Sociodemographic and clinical profiles of homeless mentally ill admitted in mental health institute of South India: ‘Know the Unknown’ project

Abstract

Objectives:

A significant number of homeless mentally ill (HMI) patients without any personal, family or other identification details represent a unique problem in the psychiatric services of developing countries like India in the context of legal, humanitarian and treatment issues. These patients pose challenge to the mental health professional in diagnosis and management.

Aims:

To study the sociodemographic and clinical profiles of HMI patients admitted under psychiatry.

Methods:

We performed a retrospective chart review of ‘HMI’ patients from 1 January 2002 to 31 December 2015, who were admitted to the Department of Psychiatry at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Sociodemographic and clinical profiles of the patients were analyzed by descriptive statistics.

Results:

Mean age of the sample was 34.6 years (±12.21 years), 42 (53.8%) were females, 74 (94.9%) were registered as Medico Legal Case and 53 (80.8%) were admitted under reception order issued by a magistrate. HMI patients brought by police were 32 (41.0%), by the public were 32 (41.0%) and 14 (18.0%) by nongovernmental organization /ambulance/social worker. In total, 51 (65.4%) of them had schizophrenia and other psychotic disorders, 24 (30.8%) had mental retardation and 23 (29.5%) had a comorbid substance use disorder. The mean Clinical Global Impression severity at admission was 5.07 (±1.7), and the mean duration of inpatient care was 15 weeks. Anemia and malnutrition were found in 34 (43.6%) and 25 (32.1%) patients, respectively.

Conclusion:

This study shows that schizophrenia, comorbid mental retardation and substance use disorder are common causes of admission of HMI patients in psychiatry. It is an emerging problem, which needs urgent interventions, and there is a need for an efficient system, guidelines and collaboration with government and nongovernmental agencies.

Keywords

Unknown homeless mental ill psychiatry family integration India

Introduction

Hospitals have a special place in delivering health care to the community. Hospitals are frequently the location of many life-defining moments – including birth, surgery, acute medical illness and death of a family member. A significant number of patients are admitted to government hospitals in the major cities without personal, family details or any identification details. These patients are admitted under the name ‘unknown’, and it is synonymous with the unnamed patient, nameless patient and unidentified patient. Unknown patients are unable to provide information at the initial point of contact in the facility due to following reasons: altered sensorium, poor attention and concentration, irrelevant speech, poor comprehension, significant memory deficits, poor fund of information, formal thought disorder, severe psychotic disorganization, catatonia, deaf and mutism. The neuropsychiatric conditions like seizure disorder, postictal state, stroke, metabolic encephalopathy, schizophrenia, bipolar disorder and mental retardation are associated with the inability to provide information. The unknown status would remain the same until their identity is established during the treatment process. It may be quite difficult for clinicians to get patient’s past medical history, medications used and allergic status. So, this group of ‘unknown’ patients represents a unique problem in developing countries like India in the context of treatment, legal issues, ethical and financial contexts, humanitarian considerations and rehabilitation issues (Singh, Shah, & Mehta, 2016; Tripathi et al., 2013; Umesh et al., 2017). In India, there is no clear estimate about the prevalence of homeless mentally ill (HMI) patients. The National Mental Health Survey (NMHS) of India–2016 guesstimates the range from ‘NIL’ or ‘almost minimal’ to ‘1% of mentally ill’ to as high as ‘15,000’ (NMHS, 2016). HMI patients in India are often found around railway stations, bus stands, pilgrim centers, beggars home, urban area and on street corners of metro cities (NMHS, 2016; Singh et al., 2016).

The prevalence of severe mental disorder and substance use disorder among homeless people is difficult to determine precisely, but it is interesting to note that majority of mentally ill patients with unknown identity are homeless, and many studies reported they are strongly linked to each other. In last few decades, deinstitutionalization has led to an increase in homelessness among mentally ill people (Nieto, Gittelman, & Abad, 2008). A study from Hong Kong shows that the point prevalence of mental illness was 56% among the homeless persons (Yim, Leung, Chan, Lam, & Lim, 2015). The homeless people are associated with high rates of severe mental illnesses like psychosis, alcohol/substance abuse, depression and personality disorders both in high- and low-income countries (Abdul Hamid, Wykes, & Stansfeld, 1993; Edens, Mares, & Rosenheck, 2011; Fazel, Geddes, & Kushel, 2014; Fazel, Khosla, Doll, & Geddes, 2008; Fischer & Breakey, 1991; Greenberg & Rosenheck, 2010; Thompson, Wall, Greenstein, Grant, & Hasin, 2013; Yim et al., 2015; Zima, Wells, Benjamin, & Duan, 1996).

The Mental Health Act (MHA, 1987) of India has provisions for the admission, treatment, detention and rehabilitation of ‘unknown’/homeless wandering mentally ill patients under reception order through police or parens patriae power (Gowda, Noorthoorn, Kumar, Nanjegowda, & Math, 2016; MHA, 1987; Testa & West, 2010). The ‘parens patriae power’ gives the government the authority to act like a parent and care for citizens who are not able to care for themselves (Testa & West, 2010). Despite this, service and provisions remain to a limited special group of population, and a majority of the HMI or unknown patients do not have adequate access to mental health facilities (Thara & Patel, 2010; Thirunavukarasu, 2011).

There is very limited published literature in India on HMI patients (Patra & Anand, 2008). To the best of our knowledge, only two studies have been done on HMI patients in India. A study by Tripathi and his group showed that 90.7% of them had a primary psychiatric illness and only 9.3% had intellectual disabilities. In the same report, they observed that 84.3% were mentally ill before leaving home, 54.3% left home themselves due to the illness and most of them improved and reintegrated into their families (Tripathi et al., 2013). Another study from India showed that 55% had schizophrenia, 52.5% showed improvement and 47.5% of them reintegrated into their family (Singh et al., 2016). The studies on HMI patients have major research barrier due to physical, linguistic, cultural inaccessibility to the health care and neglect by society. In many times, humanitarian services and care usually take precedence over scientific research on this group. Studies done previously have limitations such as retrospective chart review design, incomplete data in few domains and influence of sociocultural and local circumstances on clinical outcome (Singh et al., 2016; Tripathi et al., 2013). This makes it difficult to draw generalized conclusion and understand the practical difficulties of HMI patients.

Aims and objectives

To study the sociodemographic and clinical profiles of HMI patients admitted in psychiatry.

To identify specific issues posed by these patients to the clinicians.

Materials and methods

Study population

We conducted a retrospective chart review of ‘unknown’ patients, who were admitted from 1 January 2002 to 31 December 2015. ‘Unknown’ was operationally defined as HMI patients, who do not have any identity at the time of admission. A total of 78 patients were admitted with a name of ‘unknown’ in the Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore for treatment and rehabilitation under judicial reception order or police custody.

Clinical approach and care

Information was collected from the local person who brought the patient to the hospital. Identification and injury marks were documented in the paper file and electronic records with registration number, and a band of ‘unknown’ was affixed to the patient and file. All unknown patients are registered as Medico Legal Case (MLC). In Emergency care, our multidisciplinary team will try to find the identification of unknown patients by checking pockets of a shirt and trouser for an identity card, mobile number, AADHAR card or any proof of identity. Sometimes, the lockets wore by patient/tattoo on the body help to know the cultural and religious background of the patients. As per our clinical experiences, 70 to 80% of the family were traceable during the emergency care and rest of them were admitted as Unknown. As soon as the patient name and other personal details are confirmed, data in the system would be changed, and the old registration number is continued. Change in data will be done by the medical record personnel both in electronic and paper case records. General physical examination and neuropsychiatric evaluation were done by serial ward observations, behavior and mental status examination. Mental illness was diagnosed as per Internationational Classification of Diseases (ICD-10). In some patients requiring another set of assessments like intelligence test and diagnostic psychometry, appropriate psychological instruments were used. Patients’ clinical improvement was assessed on Clinical Global Impression (CGI) Scale for Severity and Global Improvement. Routine laboratory investigation like renal function test, liver function test, serum electrolytes, blood sugar, hemogram and neuroimaging (computed tomography (CT) brain) were done on an emergency basis in all of them. Few patients required another set of investigations like HIV, venereal disease research laboratory (VDRL), hepatitis-B surface antigen (HBsAg), urine for polydrug, X-ray and so on based on a case-to-case basis. A periodic observation report and treatment details were sent to the court about each patient monthly basis or as per reception order.

Data collection

The files were retrieved from medical records department after obtaining permission from the medical records division officer. An average of 40–60 minutes was spent to extract data from each case file. A structured data extraction tool was used in the study, covering multiple dimensions: sociodemographic profile, pathway to care, clinical profile, psychosocial interventions, discharge and follow-ups. All the obtained information has been used solely for the purpose of research. In this article, we are presenting sociodemographic and clinical profiles of HMI patients.

Ethical considerations

Institutional Ethical Committee (IEC) of National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, approved the above study project by name ‘Know the Unknown’.

Statistical analysis

Sociodemographic and clinical characteristics were analyzed by descriptive statistics.

Results

In our center, 67,210 patients were admitted to psychiatry from 1 January 2002 to 31 December 2015. The total number of admissions in psychiatry in 2014–2015 was 5,565 patients. Out of these, 112 (0.016%) patients were admitted as unknown (HMI patients) under the department of psychiatry for treatment and rehabilitation under judicial reception order or police custody. We are presenting 78 HMI patients’ comprehensive chart review, after excluding HMI patients referred to general hospital for multidisciplinary care and those having incomplete medical chart.

Table 1 shows the sociodemographic profile of HMI patients. The mean age of the sample was 34.6 years (±12.21 years), 42 (53.8%) were females, 74 (94.9%) were registered as MLC and 53 (68%) were admitted under reception order issued by a magistrate. In total, 32 (41.0%) of the patients were brought by police, 32 (41.0%) by public and 14 (18%) by nongovernmental organization (NGO)/ambulance/social worker.

Table 1.

Sociodemographic profile of patients at admission.

Variable		N = 78
Age in years (M (SD))		34.6 (±12.21)
Age in years (n (%))	<40	58 (74.6)
Age in years (n (%))	≥40	20 (25.6)
Sex (n (%))	Male	36 (46.2)
Sex (n (%))	Female	42 (53.8)
Admitted by (n (%))	Public	32 (41.0)
	Police	32 (41.0)
	NGO/health worker/others	14 (18.0)
Admission by reception order from the court (n (%))	Present	53 (68)
Admission by reception order from the court (n (%))	Absent	25 (32)
Occupation (n (%))	Employed – before illness	16 (20.5)
Occupation (n (%))	Never employed	62 (79.5)
Religion (n (%))	Hindu	47 (60.3)
	Muslim	9 (11.5)
	Christian	1 (1.3)
	Not known	21 (27)
Socioeconomic status (SES; (n (%))	BPL	32 (41)
	APL	15 (19.2)
	Not known	31 (39.8)
Marital status (n (%))	Single	12 (15.4)
	Married	32 (41)
	Not known	34 (43.6)
Languages (n (%))	Kannada	33 (42.3)
	Hindi	16 (20.5)
	Others	14 (18)
	Mute/not fluent in any language/not known	15 (19.2)
Location (n (%))	Rural	25 (32.1)
	Urban	30 (38.4)
	Not known	23 (29.5)
City (n (%))	Within Karnataka – outside Bangalore	19 (24.4)
	India – outside Karnataka	38 (48.7)
	Not known	21 (26.9)
Registered as MLC (n (%))	Yes	74 (94.9)
Registered as MLC (n (%))	No	4 (5.1)

SD: standard deviation; NGO: nongovernmental organization; BPL: below poverty line; APL: above poverty line; MLC: Medico Legal Case.

Table 2 shows the clinical profile of patients. Of the total patients, 51 (65.4%) had schizophrenia and other psychotic disorders, 24 (30.8%) had mental retardation and 23 (29.5%) had a comorbid substance use disorder. The mean CGI severity at admission was 5.07 (±1.7), the mean duration of inpatient care was 15 weeks and 69 (88.5%) had absent insight at admission.

Table 2.

Clinical profile of patients at admission.

Variable
Primary psychiatric diagnosis (n (%))	Schizophrenia and other psychotic disorder	51 (65.4)
	Mood disorders (including unipolar and bipolar)	11 (14.1)
	Others	16 (20.5)
Comorbid psychiatric diagnosis (n (%))	Mental retardation	24 (30.8)
Comorbid psychiatric diagnosis (n (%))	Substance dependence syndrome and others	23 (29.5)
Comorbid medical diagnosis (n (%))	Anemia	34 (43.6)
	Malnutrition	25 (32.1)
	Seizure disorder	7 (9)
Insight at admission (n (%))	Present	4 (5.1)
	Partial	5 (6.4)
	Absent	69 (88.5)
Reason for current admission (n (%))	Risk to self	63 (80.8)
	Risk to other	58 (74.4)
	Severe danger to health	41 (52.6)
	Inability to care for self	61 (78.2)
	Risk to public/personal property	39 (50)
	Found wandering in the city	78 (100)
Type of treatment used during IP care (n (%))	Oral medication	73 (93.6)
	Injection	43 (55.1)
	ECT	4 (5.1)
M (SD) score on CGI severity at admission		5.07 (1.7)
M (SD) score on duration of IP care in weeks		15.0 (14)

SD: standard deviation; IP: inpatient; ECT: electroconvulsive therapy; CGI: Clinical Global Impression.

Table 3 shows investigation profile of patients.

Table 3.

Investigation profile of unknown patients.

Variable		N = 78
Abnormal imaging finding (CT/MRI brain)		7 (9%)
Positive for cannabis in urine test (polydrug kit)		3 (3.9%)
Hemogram	Anemia	34 (43.6%)
Hemogram	Leukocytosis	4 (5.1%)

CT: computed tomography; MRI: magnetic resonance imaging.

Discussion

This study was conducted at a government-run neuropsychiatric hospital located in a metropolitan city. This study provides comprehensive systematic data on HMI patients admitted in the psychiatry department. In our study, majority were young females (mean age: 34.6 years), very often admitted by court order, were never employed, had a long-standing untreated severe mental illness, few had comorbid substance use and mental retardation and all were found wandering in the city. This was the state of HMI patients, who were admitted to our hospital.

Our study highlights that most of HMI (unknown) were registered as MLC. Even though public and NGO has brought HMI patients initially to the hospital, they were directed to police to get a reception order from the court. It reflects the responsibility, guardianship, hospital charge, legal, Mental Health Act, Rules, Regulations and court procedures involved in the care of HMI patients by society in India. These findings are consistent with past two Indian studies on HMI patients (Singh et al., 2016; Tripathi et al., 2013). The training of police personnel about the identification of mental illness among homeless and beggars can help in early detection of HMI patients and protect them from abuse and violence (Patel et al., 2010; Tripathi et al., 2013).

Mean age of our patients was 34.6 years; majority were aged <40 years, which is comparable with the past studies done on HMI patients in India (Singh et al., 2016; Tripathi et al., 2013). Many of HMI patients (53.8%) were female in our study, while majority were (82.9%) male in study by Tripathi and his group. Many of HMI patients were illiterate (60%), 6 of them were deaf and dumb, 15 were not able to comprehend any language or make nonverbal communication. This communication barrier hindered the process of psychosocial rehabilitation and reintegration.

Schizophrenia and other psychotic disorders were found in 65.4% of them, 30.8% of them had mental retardation and 23 (29.5%) had a substance use disorder. These findings are comparable across studies from high- and low-income countries on HMI patients(Beijer & Andréasson, 2010; Edens et al., 2011; Fazel et al., 2008; Roy et al., 2016; Singh et al., 2016; Thompson et al., 2013; Tripathi et al., 2013; Weller & Jauhar, 1987). Severe psychopathology, severe psychotic disorganization, boundary disturbance of self and other in schizophrenia, deaf and mutism and significant memory deficits due to subnormal intelligence make this population vulnerable to homelessness.

Anemia and malnutrition are the common comorbid medical conditions among HMI patients; this is comparable with the past studies on HMI patients in India and outside (Gelberg & Linn, 1989; Tripathi et al., 2013). The coexisting medical comorbidities might have been due to poor living condition, unhygienic state, undernutrition, long-standing homelessness, inability to care for self and psychotically disorganized behavior. Even though our center is a neuropsychiatric facility, all of them were evaluated for medical comorbidities in detail as a hospital-based protocol and part of a comprehensive management plan. HMI patients who had multiple comorbid severe medical conditions or had only medical disorder were referred to the general hospital for multidisciplinary care.

All patients were found wandering in the city purposelessly as per the records. On observation, most of them were unable to take care of themselves, were at risk to self, others and public/private property. These findings are similar to past studies done on HMI patients in India and outside (Singh et al., 2016; Tripathi et al., 2013; Weller & Jauhar, 1987). Some patients had coexisting medical illnesses like infection in 10 patients, genitourinary problems in 4, sexually transmitted disease in 1 and abrasions and wounds in multiple patients. Six patients were deaf and dumb, five had organic brain syndrome, two had hemiplegia and two had contracture of lower limbs and disuse atrophy. Such common physical illnesses were also observed in studies from high-income and low-income countries on homeless people (Gelberg & Linn, 1989; Hwang, 2001; Hwang & Burns, 2014; Saddichha, Linden, & Krausz, 2014).

In our study, most of them received atypical oral antipsychotics (93.6%), followed by parenteral neuroleptics (55.1%) to control aggression, agitation and violence. It shows that most of them required both oral and parenteral medication to manage behavioral problems; it may be due to the severity of illness during inpatient care. Among HMI patients, the mean duration of inpatient care was 15 weeks, compared to 3 weeks in psychiatric inpatients who were admitted with a family member to the same hospital (Gowda, Noorthoorn, Kumar, Nanjegowda, & Math, 2016). The long duration of inpatient care among HMI might be due to the following reasons: (a) time taken to overcome the lacunae of information about the patient and his condition to make a provisional diagnosis and management plan; (b) most of them had very long-standing untreated severe mental illness; (c) they needed comprehensive medical care; (d) they required skill training, psychosocial and vocational training; and (e) many of them though improved earlier were kept in hospital due to judiciary dilemma of fate of such patients in whom family reintegration did not happen.

The clinicians face many hurdles in the care of these patients such as (a) what is that the hospital needs to do? (b) When the clinical decisions should be made? (c) How do you obtain consent? (d) What is the best approach to management? (e) What kind of finances and insurances does he or she have? (f) Who will pay the hospital charges? (g) When to discharge from the hospital? (f) Where to discharge these patients? (h) What will happen after discharge? (i) Who will monitor drug adherence? and (j) Who will bring to hospital for a follow-up? Most of the HMI patients improved and were discharged, and in majority of the cases, we were able to reintegrate them into their family. The treatment and rehabilitation outcomes are encouraging even though we have multiple hurdles. It encourages the public, clinician and policy makers to take a proactive step in mobilizing resources to take care of this special group and reduce the prevalence. This throws light on significance of this population, given the dynamic age group, women security, welfare and reversibility of the condition.

Implication

The effective collaboration from NGOs, rehabilitation center, local police, judiciary and psychiatric facilities may help in defining, identifying, treating and rehabilitating HMI patients in India. The prospective research in this area is required for the care, rehabilitation, community-based activities, prevention, protection, welfare, research, training, advocacy and empowerment of HMI patients.

Limitation

This study has some methodological limitations:

It is not only a retrospective chart review design but also the only way to understand and gain information about this clinically important subgroup of the population.

The population is predominantly from South India and may not reflect the complete Indian population.

This study included only inpatients, without any outpatient or community sample. So, drawing a generalized conclusion is difficult.

Conclusion

In this study, majority of them had schizophrenia and other psychotic disorders. The mental retardation and substance use disorder were common comorbid conditions observed among HMI. There is a need for an efficient system, guidelines and collaboration from government and nongovernmental agencies in care of this patient population.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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