Prevalance of abuse and Social Neglect among Mentally ill patients admitted in selected Hospitals of Northern India

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1 Prevalance of abuse and Social Neglect among Mentally ill patients admitted in selected Hospitals of Northern India Jasbir Kaur,* Gagandeep Kaur, Avneet Kaur Abstract :The comparative study was conducted to assess the prevalence of physical abuse, sexual abuse and social neglect among mentally ill patients admitted in selected hospitals of Northern India in the month of January and February, The study was conducted on purposively selected equal number of male (45) and female (45) mentally ill patients diagnosed with Schizophrenia, Bipolar affective disorders, and Personality disorders. It was found that more number of male patients experienced verbal (75.6% vs. 64.4%) and physical abuse (53.3% vs. 46.7%) as compared to female patients, however this difference was not found statistically significant (p>0.05). In sexual abuse only 4.4% female patients experienced unwanted touch, while male patients did not reported sexual abuse. Social discrimination was reported by maximum number of patients, which was more among female patients (77.8%) as compared to male patients (51.1%). This difference was found statistically significant (p<0.05). Poor shelter and food were next common aspects of social neglect among patients, while more number of female patients (20% vs. 8.9%) reported poor clothing whereas more number of males reported (24.8% vs. 17.8%) poor personal hygiene but this was not found statistically significant (p> 0.05). Therefore, it is recommended that healthcare authorities must take initiatives to educate public as well as healthcare providers to prevent abuse of mentally ill patients. In addition, formal and informal healthcare provides must be provided with adequate support and counselling to treat mentally ill patients with dignity. Key words : Physical abuse, verbal abuse, sexual abuse and social neglect. Correspondence at : Dr. (Mrs.) Jasbir Kaur Principal, College of Nursing, DMCH, Ludhiana Introduction There is lot of stigma attached to mental illnesses which often leads to increased risk of physical abuse, verbal abuse, sexual abuse and social neglect among patients suffering with mental illness. The mentally ill persons experience stigma from variety of sources like families, communities, co-workers and mental health caregivers. The mentally ill patients experience significant trauma, loss and humiliation as a result they feel vulnerable and 155

2 powerless. They encounter negative attitude in the form of physical and psychological abuse from the family members and mental health staff. Mentally ill are treated inhumanly and are devoid to live life of dignity. Despite of all advances, they are forced to live life of incarceration and are physically, sexually abused and socially neglected. Studies have shown that sexual abuse and physical abuse was 6-23 times higher in people with mental illness as compared to healthy individuals. As found by Muenzenmiar (1993), 1 51% of mentally ill people have been physically abused. Goodman 2001, 2 found that physical abuse is more in men and sexual abuse is more in women. While Shack (2006), 3 reported that females are more likely to have physical abuse than males. Mentally ill women are the least powerful members of society and are highly vulnerable to sexual victimization (Chandra et al, 2003) 4. Women with schizophrenia and bipolar disorders are at more risk of being victim of sexual abuse (Bronoz, 1994) 5. The mentally ill people have been socially neglected throughout and as for evidence Folsom et al (2000) 6 found that onefourth of the homeless patients suffer more from schizophrenia, bipolar disorders or major depression. Prevalence of homelessness was 15% and was more in men. International Secretariat of world organization against torture (2008) 7 found that patients were kept in state of total nakedness at Pavlov Mental Hospital, kolkata, West Bengal, India. Literature reveals that the prevalence of physical abuse, sexual abuse and social neglect is a serious problem among male and female mentally ill patients, thus the need arises to conduct a study on these issues. Objectives 1. To assess the prevalence of physical abuse, verbal abuse, sexual abuse and social neglect among mentally ill patients. 2. To compare the prevalence of physical abuse, sexual abuse and social neglect among male and female mentally ill patients. Methodology A study was conducted on mentally ill patients admitted in Dayanand Medical College and Hospital, Ludhiana; Christian Medical College and Hospital, Ludhiana; Kala Nursing Home Ludhiana; Dr. Vidhya Sagar Institutes of Medical Sciences, Amritsar, Punjab and Nurmanzil, Lucknow, UP in the month of January and February, The study was conducted on 45 males and 45 female patients diagnosed with Schizophrenia, Bipolar affective disorders, and Personality disorders, however patients experiencing delusions and hallucinations were excluded from study. Sample was selected through purposive technique. The sample comprised of 20 patients from Dayanand Medical College and Hospital, Ludhiana; 5 patients from Christian Medical College and Hospital, Ludhiana; 15 patients from Kala Nursing Home Ludhiana; 28 patients from Dr. Vidhya 156

3 Sagar Institutes of Medical Sciences, Amritsar, Punjab and 22 patients from Nurmanzil, Lucknow U.P. An interview schedule was used to collect data which was divided in four sections to collect data regarding socio-demographic data (Part-A), physical abuse and verbal abuse (Part-B), sexual abuse (part-c) and social neglect (part-d). Total 50 items were included in the interview schedule. Validity of tool was established through taking inputs from experts of psychiatry, psychiatric nursing, clinical nursing and community health nursing. Permission was taken from competent authorities for data collection. Data was collected in the month of January and February Verbal consent was taken from the patient and their attendant. Patient was taken to the separate room located in the ward to ensure privacy. Interviewing one patient took 15 minutes. Data was analysed by using percentages, mean, SD, and t test and presented in the form of tables. Results The findings of the present study revealed that female patients were of younger age group as compared to male patients ie average age of female patients was 39.22±13.49 years while average age of male patients was ± years. Nearly half of male patients (46.6%) and two third of the female patients (66.5%) were below 40 years of age. As per marital status of patients it was observed that equal number of male as well as female patients were married. While more percentage of male patients were unmarried and female patient were widows and separated in higher percentage. Two third of male as well as female patients were urban dwellers and litter higher percentage of female (4.45%) was from slums as compared to male patients (2.22%). It was further observed that 4.45% female and same percentage of male patients were homeless. In regard to type of family its was found that higher percentage of female patients (53.33%) belonged to joint families as compared to male patients (48.88%) while 4.45% of male and 2.22%. It was further observed that 4.45% female and same percentage of male patients were homeless. In regard to type of family it was found that higher percentage of female patients (53.33%) belonged to joint families as compared to male patients (48.88% ) while 4.45% of male and 2.22% of female patients were living done. Educational status of female patients was better than male patients ie, 88.88% of them were literature as compared to 82.22% male patients and 40% of them have studied upto High School level as compared to 28.89% of males patients. Looking at the religion of the patients its was seen that two third of female patients were follower of Hindu religions as compared to 48.88% of male patients while higher percentage of male patients(46.67%) were from Sikh religion as compared to 28.89% of female patients and 2.22% of female patients were Christian and no male was Christian. Income of female patients was higher than male patients ie., 48.88% had income range of Rs. 5000/- to 10000/- while 42.22% of male patients had income upto Rs. 5000/- (Table I). 157

4 Table-1 : Socio demographic profile of the subjects N=90 Socio demographic Variables f (%) f (%) Age(yrs) * (20.00) 14 (31.11) (26.67) 16 (35.55) (24.44) 08 (17.77) (13.33) 03 (06.66) (15.56) 04 (08.88) Marital status Unmarried 20 (44.44) 15 (33.33) Married 21 (46.67) 21 (46.67) Separated 04 (08.89) 05 (11.12) Widow/widower (08.89) Habitat Rural 15 (33.34) 13 (28.89) Urban 29 (64.44) 30 (66.67) Slum 01 (02.22) 02 (04.45 Home/ Homeless Home 43 (95.55) 43 (95.55) Homeless 02 (04.45) 02 (04.45) Type of family Joint 22 (48.88) 24 (53.33) Nuclear 19 (42.22) 18 (40.00) Extended family 02 (04.45) 02 (04.45) Living alone 02 (04.45) 01 (02.22) Educational status Illiterate 08 (17.78) 05 (11.12) Primary school 14 (31.11) 11 (24.44) High school 13 (28.89) 18 (40.00) Graduate 10 (22.22) 11 (24.44) Religion Sikh 21 (46.67) 13 (28.89) Hindu 22 (48.88) 28 (62.22) Muslim 02 (04.44) 03 (06.67) Christian (02.22) Income < (42.22) 10 (22.22) , (31.11) (22 (48.88) >10, (26.66) 13 (28.88) *Mean age (yrs): Males (43.11±14.67) ; Females (39.22±13.49) 158

5 Table 2 depicts the illness profile of the subjects. It was revealed that majority of the male patients were admitted through voluntary mode (71.1%), while 57.8% female patients were admitted through involuntary mode. Majority of the selected subjects were cases of schizophrenia (males 60% and females 62.2%), followed by affective disorder (Males 35.5% and females 33.3%), whereas only few subjects (4.4% each) were cases of personality disorder. Mean duration of illness was 5.11 years in males and 8.04 years among female patients. Table-2 : Illness profile of the subjects N=90 Variables f (%) f (%) Type of admission Voluntary 32 (71.11) 19 (42.22) Involuntary 13 (28.88) 26 (57.77) Clinical diagnosis Schizophrenia 27 (60.00) 28 (62.22) Affective disorders 16 (35.55) 15 (33.33) Personality disorders 02 (04.44) 02 (04.40) Duration of illness (yrs) * 0-5 years 21 (46.66) 30 (66.66) 5-10 years 10 (22.22) 07 (15.55) >10 years 14 (31.11) 08 (17.77) * Mean duration of illness (year. months): Males (05.11) ; Females (08.04) Data regarding prevalence of abuse and social neglect among subjects may be perused from Table 3. It was found that more number of males mentally ill patients experienced physical abuse (75.6% vs. 64.5%) and verbal abuse (53.3% vs. 46.7%) as compared to female patients. Where as social neglect was more prevalent among female patients and 4.4% female patients also experienced sexual abuse. Among females social neglect was more interms of shelter, clothings and social discrimination while in males it was more in terms of personal hygiene. 159

6 Table-3 : Prevalence of abuse among subjects N=90 Variables f (%) f (%) Verbal abuse 34 (75.56) 29 (64.45) Physical abuse 24 (53.34) 21 (46.67) Sexual abuse* 02 (04.44) Social neglect Shelter 11 (24.45) 18 (40.00) Food 11 (24.45) 10 (23.43) Clothing 04 (08.89) 09 (20.00) Personal hygiene 10 (24.79) 08 (17.78) Social discrimination 23 (51.12) 35 (77.78) * Unwanted touch only Male patients experienced verbal abuse in the form of harsh voice (75.56%), abusive language (46.66%), blaming (11.11%) and threatening (04.44%) Similarly the female patients have also experienced harsh voice (57.77%), abusive language (46.66%), blaming (20%) and threatening (15.55%). It means than verbal abuse in the form of harsh voice and abusive language was more in male patients as compared to female patients and blaming & threating was observed more in female patients as compared to male patients. Male patients have experienced physical abuse in the form of slapping (48.88%), beating (44.44%), attack with a weapon (28.88%), mutilation (22.22%), locked in a separate room (20%), chained/hand cuffed in the room (08.88%) and whipping (04.44%). Similarly females patients had experienced slapping (44.45%), beating (42.22%), attack with weapon (17.77%), locked in the separate room (20%), chained/ handcuffed (11.11%), whipping on their backs with stick (04.44%). Hence physical abuse of all types in higher or equal in male patients except being chained / handcuffed which is higher in female patients.(table-4) 160

7 Table-4 : Verbal and physical abuse among the subjects N=90 Variables f (%) f (%) Verbal abuse Harsh voice 34 (75.55) 26 (57.77) Abusive language 21 (46.66) 18 (40.00) Blaming 05 (11.11) 06 (20.00) Threatened 02 (04.44) 07 (15.55) Physical abuse Slapping 22 (48.88) 20 (44.45) Beating 20 (44.44) 19 (42.22) Attacking 13 (28.88) 08 (17.77) Mutilating 01 (02.22) 01 (02.22) Whipping 02 (04.44) 02 (04.44) Chained 04 (08.88) 05 (11.11) Locked 08 (20.00) 09 (20.00) Table-5 shows the social neglect among the subjects. It was observed that female subjects had more neglect on shelter profile than male subjects. Neglect on food was almost same in both the subjects. Neglect in clothing was more among female subjects their male counter parts. It further illustrates that female subjects were more devoid of adequate seasonal clothes and clothes according to their choice as compared to male subjects. Poor personal hygiene was more among male subjects than female subjects and hair care is neglected equally in both the groups. Female patients were also deviad of pads during menstruation (4.44%) and toileteries (4.44%). Social discrimination is found more in female subjects than males and maximum social discrimination was found in sharing of property among female subjects. They were also devaid of attending social functions (24.44%) & not involved in household activities (11.11%) in higher percentage as compared to their male counter par ts. It was further observed from higher percentage of female patients (4.44%) were not visited during hospitalisation as compared to their male counter parts (2.22%). 161

8 Table-5 : Social neglect among subjects N=90 Variables f (%) f (%) Shelter profile Homeless 04 (08.88) 06 (13.33) No separate room 07 (15.55) 14 (37.77) No furnished room 08 (17.77) 07 (15.55) Food profile Inadequate three meals 03 (06.66) 04 (08.88) Stale food 02 (04.44) 02 (04.44) Unhygienic food 03 (06.66) 03 (06.66) No food according to choice 09 (20.00) 07 (15.55) Clothing profile Inadequate seasonal clothes 02 (04.44) 05 (11.66) Unclean clothes 03 (06.66) 03 (06.66) No clothes acc. To choice 03 (06.66) 06 (13.33) Personal hygiene No daily bath 09 (20.00) 07 (15.55) No hair wash weekly 05 (11.11) 05 (11.11) No pads during menstruation (04.44) No toiletries (04.44) Social discrimination Not attending social function 07 (15.55) 11 (24.44) No health check up 01 (02.22) 01 (02.22) No share in property 08 (07.77) 31 (68.88) Not involved in household activities 02 (04.44) 05 (11.11) Not behaved in same manner 14 (31.11) 10 (22.22) No visit during hospital 01 (02.22) 02 (04.44) Misbehaved by friends 09 (20.00) 09 (20.00) 162

9 Table-6 shows the mean percentage of verbal abuse, physical abuse, and social neglect profile of subjects. The mean value for verbal abuse and physical abuse was slightly higher among male subjects than female and the mean value for social neglect on shelter, food, clothing, and personal hygiene was slightly higher in female subjects than male subjects. But the social discrimination was found to be significantly more among female subjects (p<.05 as revealed by t-test). Table-6 : Mean distribution of abuse & social neglect among subjects N=90 Variables Mean ±SD Mean ±SD % t-test Verbal abuse 1.35 ± ± NS Physical abuse 1.73 ± ± NS Sexual abuse * 00.04±00.20 Social neglect Shelter 0.46 ± ± NS Food 0.33 ± ± NS Clothing 0.17± ± NS Personal hygiene 0.31± ± NS Social discrimination 1.02± ± * NS= Non Significant (p>0.05), df= 88, * Significant (p<0.05) df = 88 * Unwanted touch only Discussion Literature reveals that the prevalence of physical abuse, sexual abuse and social neglect is a serious problem among mentally ill patients. The present study has been undertaken with a view to identify the abuse and social discrimination among mentally ill patients. During analysis of data, it was found that the prevalence of verbal abuse and physical abuse was more in male patients than female patients. Studies conducted by Jacabson et al and Goodman (2001) 2 also shows that prevalence of physical abuse was more in men and sexual abuse is more in women. But Shack et al (2006) 3 found that females were more likely to repor t both physical abuse and sexual abuse than men. 163

10 In the present study sexual abuse was only reported by female patients (02.23%). Jacobson et.al (1987) also reported 38% of women and only 4% of men had history of sexual abuse. Bornoz et al. (1994) 5 reported that 36% men with Schizophrenia and 28% of the Bipolar disorders had been the victims of sexual abuse. Both these groups are at high risk of rape. Rose (1996) 9 also supported that sexual abuse in the mentally ill was 27%. Chandra et al (2003) 4 also reported 30% sexual coercion among women with severe mental illness. In present study it has been found that the prevalence of homelessness was more in females (13.3%) than male (08.88%). However Folsum et al (2000) 6 has reported 15% homelessness in male mentally ill patients. In present study it has been found social neglect on personal hygiene profile was more in male mentally ill patients. Mirza et al (2001) 10 found bad oral hygiene among mentally ill patients. International Secretariat of world organization against torture (2008) has also reported neglect of clothing in female mentally ill patients. In present study it has been found that prevalence of social discrimination was more in female mentally ill patients i.e % than male mentally ill patients i.e %. Muenzenmaire et al (1993) 1 found that 94% female mentally ill patients experience neglect. It is concluded that though verbal abuse and physical abuse was more among male mentally ill patients and sexual abuse and social discrimination was more among female patients. But both the gender experience abuse in one or other form which may cause hindrance in their recovery. Therefore, it is recommended that healthcare authorities must take initiatives to educate public as well as healthcare providers to prevent abuse of mentally ill patients. In addition, healthcare providers must be provided with adequate support and counselling to treat mentally ill patients with dignity. References 1. Muenzenmiar et al. Prevalence of childhood physical abuse among women with severe and persistent mental illness in USA, /ps.psychiatryonline.org/cgi/content/abstract/ 44/7/666 19/11/ Goodman. Recent victimization in women and men with severe mental illness, h3q1312u6783wh3/ 19/11/ Shack et al. Prior history of physical and sexual abuse among mentally ill male and female patients, klu/psaq/2004/ / / /11/ Chandra et al. Sexual coercion abuse among women with severe mental illness, /cat.inist.fr 12/11/ Bornoz et al. Sexual victimization in women with schizophrenia and bipolar disorders in france, u72u5h348u653j33/ 19/11/ Folsom et al. Prevalence and risk factors for homelessness and utilization of mental health services among patients with severe mental illness in a large public health system, ajp.psychiatryonline.org/cgi/content/abstract/ 162/2/370, 12/11/

11 7. International Secretariat of World Organization. Torture among women with mental illness, World_Organisation_Against_Torture_(OMCT) 7/11/ Jacobson A; Richardson. Assault experience of 100 psychiatric inpatients: Evidence of the need for routine inquiry. Am J. Psychiatry 1987; 144: Rose. Sexual abuse of mentally ill patients by neighbors in USA, ps.psychiatryonline.org /cgi/content/abstract/ 42/5/449. 7/11/ Mirza et al. Oral health of psychiatric inpatients in Hong Kong, content/full/25/4/143 15/11/