Discrimination of psychiatrically ill persons by hospitals

Discrimination of mentally ill persons by hospitals

A young woman with psychiatric illness was refused admission at a leading tertiary care hospital in Pune. The reason - “mentally unstable patients are known to cause harm not only to themselves but to others as well. The hospital lacks facilities and infrastructure for catering to psychiatric patients.” A similar unwritten policy of denying inpatient care on grounds of psychiatric illness exists in at least one other large corporate hospital in Pune.

We have already stressed the importance of access to healthcare for persons with mental illness. We will now further explore the stereotype of harm in mental illness. The stigma associated with this stereotype has an adverse impact on timely delivery of healthcare to persons with psychiatric illness.

Are mentally ill persons likely to harm other hospital inpatients?

Hospital and healthcare settings have the highest levels workplace related violence across all industry sectors (CDC 2002).  The place where patient perpetrated violence is most likely to occur is the Emergency or Casualty department not the wards (Farooq 2009). Patients of all categories mostly attack staff or junior doctors - the ones they are in regular and direct contact with. In most cases violence is perpetrated by arrogant patient attendants not the patients themselves, whatever their diagnosis. For the rest violence is a result of unacceptable staff behaviour, and dissatisfied patients or attendants. It is rare for patients of any diagnosis to physically attack and harm each other in a hospital. Even in acute inpatient psychiatry units violence towards other patients or staff is less than 3% of total incidents of violence (Biancosino 2009). So much for psychiatric illness being “known to cause harm”.

Are patients with psychiatric illnesses the only ones that harm other patients? At the height of the swine-flu scare in 2009 no patient suspected of having the disease was denied treatment or admission. Yet swine-fly is known to be highly contagious and lethal. Special protocols and facilities were drawn up and earmarked overnight. So the potential for harm is not the overriding factor in denial of treatment.

Patients with psychiatric illness require minimal investigation, and respond rapidly to cheap and effective medication. Return on investment may be what it is all about. Psychiatrically ill pateintsdo not make much money for a hospital. It is more lucrative to provide skewed facilities for a liver transplant that would require weeks of ICU care, extensive investigation and invasive procedures. It would also make news for all the right reasons.

Mental illness accounts for 80-90% of completed suicides. Serious suicide attempts by poisoning or jumping result in emergency hospital admissions. Treatments would entail stay in the Intensive Care Unit, utilisation of the Operation Theatre, mechanical ventilation, and extensive monitoring and investigations. All this translates into large cash transactions over a short period of time. No hospital administrator would deny admission to these critically ill patients - ethical considerations, policy and stigma not withstanding.

Is it really possible to exclude patients with psychiatric illness from the hospital healthcare system?

The dichotomy between soma and psyche, physical and mental is artificial. This was formally enunciated in Para 1 of the WHOs Alma-Ata declaration (1978) and is the accepted definition of health for medical students since decades. Psychiatric and somatic illnesses coexist with and impact eachother. Ignoring this interaction is adversely affecting the outcomes of chronic illnesses like diabetes, heart disease, cancer and respiratory disease. The World Mental Health Day 2010 document specifically evaluates the evidence and stresses the urgent need to integrate mental heatlhcare for these chronic illnesses which account for 60% of the worlds deaths.

Walk into any hospital ICU and you will see at least one delirious patient strapped to the bed with physical restraints. Psychological aspects of critical illness are given the short shrift only because the mindset is one of discrimination and disrespect for the individual. Psychiatric and physical health problems do not exist in isolation. Their physical basis and vice versa cannot be excluded by artificial dichotomies.

Is it desirable to treat persons with mental illness in a general hospital setting?

Integration of mental healthcare delivery with existing facilities is a major thrust of the WHO (2008). Hospitals need to provide an accessible and acceptable location for treatment of acute exacerbations of mental health disorders in the same way that they currently do for physical health disorders. This would also enable access to services for physical health problems that arise during the inpatient stays of persons with mental health problems.

Deinstitutionalisation of psychiatric and mental health care has been stressed as a human right since the mid 20th century. A step in this direction for Pune's hospitals would be to draw up and implement guidelines to prevent and manage hospital violence. These guidelines already exist (CDC 2002, OSHA 2004).

References

1. Biancosino B, Delmonte S, Grassi L, Santone G, Preti A, Miglio R, de Girolamo G; PROGRES-Acute Group. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy. J Nerv Ment Dis. 2009 Oct;197(10):772-82.
2. CDC. Violence - occupational hazards in hospitals.  DHHS (NIOSH) Publication No. 2002–101. April 2002
3. J Farooq, A Mustafa, D Singh, GH Yattoo, A Tabish, GJ Qadiri. Violence in hospitals. Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009; 16-20
4. Occupational and Safety Health Administration. Guidelines for preventing workplace violence for health care and social service workers. 2004. Publication no. OSHA 3148-01R
   
5. Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001 Jan;52(1):75-80.
6. World Federation for Mental Health (WFMH). Mental health and chronic physical illness - the need for continued and integrated care. World mental health day. 10 October 2010.
7. World Health Organisation (WHO) Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
8. WHO/Wonca.  Integrating mental health into primary care: a global perspective. World Health Organisation and World Organization of Family Doctors (Wonca). 2008.

Inclusive education for children with autism in Pune

Inclusive Education

Inclusive education for children with autism and other developmental disabilities is now approaching reality in Pune. Nine children with autism appeared for the Maharashtra 10th standard (SSC) board exam. The accommodations and waivers granted to these students reflect an infusion of the fresh breath of inclusion into the corridors of the board of education .

Sarva Shiksha Abhiyan (SSA) in Maharashtra

The Education for All Movement, the central government’s flagship SSA, seeks to ensure that every child, including those with special needs, is provided an elementary education. As far as disability is concerned the SSA has adopted a zero rejection policy. It provides for universal access to infrastructure and curricula in schools. Maharashtra is at the forefront of this scheme. In all 380000 teachers from Maharashtra attended workshops on inclusive education through the SSA. 414277 children with special needs were identified and 380723 enrolled under the SSA in Maharashtra as of Jun-2009, . Of these about 9000 children were provided a home-based education.

Beyond elementary school it is up to the state education boards to ensure access to further education. For this the Central Board of Secondary Education (CBSE) initiated accommodations and waivers in 2009. This year for the first time, 9 students with autism from Pune division and 10 students from Mumbai appeared for the Maharashtra SSC 10th standard board exams. Lets look at why this is a significant social event.

Modern education of children with disability traces its history to Jean-Marc Itard a French physician. On the cusp of the 18th and 19th centuries Itard attempted to educate Victor, a feral child discovered in the forests of Aveyron. Although Itard himself judged his work with Victor a failure, this renowned experiment marked the first time that anyone considered the possibility that persons with disabilities could be educated.

Edouard Seguin (mid 1800s), a French educator, developed a method for teaching children with intellectual disability in order for them to take their rightful place in the societies of their day. The early training schools were based on these concepts. The schools were small and homelike with 8 to 10 residents. The original goal was the return of children to their families after a period of intervention.

Institutionalisation

Despite these early efforts, it was later concluded that educational and therapeutic approaches had failed. Persons with intellectual disability were scapegoated and regarded as the root cause of many social problems. Institutionalisation and segregation into special schools became the principal means of ‘protecting’ intellectually disabled persons from society and also for ‘safeguarding’ society against the social ill thought to be caused by an expanding population of defectives (Jackson 1999).

Mainstreaming

Lloyd Dunn (1968), a special educator, declared that most children with mental retardation could be "mainstreamed" in classes with typically developing age-mates. He questioned the need for segregated special education classes for most children with mental retardation. He highlighted the lack of evidence to show that children with mild mental retardation learn any better in special education classes than in regular classes. Lloyd Dunn pointed out that educational techniques had advanced sufficiently to allow the effective schooling of most children with retardation alongside other typical children.

Normalization

Wolf Wolfensberger (1972), a scholar, activist and prolific author in the field of development disabilities extended the idea of normalization to the service delivery system itself. He called on all residences, schools, and other services for persons with retardation to be as normative as possible. Parent and professional advocacy groups also fought hard for legislative and legal victories to decrease the size of large institutions.

Inclusion

Inclusive education seeks to overcome every barrier - physical and academic- to ensure the child is educated with their peers (Sigafoos 2003). It stresses the importance of peer interaction in the final outcome for the child who is to enter into the adult world on a level playing field. To this end academics is given a secondary role. The child is supported for all physical needs to enable participation in the classroom experience with their peer group. Academic difficulties are addressed by a remedial teacher or special educator attached to the class who helps the child in parallel with the regular curriculum. The child may be learning at a level many grades below the rest of the class but has the benefit of meaningful social interaction.

It has taken 200 years for the vision of Itard to reach the SSA, the national inclusive education program. The universal principles of justice, fraternity, and equality secured for all citizens by the constitution are driving us to ensure children with autism and other disabilities are educated alongside their peers. That is why nine children with autism have appeared for a board exam in Pune. That is why this is a significant social event.

References

1. CBSE. Amendments/Additions in Examination Bye Laws. 2009
2. Dunn L M. Special education for the mildly retarded—is much of it justifiable? Except. Child. 35:5-22, 1968.
3. Jackson, Mark. Mental Retardation In: A century of Psychiatry. Ed. Hugh Freeman. London: Harcourt Publishers, 1999.
4. Sigafoos, Jeff, Michael Arthur, and Mark O'Reilly. Challenging Behaviour and Developmental Disability. London: Whurr Publishers, 2003.
5. SSA, Inclusive education. Accessed 04-Jul-2011
6. SSA. Kolkotta National Workshop. Accessed 04-Jul-2011

Neurotoxic effects of alcohol on the adolescent and young adult brain

(or why the 25 year age-bar on alcohol consumption could be reasonable)

Does alcohol have specific neurotoxic effects on the adolescent or young adult brain? This question is the only important one for deciding whether the 25 year age-bar on alcohol consumption in Maharashtra is justifiable. While the debate rages two students from the premier medical college of India drowned in an alcohol fuelled swimming pool misadventure, and in an unrelated incident on the same night five inebriated youths were arrested for disturbing the peace in a residential area. We have seen how to recognise problem alcohol drinking in teenagers, and how to refuse alcohol. This article probes the specific effects of alcohol on the maturing brain.

Infancy

Alcohol is a neurotoxin. It distorts the normal architecture of the developing brain. This distortion starts during pregnancy when imbibed maternal alcohol crosses the placenta into the foetus. In the foetus alcohol acts on the specially vulnerable immature insulating cells (oligodendroglia) of the brain. The child is born with Fetal Alcohol Syndrome, characterised by irreversible mental retardation, a small head, small stature and facial abnormalities. Because the exact amount of alcohol required and the most vulnerable periods of pregnancy have not been definitively established all pregnant women are advised to abstain from any use of alcohol.

Childhood

By the second year of life the number of connections between brain cells (synapses) are at a maximum. These synapses are gradually reduced to the adult number (synaptic pruning). This process is controlled by immature excitatory (glutamate) receptors in the synapses. These receptors differ from adult ones by allowing quicker and longer excitation. Immature glutamate receptors are vulnerable to the effects of alcohol. Their over-stimulation distorts synaptic pruning (Johnston 1995).

Adolescence

In adolescence there is a rapid growth of gray matter and the formation of new connections (proliferation) in the brain. Elimination of some synaptic connections (pruning) enables the adolescent or young adult brain to change in response to environmental demands. Stability of these connections is enhanced through insulation of neuronal fibres (myelination). Myelination increases the overall speed of information processing within the brain. These maturational processes are critical for cognitive development. They are all adversely affected by alcohol (Guerri 2010).
These adverse effects specifically impact the frontal lobes of the brain and are highly associated with level of intelligence. In addition the brain area essential for working memory (hippocampus) is preferentially damaged by alcohol (De Bellis 2000). Gender effects render female adolescents more vulnerable than males to these alcohol effects.
The reward system of the brain is responsible for motivation and learning. The immature reward system has an adolescent-specific vulnerability for alcohol and drug addiction. Early exposure to alcohol sensitises the brain regions involved in drug addiction and alters gene expression in the brain reward regions (nucleus accumbens).
The pattern of brain electrical activity changes during the transition from adolescence to adulthood. Alcohol also has a premature aging effect on brain electrical activity during wakefulness and sleep. Animal models have shown that even brief exposure to alcohol in adolescence can cause long lasting changes in brain electrical activity. These changes place the adolescent at a high risk for later substance abuse and addiction (Ehlers 2010).

Youth

Alcohol differentially impairs the young persons judgement and motor skills. The evidence for this is so robust that some administrations have placed a lower legal blood alcohol level limit on drivers less than 21 years old (Hingson 1994). This differential susceptibility to alcohol has been shown to persist up to 30 years of age when a specific impact is seen on frontal lobe functions related to driving skills (Domniques 2009).

Whether the authorities considered the neurotoxic effects of alcohol while imposing the 25 year age-ban on alcohol consumption is a moot point. However, educating adolescents and youth regarding these adverse alcohol effects should be the duty of every parent.

References

1. De Bellis MD, Clark DB, Beers SR, Soloff PH, Boring AM, Hall J, Kersh A, Keshavan MS. Hippocampal volume in adolescent-onset alcohol use disorders. Am J Psychiatry. 2000 May;157(5):737-44.
2. Domingues SC, Mendonça JB, Laranjeira R, Nakamura-Palacios EM. Drinking and driving: a decrease in executive frontal functions in young drivers with high blood alcohol concentration. Alcohol. 2009 Dec;43(8):657-64.
3. Ehlers CL, Criado JR. Adolescent ethanol exposure: does it produce long-lasting electrophysiological effects? Alcohol. 2010 Feb;44(1):27-37.
4. Guerri C, Pascual M. Mechanisms involved in the neurotoxic, cognitive, and neurobehavioral effects of alcohol consumption during adolescence. Alcohol. 2010 Feb;44(1):15-26.
5. R Hingson, T Heeren, and M Winter. Lower legal blood alcohol limits for young drivers. Public Health Rep. 1994 Nov-Dec; 109(6): 738–744.
6. Johnston MV. Neurotransmitters and vulnerability of the developing brain. Brain Dev. 1995 Sep-Oct;17(5):301-6.

School bullying

Bullying by children in schools has serious mental health effects on the victim and the bully. Up to 25% of high school students report being victimised by bullies. 13% of victims have considered suicide. In rural India 31% of middle school students report being bullied (Kshirsagar 2007). Bullying is twice more prevalent in coeducational schools than in girl schools. The prevalence of bullying increases from 13% in the 3rd grade to 46% in the 6th grade. Bullying is higher in classes with more retained students.

Bullying occurs in a variety of settings that are an extension of your child's school life. Bullying can occur face to face, by texting or on the web (cyberbullying). Bullying is not a phase of growing up, it is not a joke, and it is not a sign that boys are being boys. Bullying can cause lasting harm - to the victim, the bully and the bully-victim (children who are bullied and also bully other children).

Bullying takes many forms

• Verbal: Name calling, teasing
• Social : Spreading rumours, leaving people out of groups on purpose, breaking up friendships
• Physical : Hitting, punching, shoving (5% in Indian schools)
• Cyberbullying

When is it bullying? It’s bullying when there are three features to the interaction

1. Imbalance of power: People who bully use their power to control or harm. The victims may have a hard time defending themselves.
2. Intent to cause harm: The person bullying intends to harm the victim
3. Repetition: Incidents happen to the same person over and over by the same person or group

It’s not bullying when there are

• Mutual arguments and disagreements
• Single episodes of social rejection or dislike
• Single episode acts of nastiness or spite
• Random acts of aggression or intimidation

Effects of bullying

(www.stopbullying.gov)
Those who are victims are at a high risk for mental health problems

• Higher risk of depression and anxiety with increased thoughts of suicide
• More likely to have health complaints
• Have decreased academic achievement
• More likely to miss or drop out of school
• More likely to retaliate (12/15 shooters have a history of being bullied)

Bullies are more likely to manifest behaivour problems that continue into adulthood when these behaviours manifest as criminality

• Higher rates of alcohol/substance abuse
• More likely to get into fights, vandalise property
• More likely to be abusive towards partners, spouses or children later in life.

Bully-victims are the worst affected. They develop both mental health and behavioural problems

Is your child being bullied?

If your child has any of these features it is very likely they are being bullied in school

• Comes home with torn clothing or missing belongings
• Appears sad, moody, depressed or anxious especially on returning home from school
• Prefers to be alone

These symptoms are also likely in victims of bullying

• Is afraid of going to school
• Vomiting
• Sleep disturbances including insomnia and nightmares

These symptoms are commonest in victims

• Frequently falling sick
• Headaches
• Bodyache is the next most common symptom in female victims. In male victims nightmares are the next most common.

Is your child a bully? Consider these common traits of bullies

• Become violent with others, gets into physical or verbal fights
• Get sent to the Principal’s office often
• Has extra money or new belongings which cannot be explained
• Will not accept responsibility for their actions
• Need to win and be best at everything

Do’s and Don’ts

For parents whose children are victims of bullying (Carr-Gregg 2011)
Do NOT

• Tell the your child to ignore the bullying. This allows the bullying and its impact to become more serious
• Blame your child or assume that they have done something to provoke the bullying
• Encourage retaliation
• Criticise how your child dealt with the bullying
• Contact the bully or parents of the bully

Do

• Communicate with your child
1. Listen carefully. Ask who was involved and what was involved in each episode
2. Empathise and reinforce that you are glad your child has disclosed this
3. Ask your child what they think can be done to help
4. Reassure your child that you will take sensible action
• Contact the teacher and/or principal and take a cooperative approach in finding a solution
• Discuss the matter in a face-to-face meeting. Stay calm. Take along any evidence you may have gathered. Ask three key questions
1. How will this matter be investigated?
2. How long will this investigation take?
3. When will you get a follow up meeting to discuss the results?
• Contact school authorities if bullying persists and escalate your communications up the chain of command. Here’s where your paper trail comes in useful

Every child deserves an education free of fear

References

1. Carr-Gregg M, Manocha R. Bullying - effects, prevalence and strategies for detection. Aust Fam Physician. 2011 Mar;40(3):98-102.
2. V .Y. Kshirsagar, Rajiv Agarwal and Sandeep B Bavdekar. Bullying in Schools: Prevalence and Short-term Impact. Indian Pediatrics 2007; 44:25-28
3. www.stopbullying.gov

Quit Smoking for World No Tobacco Day (31-May)

Fagerstrom Test for Nicotine Dependence

---

Quitting tobacco is the most important thing you can do to protect your health

---

(AHRQ)

Quitting by willpower only

40% of smokers try to quit each year. The success rate of those who quit on their own is about 5% and with self-help books it is about 10%. Most smokers make 5-10 attempts to quit. Unsuccessful attempts to quit are a sign of nicotine dependence.

85% of current daily smokers are nicotine dependent

Signs of nicotine dependence

1. Tolerance - Increasing the number of cigarettes smoked per day (Most smokers escalate to a pack)
2. Withdrawal - Mood changes, irritation, anxiety, insomnia, restlessness when unable to smoke
3. Loss of control - Most smokers do not intend to continue, but 5 years later 70% do
4. Increased time spent using the drug - Leaving office/ work-site to smoke
5. Continued use despite harm - cough, hypertension, heart disease
6. Giving up important activities - air travel

Are you nicotine dependent?

Take the Fagerstrom Test
You can quantify the extent of your dependence by adding your points scored for each question.

• 7-10 points - high level of addiction
• 4-6 points - medium level of addiction
• 0-3 points - low level of addiction

Why does nicotine produce a severe dependence?

• Nicotine has direct effects on concentration and mood
• Nicotine reaches brain in seconds → a rapid effect
• Allows user to titrate the dose by varying puff frequency and depth
• The habit is Intense (>200 puffs/day x 20 years)
• There are many environmental cues (eg, others smoking/ ads)
• Never impairs the user via intoxication

How do I quit?

Make a START

Set a quit date-today! Choose a birthday, wedding anniversary, New Year’s Day
Tell family, friends and co-workers – Enlist their support
Anticipate challenges- Withdrawal symptoms and craving will occur. Tell yourself that you can face the challenges ahead. Behavioural techniques will help you through this phase.
Remove cigarettes and all related products-lighters, matches, ashtrays from your home and workplace
Talk to your doctor – Medication, Behaviour therapy and Nicotine Replacement Therapy are the mainstay of treatment. Your doctor will help you decide what suits you.

After quitting

The habit is still latent after you have quit tobacco smoking. Some vigilance is required to stay quit. However, the longer you stay quit the easier it becomes. Some of the things you could do to reduce the chances of a relapse are as below

Watch out for the triggers

• Habit situations (things you used to do while smoking)
• Stress / -ve moods
• +ve moods/ celebrations
• Alcohol
• Use coping skills to beat the urge and handle craving

Avoid smoking at all costs

• If you do slip
ACT!- QUIT IMMEDIATELY
• Can I have just one cigarette?
You must do everything you can to avoid that first cigarette

---

9 out of 10 people who have that one cigarette after quitting return to regular smoking.

---

Enjoy the rewards of quitting!

• Within 20 minutes Heart rate slows towards normal
• 8 hours Carbon monoxide levels drop to normal
• 2 weeks-3months Heart attack risk lessens, lung function improves
• 1-9mths Coughing and breathlessness reduce
• 1 year - Heart disease risk ½ of chronic smokers
• 5-15 years - Stroke risk = non-smokers
• 10 years - Risk of death due to lung cancer same as that of non-smoker
• 15 years - Coronary heart disease risk same as that of non-smoker

References

1. Agency for Healthcare Research and Quality
2. Centers for Disease Control and Prevention
3. Heatherton T, Kozlowski L, Frecker R, Fagerström K: The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. British J Adict 1991, 86:1119-27.