Revolving Door Phenomena and its Associated Factors among Patients with Psychiatric Illnesses

 

Daljit Kaur¹, Bharat Pareek², N Sujata³

¹MSc Nursing Student, Saraswati Nursing Institute, Punjab

²Vice Principal, Saraswati Nursing Institute, Punjab.

³Associate Professor, Saraswati Nursing Institute, Punjab

 

ABSTRACT:

Mental illness is a global public health concern. The revolving door phenomenon was observed in association with the process of re-institutionalization of psychiatric patients. Several factors are thought to contribute to their frequent admissions. Psychiatric rehospitalization of patients imposes heavy burdens on caregivers/families. A study was conducted to explore the caregivers perceived factors associated with revolving door phenomena among patients having psychiatric illnesses. A total of 160 care givers of patients having psychiatric illnesses were selected by purposive sampling technique.  A Semi structured interview schedule was developed to collect data. Findings of the study revealed that the Prevalence of revolving door phenomena was 164/1000 of population. Psychological, personal and cultural factors were explored as high contributing whereas disease related, Physiological and Mental health services related factors as low contributing factors associated with revolving door phenomena as  perceived by the caregivers. Item wise analysis revealed major precipitating factors were patient’s suspiciousness , Lack of knowledge, Forget to take medicine by patients, Treatment negligence, Anxiety, Emotional disturbance, Long term treatment, Cost of treatment, Felt social isolation, Non compliance to treatment, Care giver burden, Lack of insight, Use of drug/alcohol and Cultural belief, myths. Significant associations were observed between patient’s socio-demographic characteristics and personal, psychological, sociological, economical and cultural factors. The study concluded that there were many factors found to be contributing to revolving door phenomena among patients with psychiatric illness, and also observed that many of these factors are modifiable.

 

 

 

INTRODUCTION:

Mental illness is a global public health concern. According to the World Health Organization, one out of four (25%) persons is affected with some kind of mental illness.

The presence of mental illness does affect not only the individual but his personal, social, educational and occupational life, but it also makes his entire family to suffer from negative consequences¹.

 

The greater the numbers of readmissions is greater the pressure on hospitals psychiatric wards and their limited resources. Readmission of inpatients has been one of the most important problems in the field of psychiatry for the last decade. The problem has a major role in reducing the quality of life and increasing the years of lost life². The revolving door phenomenon was first described in the 1960s in association with the process of re-institutionalization of psychiatric patients. Several factors are thought to contribute to their frequent admissions. Social conditions and the severity of the illness are associated with an increase in the number of readmissions. Other factors associated with recurrence include: violent behaviors, criminality, alcohol abuse, drug addiction, non-compliance with the treatment, and lack of social support³. Non-adherence is a significant problem in all patients, from children to elderly. Adherence rates are typically higher among patients with acute conditions, as compared to those with chronic conditions. This tends to worsen the longer a patient continues on drug therapy⁴. Psychiatric readmissions are a consequence of a complex combination of factors that go beyond the severity of the psychiatric disease and include availability of services, quality and continuity of care, and family and social support, among others. Several studies have identified strong predictors of readmission, such as poor treatment adherence, low level of education, deficient follow-up after hospital discharge, involuntary admission, lack of social or family support, and diagnoses of schizophrenia and substance use disorders⁵. The rates of rehospitalization range from 22%-80%, and these rates are higher during the first months following patient discharge. Rehospitalization is a source of frustration and suffering for both patients and their families. This phenomenon also negatively affects health care systems due to the increasing cost of care⁶. Relapses are common and a higher number of relapses involve a greater cognitive impairment of the patient. Prevention of relapses is therefore the primary objective of treatment. Non compliance is the main reason for relapses followed by lack of efficacy. The results appear to confirm that drug abuse might influence in a direct (drug abuse itself) or indirect (non compliance because of drug abuse) way in a higher number of relapses⁷.

 

Objective:

·      To determine point prevalence rate of revolving door phenomena among patients having psychiatric illnesses.

·      To explore the caregivers perceived factors associated with revolving door phenomena among patients having psychiatric illnesses.

·      To determine association between perceived factors associated with revolving door phenomena and selected demographic variables of patients having psychiatric illnesses.

 

MATERIALS AND METHODS:

A exploratory study has been conducted to explore the caregiver perceived factors associated with revolving door phenomena among patients having psychiatric illnesses at selected mental hospitals/clinics, Punjab. Theoretical framework used to guide this study was based on combined Theory of Reasoned Action (TRA) and Theory of Planned Behavior (TPA). It was originated in the field of social psychology and developed in 1967: further developed during in 1970_s. Purposive sampling was used to select sample of 160 caregivers of patients having psychiatric illnesses from the selected mental hospitals/clinics, Punjab. A semi structured interview schedule was developed first in English and then translated in Hindi and Punjabi language. Conceptual equivalency of the translated tool was determined by retranslating the interview schedule in English with the help of language experts. Interview schedule was composed of two parts; part one consist of 34 items to collect the information about characteristics of caregivers, patients and patient’s disease profile and part two included the items to explore caregivers perceived factors associated with revolving door phenomena. Study participants were asked to select one response that matches most closely with his/her perception of statement. Seven experts from the field of psychiatric nursing determined the content validity of the tool. Cohen’s Kappa statistics was used to determine inter rater reliability of the semi structured interview schedule and tool was found to be reliable (p=0.07). Pilot study was conducted on eight study participants to check the clarity, feasibility and practicality of the study. It took around 20 min on an average to complete interview from each study participant. The respondents clearly and easily understood the language and study found to be feasible. Ethical clearance to conduct the study was obtained from institutional committee of Saraswati nursing Institute, Punjab, India. The permission for data collection was obtained from the concerned authority; the investigator assured the anonymity to the study participants, and their consent was obtained. Data were collected from the study participants with the help of semi structured interview schedule from 20 Feb to 31 March 2016. Descriptive mean and standard deviation) and inferential (paired T test, ANOVA and Karl Pearson’s) statistics was used for data analysis.

 

RESULTS:

Section 1

Socio demographic characteristics of patients:

Tables 1 represent that data regarding socio demographic characteristics of patients having psychiatric illnesses. Most of the patients 28.7% were in age group 30-40 years, Religion wise majority of patients 53.8% were Hindu, 78.10% patients were married, 38.1% patients were educated (up to 8^th class) and only 9.3% patients were illiterate, 73.10% patients were unemployed, 13.7% earning between Rs.5001-15000/-, maximum patients 77.5% were from nuclear families, 85% patients were without family history of psychiatric illnesses, 65% patients were from urban area, 85% patients were having hospital distance from residence less than 100km, 74.4% were not taking any drug or alcohol where as 4.30% were patients doing smoking, 14.40% were taking alcohol and 6.90% patients were use smoking and alcohol.

 

Table 1; Frequency and Percentage Distribution of patients as per their Socio-Demographic Variables (N=160)

Demographic Variable	Frequency (f)	Percentage (%)
Age in years 19-29yrs 30-40yrs 41-51yrs >51	35 46 33 46	21.8 28.7 20.6 28.7
Religion Sikh Hindu Muslim Christian	72 86 01 01	45.0 53.7 0.6 0.6
Marital Status Unmarried Married Divorced/Separated Widow	28 125 01 06	17.5 78.1 0.6 3.7
Education Illiterate Primary (up to 8th class) Secondary (up to 12th class) Graduate & Above	15 61 60 24	9.3 38.1 37.5 15.0
Employment status Employed Unemployed	43 117	26.8 73.2
Total monthly Income ( INR) Not earning Less than Rs.5000 Rs.5001 to Rs.15000 Rs.15001 to Rs.25000 Above Rs.25000	117 08 22 09 04	73.1 05 13.7 5.6 2.5
Type of Family Joint Nuclear	36 124	22.5 77.5
Family history of psychiatric illness Yes No	24 136	15 85
Area of residence Urban Rural	104 56	65 35
Distance of residence from hospital (in KM) <100 100-200 201-301 302-402 >402	136 19 02 02 01	85 11.8 1.3 1.3 0.6
Use any kind of drug/alcohol Yes Smoking Alcohol Smoking and alcohol No use of drug/alcohol	07 23 11 119	4.3 14.4 6.9 74.4

 

Section 2

PREVALENCE OF REVOLVING DOOR PHENOMENA AMONG PATIENTS HAVING PSYCHIATRIC ILLNESSES:     

Point prevalence was calculated on the bases of total number of patients reported (with or without relapse) during the time of data collection at the study centers. The formula used to calculate prevalence rate was as follow:

Number of patients reported with the revolving Door Phenomena at the time of data collection

-------------------------------------------------------------------------------- x K

Total Number of patients reported at the time of data collection

 

Total no of patient reported during the period of data collection = 975

Patients reported with Revolving door phenomena = 160

K= is the number of people for whom the prevalence rate establish i.e. per 1000 population

Prevalence rate based on the given formula was observed 164/1000 population or 16.41/100 population.

 

Section 3

Care givers perceived factors affecting revolving door phenomena among patients having psychiatric illnesses:

Study revealed that the mean percentage of total score of factors that were associated with revolving door phenomena (relapse/readmission) was (13.9) with mean± SD of 6.94± 7. The factor wise mean percentage of care giver perceived factors associated with revolving door phenomena was highest in the psychological factor 22.5%, personal factor 19.1%, cultural and traditional factor 14%, economical factors11.5%, sociological factors 9.6%, care giver related factors 8.26%, disease related factors 8%, physiological factors 4% and mental health services related issues 1.5%. (Table 2, Fig: 1)

 

Table2: Mean, SD and mean% of Care givers perceived factors affecting revolving door phenomena (N=160)

 

 

Fig: 1 Factors affecting revolving door phenomena

 

 

 

Major precipitating reasons associated with revolving door phenomena among patients having psychiatric illnesses:

Figure 2: Reveals care givers reported major precipitating reasons associated with revolving door phenomena (relapses/readmissions) among their patients. Major factors were Suspiciousness 56.3%, Lack of knowledge 55.6%, Forget to take medicine by patients 55.6, Treatment negligence 54.4%, Anxiety 38.8%, Emotional disturbance 36.9%, Long term treatment  29.3%, Cost of treatment 28.7%, Felt social isolation 28.8%, Non compliance to treatment 28.1% and Care giver burden 27.5%.

 

 

 

Figure 2: Major precipitating reasons of revolving door phenomena among patients having psychiatric illnesses.

 

Section 4:

ASSOCIATION BETWEEN SELECTED DEMOGRAPHIC VARIABLES OF PATIENTS AND PERCEIVED FACTORS OF REVOLVING DOOR PHENOMENA:

 

Table 3: statistical association of socio-demographic variables of patients and caregiver perceived factors of Revolving Door Phenomena (N=160)

Sociodemographic variables	Chi2	Result
Personal factors
Religion Education	8.00 20.6	.04* <.001**
Physiological factors
Education Type of family Distance of residence from hospital	14.8 7.97 18.5	.002* .005* .001*
Economical factors
Distance of residence from hospital	14.7	.005*
Sociological factors
Area of residence	4.7	.02*
Disease related factors
Distance of residence from hospital	11.8	.01*
Mental health services related issues
Age Education Type of family Family history of psychiatric illness Area of residence Distance of residence from hospital(in km)	8.3 7.8 3.5 4.2 4.2 20.9	.04* .05* .05* .04* .03* .000*
Cultural and traditional factors
Marital status Education Area of residence	8.00 8.1 10.0	.04* .04* .002*
Care giver related factors
Area of residence	3.9	.04*

 

Table 3: Shows association between perceived factors of revolving door phenomena and selected demographic variables of patients having psychiatric illnesses. There was significant association of personal factors with religion and education (0.04* and 0.001**), Physiological factors with Education, Type of family and Residence distance (0.002*, 0.005* and 0.001*), Economical factor with Residence distance (0.005*), Sociological factors with Area of residence (0.02*), Disease related factors with Residence distance (0.01*), Mental health services related issues with Age, Education, Type of family, Family history of psychiatric illness, Area of residence and Residence distance (0.04*, 0.05*, 0.05*, 0.04*, 0.03* and 0.000* respectively ), Cultural factors with Marital status, Education and Residence area (0.04*, 0.04* and 0.02*) and Care giver related factors with Area of residence (0.04*). There was No significant association observed with other perceived factors of revolving door phenomena i.e.; Income, Gender and Satisfaction level with current health services.

 

DISCUSSION:

Present study revealed No significant association of patient gender with perceived factors of revolving door these findings are contradictory with the study done by Hamitlon JE (2015) where he reported that male patients were more likely to readmit within 1 year.⁸

 

The findings of study were discussed in accordance with the objectives of the research and literature review. Result of the present study showed that Point prevalence for revolving door phenomena among patients with psychiatric illness was calculated on the bases of total number of patients reported (with or without relapse) during the time of data collection at the study centers and prevalence rate  was 164/1000 population (16.41%). Somewhat similar prevalence rates of readmission and their predictors  at 14 days, one year, and five years after discharge for the psychiatric population in Taiwan were reported by Chuan-Hsiung Lin et al in (2010) incidences were estimated at 6.1%, 22.3%, and 37.8%, respectively.⁹

 

In present study majority of the revolving door patients were suffering from depression, (40%), BPAD (21.3%) and anxiety disorder (33%)  These findings are consistent with the study conducted by Downey VA (2015) where Depression, BPAD and Schizoaffective disorder were reported closely associated with revolving door phenomena.¹⁰

 

Warnkl I et al (2010) stated based on study conducted to test the influence of various clinical and social factors of readmission significantly influences the risk of psychiatric readmission. These findings are consistent with the findings of present study where social and clinical factors were perceived by the care givers as the major contributing factors of revolving door phenomena.¹¹

 

The present study revealed that age, marital status and duration of illness significantly associated with perceived factors of revolving door phenomena. Somewhat similar findings were reported by   Hemendra Singh et al (2014) based on a study conducted to analyze the socio demographic and clinical factors associated with readmission and revealed certain socio demographic factors (Age, marital status, sex and duration of staying in current admission) influence readmission rates.¹²

 

LIMITATIONS OF THE STUDY:

The present study has its own limitations like any other study. Following are the limitations of the study:

1.    The caregivers perceived factors associated with revolving door phenomena may not be exhaustive. There could be other associated factors which this study did not reveal.

2.    The present study explore caregiver perceived factors associated with revolving door phenomena therefore there is a scope of subjectivity of perception which may limits the generalization of findings.

3.    In present study data were collected from two psychiatric setting only which limits the   generalization of findings.

4.    Sample size for the present study was calculated based on the findings of pilot study therefore there may be issue of precision.

5.    Perception of patients were neither explored nor correlated with caregivers perception to validate the perceived factors of revolving door phenomena.

 

ACKNOWLEDGEMENT:

I would like to acknowledge the study participants for providing me their keen responses. My sincere thanks to all those who assisted me, directly or indirectly, especially the Institutional Ethical Committee of Saraswati Nursing Institute, Punjab, India in the successful completion of this study.

 

CONFLICT OF INTEREST:

The study entitled “Revolving Door Phenomena and its associated factors among Patients with Psychiatric Illnesses” is a bonafide research work of Ms. Daljit Kaur MSc (N) 2^nd year, Saraswati Nursing Institute, Punjab, India. Authors do not have any relationships/ condition/circumstances that present a potential conflict of interest.

 

SOURCE OF FUNDING:

The study entitled “Revolving Door Phenomena and its associated factors among Patients with Psychiatric Illnesses” is a self funded research work of Ms. Daljit Kaur.

 

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Received on 10.06.2016                Modified on 20.06.2016

Accepted on 30.06.2016                © A&V Publication all right reserved