Abstract
Aim
In a developing country such as India, the abuse of patients suffering from psychiatric disorders has been underreported. The aim of this study was to detect abuse in chronically ill psychiatric patients visiting a psychiatric outpatient setting in a tertiary care hospital in Delhi, India.
Material and Methods
A cross-sectional descriptive written survey was carried out on 406 patients. A self-administered questionnaire for patient abuse was developed in Hindi based on the World Health Organization’s Domestic Violence Questionnaire that encompassed questions regarding physical, emotional and sexual abuse.
Results
Of the 406 patients, 294 (72%) suffered from abuse, with 64% experiencing emotional abuse, 39% physical abuse and 21% sexual abuse. In chronically ill psychiatric patients, a significant association was found between education and abuse, with most abuse occurring among senior secondary pass outs (i.e. 11–12 years of education) and least among junior high school pass outs (6–8 years of education). A majority (74%) of these patients lived in urban areas (p = .020). A significant association was also found between abuse and the psychiatric diagnosis of the patient, with 53% suffering from depression, 66% anxiety disorder, 81% bipolar disorder, 94% psychotic disorder, 86% obsessive compulsive disorder, 44% sexual disorder and 12% other psychiatric disorders.
Conclusions
There is a need to create awareness in society in order to prevent abuse. Screening for abuse in routine psychiatric practice is of utmost importance so that timely interventions can be given, thereby preventing its deleterious health consequences.
Introduction
Patient abuse or neglect is defined as any action or failure to act which causes unreasonable suffering, misery or harm to the patient. It includes physically striking or sexually assaulting a patient, as well as withholding necessities such as food, physical care and medical attention. 1 There is a dearth of studies on the prevalence of abuse among outpatient psychiatric patients from India. In a preliminary survey, domestic abuse was reported in 53% of female psychiatric patients. 2 The lifetime prevalence of domestic violence among women presenting to non-psychiatric settings such as emergency departments was reported as 54.2%. 3 Carmen et al. 4 reported an overall prevalence rate for any form of abuse as 43% in male and female psychiatry inpatients, and an additional 7% with suspected abuse. Out of these cases, 53% experienced physical abuse only, 19% sexual abuse, and 29% experienced both forms of abuse. The vast majority (92%) were physically abused by a family member, that is, abused by a husband or ex-husband (51%), fathers or stepfathers (40%) and mothers or stepmothers (23%).
Sexual assault was primarily perpetrated by strangers (29%) and siblings (16%). According to Carmen et al., 4 those victims who reported violence were more likely to be adolescent males and adult females. Male victims were more likely to abuse others than female victims were. In another study, Jacobson and Richardson 5 found that 81% experienced at least one type of assault (physical or sexual assault in adulthood or childhood), 60% experienced two or more types of assault and 22% experienced three or four types of assault. Adult males were significantly less likely to report sexual assault than adult women were.
According to Bergman and Ericsson, 6 patients with an affective disorder tended to report the experience of domestic violence less frequently than those with personality disorder and schizophrenia. The lifetime prevalence of psychiatric disorders in domestic violence survivor females were reported as post-traumatic stress disorder (PTSD; 78%), major depression (65%), alcohol abuse/dependence (21%), panic disorder (15%) and avoidant personality (12%). 7 Porcerelli et al. 8 also found that for both male and female patients, violence was related to symptoms of depression. Danielson et al. 9 assessed the relationship between adult partner abuse and psychiatric disorders. They found that 55.7% of the women experiencing any form of violence exhibited a diagnosable problem, with mood disorder being the most prevalent (35.7%). Among women who experienced severe violence, 64% had received a psychiatric diagnosis. The most prevalent were mood disorder (44.4%) and substance abuse (18.5%), followed by eating disorder (7.4%) and antisocial personality (3.7%). In a study 10 among 150 adolescents suffering from their first episode of psychosis, the prevalence of abuse by a parent (mostly mothers) was 40.7%.
The studies published on prevalence and risk factors of patient abuse in mental health settings had many lacunae. First, the small sample size greatly hinders generalisation of results. It reduces statistical power, making it more difficult to identify differences that may exist across different diagnostic or demographic categories. Second, most of the studies focused only on physical form of abuse. The present study overcomes these shortcomings and provides data on emotional, physical and sexual abuse in chronically ill psychiatric patients and helps to provide a better approach towards the assessment of abuse.
The primary objective of the study was to determine the prevalence and nature of abuse in chronically ill psychiatric patients and new visit female patients coming to the psychiatric outpatient department of a tertiary care hospital. The secondary objective was to determine the association of abuse with psychiatric diagnosis and the sociodemographic variables.
Materials and methods
A cross-sectional descriptive written survey was carried out in a tertiary care hospital in Delhi, India. A total of 406 psychiatric patients were included, of whom 206 (99 males) were chronic mentally ill patients and 200 were new female patients. Their ages ranged from 18 to 45 years.
Tools
Patients completed a psychiatric history proforma, which collected information related to sociodemographic details, history and psychiatric diagnosis. All patients gave written informed consent. Approval was granted by the Institutional Ethical Committee.
Patients completed two self-administered questionnaires in Hindi. Both questionnaires were approved by the Institutional Ethical Committee and Indian Council of Medical Research, Delhi.
The first – the patient abuse questionnaire – contained 31 questions relating to different aspects of physical, emotional and sexual abuse. This questionnaire was also prepared in English. It was reviewed for content validity by experts, and was pilot tested among patients and modified to ensure clarity and readability.
The second questionnaire was a modified version of the World Health Organization (WHO) Domestic Violence Questionnaire. This was a seven-page, 14-item written questionnaire encompassing questions about physical, emotional and sexual violence. This questionnaire was translated into Hindi, and an independent back translation was also carried out. As a result, it was further modified in Hindi by a language expert. The final version was pilot tested on 20 patients to ensure clarity and readability.
All consecutive patients who gave consent were recruited. The patients were informed that their identity would be kept confidential for the purpose of the study. Patients were assessed by a psychiatrist using the psychiatric history pro forma, and the psychiatric diagnosis was established according to ICD-10 criteria. 11
The study included chronic stable patients having a diagnosable psychiatric disorder and receiving treatment for at least of two years with no active psychopathology for a minimum of two years. All female patients (age range 18–45 years) visiting the outpatient psychiatric setting for the first time were also included. Patients suffering from an organic brain disorder, head injury, recent onset of seizures, unconsciousness (MMSE score <24), substance intoxication, any unstable medical/psychiatric illness or those who did not give consent were excluded. Literate patients were given the questionnaire and sent to a separate room. They were left alone with the questionnaire for 5–10 minutes. Assistance in completing the questionnaire was offered, if required. The questionnaire was read out to illiterate patients, and their responses were marked on a separate sheet. Confidentiality of the information was assured. After completion of the questionnaire, the patients were encouraged to share any concerns about personal injury or violence.
Emotional abuse was defined as answering yes to questions about being insulted or being made to feel bad by caregivers, or purposefully being made to feel scared, or being threatened with being hurt or threatening to hurt someone they cared about. Physical abuse was defined as being slapped or attempted to be hurt, or being punched or hit with something which could have hurt. Instances of hair pulling, or being pushed, kicked, dragged, beaten up, choked or purposefully burnt, or being threatened with a gun, knife or a fatal weapon were considered as physical abuse. Sexual abuse was defined as being physically forced to have sexual intercourse against their will and under threat. Total abuse was defined in those who faced any kind of abuse during their lifetime, including physical, emotional and sexual abuse or abuse in the form of medical negligence, negligence with regard to food intake or any kind of economic deprivation.
Statistical analysis
SPSS v17 was used for data analysis, with each form of abuse being analysed. The second set of analyses explored the relationship between the overlapping forms of abuse with that of demographic variables, diagnosis and duration of illness. The duration of abuse, whether within the last 12 months (acute) or before that (chronic), and its frequency were also analysed. The sociodemographic data, psychiatric diagnosis and type of abuse were included in the analysis, and an attempt was made to study any possible associations.
Results
A total of 600 patients were chosen randomly at two equally distant time intervals from the psychiatric outpatient department. Out of these, 172 patients were excluded. Out of the remaining 428 patients who met the eligibility criteria, 14 refused consent. A total of 414 patients who consented to take part in the study were given the questionnaire. Out of 414 questionnaires collected, eight were rejected due to incomplete information, and the remaining 406 were entered into the database for analysis, as shown in Figure 1.
Flow chart showing the recruitment of the patients (N = 600).
Sociodemographic profile of patients visiting the psychiatric outpatient Clinic (N = 406).
Pie chart showing psychiatric diagnoses of chronic patients visiting the psychiatric outpatient clinic (n = 206).
Pattern of emotional abuse in chronic patients visiting the psychiatric outpatient clinic (n = 206).
Pattern of physical abuse in patients visiting the psychiatric outpatient clinic (N = 406).
Pattern of sexual abuse in patients visiting the psychiatric outpatient clinic (N = 406).
Of the 406 patients, 65% suffered from some form of abuse, with 52% suffering emotional abuse, 27.6% physical abuse and 24.8% sexual abuse (Figure 3).The perpetrators of the abuse were mainly the caregivers, including their spouses, in-laws, parents, relatives and others, in descending order. Around a quarter of chronic patients reported facing sexual abuse during the course of their illness by their spouses. About 4% also faced negligence in the form of withholding medicine, proper treatment and food. Twenty-eight per cent of the chronic patient population also reported economic abuse in forms of monetary insufficiency, difficulty in finding a job and alienation from the household during the course of their illness.
Prevalence of abuse in patients visiting the psychiatric outpatient clinic (N = 406).
The pattern of abuse reported in new consecutive female patients (n = 200) was emotional abuse (75%), physical violence (51%), sexual violence (17%) and economic abuse in the form of economic deprivation (43%). Twenty-nine per cent said that they were not included in matters concerning day-to-day decision making.
Around a quarter of chronic patients had faced sexual abuse from their spouses during the course of their illness. About 4% had also faced negligence in terms of receiving medication, proper treatment and food.
In new consecutive female patients (n = 200), 99% of the emotionally abused had been suffering a chronic form of violence, while 59% had been facing it for the last year. All the patients who faced physical violence had been suffering for more than a year. Among the patients who reported sexual violence, all had been suffering for more than 12 months, while 65% had been facing this form of violence for the last 12 months, as shown in Figure 4(a).
(a) Abuse in new female patients (n = 200) and (b) Abuse in chronic patients (n = 206).
Of the 206 chronic patients, 76% of the emotionally abused had been suffering for more than 12 months (chronic form), while 52% had been abused during the past year (acute). Seventy-three per cent of physically abused patients had been suffering chronically, while 50% of them had been abused during the last year. Among the patients reported to have been sexually abused, 80% had been chronically abused, while 43% had been facing it during the last 12 months (Figure 4(b)).
p-Value for the association of various sociodemographic variables of chronic patients (n = 206) with various forms of abuse using Pearson’s chi-square test.
p < .05.
A significant association was found between the education of chronic patients (n = 206) with emotional abuse (p = .007), sexual abuse (p = .009) and total abuse (p = .034). Even though no specific trend was observed between abuse and education, it was noted that victims of maximum abuse of all types, including emotional (73%) sexual (48%) and total (84%) abuse, had completed their 11–12 years of education, while the patients who had completed six to eight years of education faced minimum emotional (50%) and total (34%) abuse. Sexual abuse (10%) was found least in patients who completed 9–10 years of education.
A significant association was also found between physical abuse and domicile abuse in chronic patients (p = .020). Of 206 chronic patients who experienced physical abuse, three quarters (74%) belonged to the urban population.
An association was also found between the income of chronic patients (n = 206) suffering physical and sexual abuse. The most abuse (i.e. 75% physical and 50% sexual abuse) was perpetuated by individuals having no income. Even though no trend was found in this association, comparatively less abuse (i.e. 21% physical and 23% sexual) was seen in individuals having an income of >10,000 INR.
A strong association was found between the diagnosis of chronic patients (n = 206) and total abuse (p = .000) as well as emotional abuse (p = .000). The most emotional and total abuse was found in patients suffering from psychotic disorders, while the patients suffering from sexual disorders faced the least proportion of this abuse. The prevalence of total abuse in the patients according to psychiatric diagnosis was depression (53%), anxiety disorder (66%), bipolar disorder (81%), psychotic disorder (94%), obsessive compulsive disorder (OCD; 86%), sexual disorder (44%) and other psychiatric disorders (12%). The prevalence of emotional abuse according to psychiatric diagnosis was depression (44%), anxiety disorder (53%), bipolar disorder (71%), psychotic disorder (80%), OCD (46%) and sexual disorder (39%). No emotional abuse was reported in other psychiatric disorders such as PTSD, personality disorders, somatoform disorders, dissociative disorders and so on.
Discussion
The prevalence of different forms of abuse in the present study was 72%. These findings are in accordance with the study by Jacobson 12 which showed an overall prevalence of abuse of 68%, although they had centred their study on physical and sexual abuse only. The prevalence of abuse in the present study was lower than that of Jacobson and Richardson (81%), 5 but it was higher than that of Carmen et al. (43%). 4 The present study showed a high level of prevalence of patient abuse across society. Despite the existing laws for protecting women from domestic violence, 13 the high prevalence suggest gross ignorance in society.
A study by the WHO reported that in most countries, 4–54% women had faced physical or sexual violence or both by a partner within the 12 months prior to the study. 14 A cross-sectional, multi-centre study of women from five countries (Denmark, Finland, Iceland, Norway and Sweden) found the lifetime prevalence for physical abuse as 38–66%, emotional abuse 19–37% and sexual abuse 17–33%. 15 Richardson et al. 16 reported that 41% women had experienced physical violence at some point in their lives, and 17% had experienced it within the past year. This is accordance with the present study which found the overall prevalence of physical abuse to be 27.6%.
An interesting finding from the present study was that the majority of abuse was concentrated in the urban population. This could be attributed to the stressful lifestyles, hectic schedules and high cost of treatment borne by the caregivers, which leads to neglect and hence abuse. This is also supported by the fact that the majority of abuse significantly prevailed in individuals from the low-income group. This proves that a combination of stress and the high cost of treatment can lead to the perpetuation of abuse. A significant association of physical and sexual abuse with income was found in the current study with a reduced income indicating more abuse. The per capita income of India is $1219, ranked 142nd in the world, with a quarter of the nation’s population earning less than the government-specified poverty threshold of about $0.40/day. 17
The overall urban–rural distribution of the population in India according to the 2011 census is 68.84% in rural areas and 31.16% in urban areas, 18 which is different to the present study where 70.3% were from an urban population and 29.7% a rural population. The possible difference in the urban–rural divide can be explained by the fact that the authors’ hospital is a tertiary care teaching hospital which caters mainly for the urban population of Delhi and the neighbouring states.
Even though an association was seen between abuse and education, no specific trend could be found, proving that abuse is a universal phenomenon and equally prevalent in educated and uneducated individuals.
According to a study by Kumar et al., 19 40% of 9938 females reported poor mental health. They also found that physical violence was associated with poor mental health. The present study also found that psychiatric diagnosis had a statistically significant association with abuse. Ninety-four percent of abuse was in patients suffering from psychotic disorders such as schizophrenia. The likely explanation for psychotic patients being abused maximally is because their behaviour is most intrusive and hence more likely to attract social sanction. Also, because of the stigma associated with mental illness being rampant in a developing country such as India, the abuse of psychiatric patients often goes unreported.
Even though a correlation between abuse and gender has been previously been reported,4,5 such an association could not be found in the current study. It is possible that a larger sample size may overcome this limitation.
Further studies are required to elicit the cause of the abuse. It could be caused by factors such as alcohol or drug abuse by the caregivers, poverty, poor relationships, lack of discipline and so on prevalent within the family. Patient abuse is a high-priority issue of major public-health importance. There is an immense need for routine screening of abuse in all age groups so that interventions can be made at an early stage and long-term deleterious health consequences can be prevented.
The public needs to be made aware of the Domestic Violence Act and the other related laws so that all forms of abuse can be prevented. Routine screening for different forms of abuse must be made mandatory in outpatient and emergency settings. There is a need for early detection of different forms of abuse by training mental health professionals and clinicians.
The strengths of the present study include that it was statistically sound, using standardised questionnaires. The patients included in the study were psychologically stable and hence could self-administer the questionnaire, thus eliminating observer bias. The study was aided by a team of skilled professionals, including psychiatrists and psychiatric nurses, for management of the victims. Patients were provided with regular care and interventions as and when required. Different forms of abuse were analysed, and correlates of the various parameters with each form of abuse were detected.
The study’s limitations include the small sample size which might lead to bias. Other causes of abuse related to alcohol and drug dependence on part of the caregivers, poverty, poor relationships, lack of discipline and so on could not be assessed. A significant correlation of gender, marital status, religion or other parameters could not be found. Multiple interviewing at different time intervals was not done, which could have led to underreporting of the abuse. The severity of the abuse was also not assessed.
Interventions for victims/abuser
The detailed psychiatric and medical evaluation, pharmacological interventions and support through legal/public help systems is provided free of charge in the authors’ tertiary care hospital. Medico-legal work done by a multidisciplinary team including gynaecologists, surgeons, physicians and forensic experts along with police is a necessity for cases facing physical and sexual violence. The victims are provided treatment free of charge. The perpetrators are counselled for anger management.
Family members are trained to improve communication and problem-solving skills. Education, awareness and treatment are given for both the victim and the perpetrator. Legal help is sought for the safety of the victim. In a therapeutic setting, the patient is counselled and treated. If the abuser is a spouse, then the couple is involved in marital counselling. Social workers are also involved in the remedial process.
In the current Indian scenario, it is not mandatory for a physician to report acts of abuse to the police or legal agencies. The patient is made aware of her rights. The responsibility lies with the patient or her caregivers to report the incident to the police. Under the Domestic Violence Act, 13 an aggrieved woman or any other person on behalf of the aggrieved person may present an application to the Magistrate seeking one or more reliefs under this Act. The relief sought may include payment of compensation or damages without prejudice to the right of such person to institute a suit for compensation or damages for the injuries caused by the acts of domestic violence committed by the respondent. As in some countries such as the UK, there should be more responsibility on professionals to report abuse when detected during treatment. In developing countries such as India, where housewives are dependent financially on the perpetrator and also live in the same family unit, the victims do not report or are afraid of disclosing abuse. Patient abuse holds implications for society, and the policymakers must involve non-governmental organisations, local resident welfare associations and legal agencies to identify and report the cases.
Conclusions
Various forms of abuse are common among psychiatric outpatients in India, but such abuse often goes underreported. This may be due to the dependency of victims on the perpetrators. Awareness needs to be raised through mental-health campaigns and the media to sensitise the public towards the elimination of abuse. Providing helpline numbers is also useful in identifying and treating the victim. Screening for patient abuse in routine psychiatric clinical practice is of utmost importance so that timely interventions can be given, thereby preventing deleterious health consequences.
Footnotes
Funding
The authors are thankful to the Indian Council of Medical Research (ICMR) for its valuable support in carrying out the study.
Conflict of interests
The authors declare no conflict of interest.