaranteed under section 18 of the MHC act 2017 poses barriers to others in need of quality inpatient MHC. Facilitating the transition of patients from these SFPH into the community and creating systems to record the waiting period for admission of persons seeking IP care at these hospitals is an urgent need.
Implications
The supreme court of India recommends supported housing for PMD through Gaurav Bhansal versus Union of India and Sunanda Bhandare versus Union of India, and cases are still a long way to become a reality. Our estimation of the minimum number of additional psychiatric admissions that could be accommodated under SFPH offers a different perspective to the policymakers and fund allocators for expediting the processes of establishing community-based psychosocial support systems, including halfway and long-stay homes for those who continue to stay at TCPH for decades.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Correspondence Address:
Hareesh Angothu,
Department of Psychiatry, National Institute of Mental Health and Neuroi Sciences, Bengaluru - 560 029, Karnataka
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_72_22
[Table 1], [Table 2], [Table 3], [Table 4] |
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