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|Year : 2016
: 58 | Issue : 6 | Page
|Perceived coercion in persons with mental disorder in India: A cross-sectional study
BN Raveesh1, S Pathare2, P Lepping3, EO Noorthoorn4, GS Gowda5, J G F Bunders-Aelen6
1 Department of Psychiatry, Dharwad Institute of Mental Health and Neurosciences, Dharwad, India
2 Co-ordinator, Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
3 Honorary Professor (Bangor University and Mysore Medical College and Research Institute, India), Consultant Psychiatrist (BCULHB), Centre for Mental Health and Society, N Wales, United Kingdom
4 Head of research GGnet Community mental Health Centre, PO Box 2003, 7230 GC Warnsveld, the Netherlands and main researcher of the Dutch Information Center for Coercive Measures, Stichting Benchmark GGZ, Bilthoven, Netherlands
5 Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru, India
6 Professor of Biology and Society, Vrije Universiteit, Amsterdam, Netherlands
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|Date of Web Publication||27-Dec-2016|
| Abstract|| |
Background: Little is known about how patients in India perceive coercion in psychiatric care.
Aims: To assess perceived coercion in persons with mental disorder admitted involuntarily and correlate with sociodemographic factors and illness variables.
Materials and Methods: We administered the short MacArthur Admission Experience Interview Questionnaire to all consecutive involuntary psychiatric patients admitted in 2014 in Mysore, India. Multivariate linear regression was used.
Results: Three hundred and one patients participated. "Perceived coercion" subscale scores increased with female gender, nuclear family status, Muslim and Christian religion, lower income, and depressive disorder. It decreased with former coercion, forensic history, and longer illness duration. Drug use increased total scores; the extended family item decreased them. "Negative pressure" increased with male gender, extended family, lower income, forensic history, and longer illness duration.
Conclusions: The study shows perceived coercion is a reality in India. Levels of perceived coercion and the populations affected are similar to high-income countries.
Keywords: Coercion, mental health, subjective perception
|How to cite this article:|
Raveesh B N, Pathare S, Lepping P, Noorthoorn E O, Gowda G S, Bunders-Aelen J. Perceived coercion in persons with mental disorder in India: A cross-sectional study. Indian J Psychiatry 2016;58, Suppl S2:210-20
|How to cite this URL:|
Raveesh B N, Pathare S, Lepping P, Noorthoorn E O, Gowda G S, Bunders-Aelen J. Perceived coercion in persons with mental disorder in India: A cross-sectional study. Indian J Psychiatry [serial online] 2016 [cited 2021 Apr 13];58, Suppl S2:210-20. Available from: https://www.indianjpsychiatry.org/text.asp?2016/58/6/210/196846
| Introduction|| |
Psychiatry is an area of medical practice where coercive treatment, although controversial, is specifically sanctioned by law under limited conditions (Szmukler, 2008). Increasing patient autonomy and decreasing coercion are frequently cited goals in mental health care (Heinz et al., 2016). Coercive measures always involve a conflict of medical ethical principles. Medical professionals need to balance beneficence ("doing good") and nonmaleficence (avoiding harm) with the requirement to respect the patient's autonomy to justify coercion in extreme situations (Beauchamp and Childress, 2001). This includes best interest decisions for patients who lack capacity to make autonomous decisions. Patients who lack insights into their illness are of particular concern, as they often feel particularly strongly about being coerced (Newton-Howes, 2010). In addition, patients who regain insight into their illness are far more likely to approve of coercive measures retrospectively compared to those patients who do not regain insight (Owen et al., 2013). Furthermore, the United Nation Convention on Rights of Person with Disability promote, protect, and ensure the full and equal enjoyment of all human rights and fundamental freedom.
Coercion is defined as "any action or threat of actions which compels the patient to behave in a manner inconsistent with his or her own wishes." In a psychiatric context, the term "coercive measures" usually refer to coercive interventions occurring during hospitalization on psychiatric wards (Kalisova et al., 2007). However, with the expansion of community care, coercion can be experienced outside hospital settings, too. Coercion classically includes seclusion, restraints, and involuntary medication, but increasingly, implied pressure to comply with treatment plans can be perceived by community patients (Burns et al., 2011), without the use of standard forms of restraint. Szmukler points out that coercion covers both compulsion and threats (Szmukler, 2015), in contrast to Wertheimer who contrasts threats and offers, with the latter not being considered coercive (Wertheimer, 1993). In emergencies, when a patient is at imminent risk of harming him/herself or others, the need for coercion is less disputed (Swartz et al., 2002). The question is more difficult in situations which are not emergencies, but where aspects of safety or harm to health are the main consideration. Such situations commonly occur in geriatric medicine and psychiatry. In these cases, it can be unclear whether the principle of acting in the patient's best interest justifies the restriction of the patient's autonomy.
Even though a controversial area at the time, the first studies on coercion were conducted as early as the 1970s and 1980s (Shannon, 1976; Toews et al., 1984; and Carpenter et al., 1988). These studies from Canada and Australia showed that patients were not always aware that they had been involuntarily admitted or felt that they were denied the chance of a voluntary admission. Starting in 1988, the MacArthur Coercion Study was designed to provide information to policymakers, clinicians, patients, and family members to broaden and deepen the conversation about the appropriate role of coercion in the provision of mental health services. This was arguably the beginning of systematic research into the use of coercion (Bradfor et al., 1986; Monahan et al., 1995; and MacArthur Research Network, 2001). It showed that a substantial percentage of psychiatric patients feel coerced in the community, especially in the United States (MacArthur Research Network, 2001). A third of patients in the United Kingdom felt coerced in the community, which is substantially less than patients in the United States (Monahan et al., 2005), but still a significant minority. At the same time, differences in mental health legislation between countries were systematically examined (Röttgers and Lepping, 1999; Kallert et al., 2005; Salzine et al., 2005; and Steinert et al., 2009). These analyses showed significant differences in legislation as well as standard practice. They revealed a trend toward a steady increase of the number of people detained under mental health legislation in the European Union (Salize et al., 2005).
Furthermore, substantial differences in the prevalence of coercive measures between countries emerged (Steinert et al., 2014; Noorthoorn et al., 2015). Importantly, a recent study using whole country data from Wales, Ireland, Germany, and the Netherlands obtained very comprehensive coercion data, suggesting that there are still significant differences in the type of coercion used across Europe. However, the prevalence of coercion is remarkably similar across those four countries with big differences seen between hospitals in each of the four countries surveyed.  It is interesting that big differences between hospitals persist (Noorthoorn et al., 2015 and Steinert et al., 2015), but differences regarding the prevalence of coercion between countries with similar health economies may be fewer than previously thought (Lepping et al., 2016). These findings may seem surprising in an era of evidence-based medicine but demonstrate the extent to which coercive measures are still based mainly on local and national traditions rather than scientific evidence.
Because the majority of the literature on coercion is from high-income countries, their findings may have limited relevance for a middle-income country such as India in terms of planning and providing mental health services. In many Indian settings, dormitories with ten or more patients in one room are standard practice in government-run psychiatric hospitals. Moreover, it is normal that one relative is expected to stay with the patient at all times to help with feeding, personal care, and supervision. This creates different perspectives on coercion compared to European or North American settings because the relative can be a trigger, target, and manager of patient aggression as well as being part of the application of a coercive measure. The prevalence of coercion is understudied in India. We know of only one study that looked at the level of coercion systematically, and which used an instrument to record violence and coercion adjusted for the Indian setting (School of Oriental and African Studies-Rhode Island) (Danivas et al., 2016). This study found a high level of coercive measures being used on psychiatric admission wards in Mysore, South India. The Mental Health Care Bill (MHCB-2013 in India, which is likely to be ratified in autumn 2016, advocates least restrictive alternatives in psychiatric treatment. However, there are no published studies looking into the levels of perceived coercion patients experience in India. Understanding the patient's coercion experience will help mental health professionals to respect patient experiences and improve staff and patient capabilities to participate in quality treatment.
| Materials and methods|| |
To assess the subjective perception of coercion in involuntarily admitted patients and to relate their subjective perception of perceived coercion with sociodemographic variables such as age, gender, educational status, marital status, family size, average family income, distance from hospital, and illness variables duration of illness, diagnosis, forensic history, and former coercive interventions.
The study was conducted over a period of 1 year from January 1, 2014 to December 31, 2014 at the Department of Psychiatry, Krishna Rajendra Hospital, Mysore Medical College and Research Institute, Mysore, South India. The hospital is a government institution and caters primarily for the middle and lower economic classes. After obtaining informed consent, all consecutive involuntarily admitted patients were interviewed and assessed for their coercion experience using the MacArthur Admission Experience Interview Short-form (MAEIS) at the time of discharge. Ethical approval was obtained from the Institutional Ethics Committee (MMCEC 07/15). Inclusion criteria were patient age between 18 and 65 years, any psychiatric illness, and involuntary legal status on admission. Exclusion criteria were impaired cognitive function, inability to give informed consent as prescribed by the study protocol, presence of organic brain syndrome, learning disability, dementia, developmental disorders, and voluntary admission status. Out of total 310 samples, 9 were excluded (6 did not agree to participate and 3 were having alcohol dependence syndrome who got discharged against medical advice) with final 301 participants in the study.
The MAEIS (Gardner et al., 1993) is a short version interview-based questionnaire with 15 items requiring "true," "false," or "do not know" responses. Inter-rater reliability is 0.89, test-retest scores are 0.81, and reliability as determined by Cronbach's alpha is a very good 0.77 (Cronbach, 1951). The Kannada version was translated by Central Institute of Indian Languages at Mysore (Premier Institute for translation work in India) and back-translated to English. The back-translated version was compared with the original scale. The MAEIS contains four subscales covering (a) perceived coercion, (b) negative pressure (people putting pressure on patient to come into hospital), (c) voice (i.e., ability to voice own opinion), and (d) affective reaction. The interview has good internal consistency with regard to variation in site, instrument format, patient population, and interview procedure. In the domains, perceived coercion, negative pressure, and voice; the scale consists of a sum of all items. The subscale score for affect covers four negative and two positive affects (i.e., emotional responses to admission), which are inversely coded to construct the total score. In this domain, a higher score corresponds with a more positive affect. This is contrary to all other subscales of the MAEIS.
Clinical and sociodemographic characteristics of the sample were related one by one to the separate item responses as well as the scale scores by descriptive statistics. Independent sample-t-test and paired samples-t-test were used to assess relevant differences over scores by groups. Chi-square was used to assess discrete variables. Statistical analyses were performed using the level of statistical significance set at P < 0.001, using the Bonferroni correction (Bonferroni, 1936).
A multivariate linear regression was performed on the MAEIS total score as well as on all subscales. Perceived coercion, negative pressure, voice, and affective reaction to hospitalization were separately analyzed to identify which variables contributed more or less to perceived coercion, pressure, and voice of the patient as the most important domains of the MAEIS. Items with a P < 0.2 were left in the final model, following recommendations by Hosmer and Lemeshow on regression analyses (Paul et al., 2013). The multivariate linear regression included all sociodemographic and diagnostic details, and the MAEIS and its sub-scales as outcomes and confirmed the results from the univariate analysis. Here, we set the significance at 0.05 with a sample size of 301. As the multivariate linear regression corrects for interdependencies, the main conclusions should be drawn from these.
We first present plain frequencies [Table 1], followed by interview and subscale mean scores and univariate standardized beta and the final model betas [Table 2]. The significant final model betas represent the predictors. The explained variance of the model identifies to what extent the included variables explain outcome. In health care, an explained variance of above 15% is valued reasonable and above 30% as good (Achen, 1982).
|Table 1: Univariate comparisons of patient characteristics with the MacArthur's admission perceived coercion scale*|
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|Table 2: Univariate and multivariate regression of MacArthur scale by patient and treatment history characteristics*|
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| Results|| |
In our study, 301 involuntarily admitted patients participated in the study. Two hundred and fourteen (71%) were male, 146 (49%) were under 35 years, 142 (47%) between 35 and 55 years, and only 13 (4%) between 55 and 65 years. One hundred and seventy-nine (64%) belonged to a nuclear family, 169 (58%) had a family income of 50,000-100,000 Indian Rupees a year (in September 2016), and 162 (59%) were Hindu. Eighty-nine (30%) patients were admitted with a substance misuse disorder, 65 (23%) with psychosis, 67 (25%) with depression, and 35 (13%) with a bipolar disorder. Two hundred and thirty-five (85%) had an illness duration of 1-10 years, 202 (73%) had past experiences with coercion, and 46 (16%) had a forensic history, i.e., having been in contact with either police or the court.
[Table 1] shows the raw data for each item of the MAEIS across the basic demographic data, diagnostic, and illness history details. Diagnosis was left out of this table to improve readability. It showed a pattern of lower scores in patients with depression compared to all other diagnostic categories. [Table 2] first presents the mean scores on the main interview and subscales before showing regression findings.
At first, we present results regarding patient sociodemographic variables, focusing on statistically significant results. We observe more negative pressure experienced by patients between 35 and 55, compared to younger and older patients. Male patients showed more negative pressure. Patients with nuclear family rather than extended family support felt less own choices and more perceived coercion but less negative pressure. Muslims perceived more coercion but less negative pressure. In all patients, results showed that the higher the income, the lesser the scores on perceived coercion and negative pressure. Marital status did not discriminate between items and was also left out of the table. [Table 1] confirms that patients with high-income score were lower on most items measured throughout the MAEIS. Distance to the hospital showed an inconsistent association with the subscales measuring perceived coercion and negative pressure.
A legal history was associated with more perceived negative pressure. The longer the illness duration, the less coercion was perceived. Female had more positive affective responses than males. Patients with higher income had more positive affect scores. Patients with previous coercion have more negative affective responses than those without, as do patients with a legal history. Muslim and female patients felt more relieved at admission than men and Hindu or Christian patients.
Regarding diagnosis as shown in [Table 2], patients with a psychotic disorder felt less coerced, but more negative pressure than those with other diagnoses. Patients with a depressive disorder felt less coerced into being admitted than patients with psychosis, substance misuse disorder, or bipolar disorder. Former coercion was associated with a higher total score, more perceived coercion, and a higher voice scale score, but not negative pressure.
[Table 2] summarizes the multivariate regression. It is important to notice the differences in the associations of the predictors with regard to the total score and the four MacArthur Admission Experience Interview sub-scales:
- We observed only two significant associations in the final model regarding "total scores," with a limited explained variance of 16%: Total score decreasing by being from an extended family type (β = −0.19; P < 0.001). Drug abuse increases total score (β = 0.12; P < 0.05)
- "Perceived coercion" increased with female gender (β = 0.15; P < 0.001), with being either of Muslim or Christian religion (β = 0.17; P < 0.001), having a lower income (β = 0.21; P < 0.001), and a depressive disorder (β = 0.12; P = 0.02). It decreased with extended family type (β = −0.21; P < 0.001), in case of former coercion (β = −0.24; P < 0.001), forensic history (β = −0.11; P = 0.03), and with larger illness duration (β = −0.21; P < 0.001). The model showed a good explained variance of 31%
- "Negative pressure" decreased with female gender (β = −0.25; P < 0.001), with higher income (β = −0.21; P < 0.001), and the category "other diagnosis" (β = −0.12; P = 0.02). It increased with extended family type (β =0.12; P = 0.02), forensic history (β = 0.09; P = 0.05), and longer illness duration (β = 0.28; P < 0.001). Again, the model showed a satisfactory explained variance of 27%
- "Voice" (being heard) increased by female gender (β = 0.15; P < 0.001), being of extended family type (β = 0.17; P < 0.001), and being of either Muslim or Christian religion (β = 0.14; P = 0.01). It decreased by former coercion (β = −0.21; P < 0.001). This model showed a low explained variance of 11%
- "Affect" (emotional response) showed an increase with female gender (β =0.17; P < 0.001), higher income (β = 0.14; P = 0.01), and former coercion (β = 0.12; P < 0.04). It decreased with longer illness duration (β = −0.19; P < 0.001), with a limited explained variance of 16%.
In short, perceived coercion as well as negative pressure showed associations with a number of patient characteristics. Total score, affect, and voice showed looser associations.
| Discussion|| |
In our study, higher total scores for perceived coercion were associated with drug abuse, while lower total scores were associated with being from an extended family. Higher scores in the subscale of "perceived coercive experience" were associated with female gender, coming from a nuclear family, not Hindu, lower socioeconomic status, depression, former coercion, forensic history, and a longer duration of illness. "Negative pressure" proved to be associated to male gender, being of an extended family, having a higher income, not having a diagnosis of depression, having a diagnosis categorized as "other," having a forensic history, and longer illness duration. "Total score," as well as the subscales "voice" and "affect" showed fewer associations with the variables included in the analysis. There was a substantial to good explained variance in the subscales "perceived coercion" and "negative pressure" in contrast to the subscales "voice," "affect," and the total scores. This shows that in the sample items mentioned in the first two subscales are associated with a number of predictors. This association is far more powerful than associations of determinants in the subscales "voice" and "affect." This implies that patients in this Indian setting provide more consistent responses in the first two domains than in the last two.
Furthermore, it means that coercive experiences are associated with several sociodemographic and clinical variables, especially with respect to perceived coercion and negative pressure. Our findings were consistent with most studies from high-income countries (Bindman, Tighe, Thornicroft, and Leese, 2002; Rain et al., 2003; Swartz and Swanson, 2004; Kjellin et al., 2006; Sheehan and Burns, 2011; Bergk, Einsiedler, Flammer, and Steinert, 2011; Anetis et al., 2013; and O' Donoghue et al., 2014). They confirmed early studies by Gardner et al. (1993) showing subscale scores can be of more importance in some patient groups than the total scale scores of the MAEIS (Hoge et al., 1997 and 1998).
To the best of our knowledge, there is only one other Indian study investigating the correlation between patients' sociodemographic and clinical variables and their relationship with coercive experiences. This Bangalore study was a pilot study with a limited sample size of n = 83 (Gowda et al., 2016). Our study is very important in the current Indian context because of the new MHCB-2013 (Chadda and Deb, 2013). India has been characterized as being a traditional and family-centered society, with traditionally higher respect for collective decisions over individual ones and at least in theory, more acceptance of medical paternalism ("the doctor knows best") (Shah and Basu, 2010). Nevertheless, our findings show few differences in comparison with similar studies from high-income countries. This suggests that the current rapidly changing social, economic, cultural, and psychosocial profile in India may have made changes to medical practice with fast diminishing differences between Indian and high-income cultures. The daily practice steadily moves away from a medical paternalistic model of doctor-directed care toward a model of information sharing and autonomous decision-making by patients (Burns et al., 2013). Our findings suggest that the more autonomy-based MHCB-2013 for India is in keeping with these developments.
Our study has shown that perceived coercion is a significant problem in Indian psychiatric settings and certain at-risk groups have emerged, while other factors may be protective. One of the important aspects of current psychiatric practice includes improving autonomous decision-making capacity by sharing, discussing, offering, and repeated disclosure of information to patients through individual counseling, information booklets, group therapy, and involvement of carers. The main way of achieving this is by training personnel in skilled communication that is two-way, open, repeated, empathic, and accommodative. Our results allow staff to focus, especially on at-risk groups. One way of potentially reducing perceived coercion is advanced planning for the possibility of future incapacity. However, evidence for advanced directives and joint crisis plans from high-income country studies remains ambiguous; some authors advocate their use, whereas others find little evidence for their efficacy to reduce readmission rate or coercive measures. In India, the use of advanced directives has a number of advocates (Thornicroft et al., 2013; Raveesh and Lepping, 2013). Their effectiveness in the Indian context, however, needs further exploration.
Strengths and limitations
To the best of our knowledge, this is the first cross-sectional study in India with a large sample size. It presents a consecutive sample but included only involuntarily admitted patients. All patients were recruited and interviewed during admission and assessed by face-to-face interviews using a validated scale. The study has some methodological limitations. It was limited to inpatients, while we know that coercion is a significant problem in the community, too. The study was from a single center in the south of India. The population was, therefore, predominantly from South India and from lower socioeconomic backgrounds and may not represent the entire Indian population. The effects of different practices, resources, treatment facility, and treatment components on perceived coercion were not considered in this study.
| Conclusions|| |
The results of our study highlight that clinical and sociodemographic characteristics influence the coercive experience of patients. Developing standardization in how to deal with difficult situations in aggressive patients may help develop guidelines, improve safety, develop training, and start analyzing and benchmarking current practices of coercive measures. Guidelines should be developed regionally or nationally, they should be based on evidence, and they should be practical in the Indian context (Thornicraft et al., 2013). Clinicians in India should develop appropriate ways to reduce coercion; this study allows them to identify specific at-risk groups. The study shows that perceived coercion is a reality in India. Our data suggest that the level of perceived coercion and the populations affected are similar to high-income countries. It suggests that a move is required from sociopolitical models to modern bioethical models in Indian clinical practice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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B N Raveesh
Dharwad Institute of Mental Health and Neurosciences, Dharwad - 580 008, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]