Nurses' knowledge, attitude and practices on use of restraints at State Mental health care setting: An impact of in-service education programme.

OBJECTIVES: To evaluate the effectiveness of short-term in-service education program in improving nurse's knowledge, attitude and self-reported practices related to physical restraint use. METHODS: A quasi-experimental one group pre-post study was conducted involving nurses working at a tertiary mental health care setting, Dharwad, India. We provided 3 consecutive days of intensive restraint management education (total 6 hours-two hours per day) with a follow-up assessment after one month. The standard questionnaires on knowledge, attitude and practice regarding physical restraints were used as tools for measuring the impact of in-service education program. The program was conducted for a group of five to six nurses at a time. Teaching was done using lecture method, group discussion and demonstrations. RESULTS: Of the 52 nurses who participated in the study, 52% were male, 58.5% had a baccalaureate degree. The mean age of respondents was 33.3 years, the mean work experience was 6.7 years. The findings of the study revealed that the mean scores on the knowledge regarding physical restraints increased after the in-service education from 6.4 to 8.2 (p<0.001). The mean attitude scores improved from 18.5 to 23.1 (p<0.001). There was a significant difference in mean practice scores between pre and post-intervention phases (23.7 versus 25.4; p<0.001). There was a significant correlation between post-test knowledge, attitude and practice scores. CONCLUSIONS: The in-service education program improved nurse's knowledge, attitude and self-reported practice scores. This may lead to more effective restraints management by psychiatric nurses.

Effectiveness of Milieu Therapy in reducing conflicts and containment rates among schizophrenia patients.

OBJECTIVES: To evaluate effectiveness of Milieu Therapy in reduction of conflict and containment rates among schizophrenia patients. METHODS: This study utilized quasi experimental non-equivalent control group pre-post design. One hundred schizophrenia patients admitted in acute psychiatric wards were non-randomly assigned to either of the experimental (n=50) or control group (n=50). The experimental group received both milieu therapy and routine hospital treatment. The Milieu Therapy intervention Included environmental modification and structuring ward activities, establishing effective interaction with patient, and teaching caregivers on managing conflict behavior of patient. The control group received only routine treatment in the hospital. Outcome measures on conflict and containment rates were evaluated for both the groups at baseline and at 2nd, 3rd and 15th day. The Patient-Staff Conflict Checklist Shift Report (PCC-SR) was used to collect information about rates of conflict and containment. RESULTS: Compared with control group, the experimental group participants showed decrease in aggressive behavior, self-harm behavior and general rule breaking behavior at baseline and 2nd, 3rd and 15th day (F=4.61, p < 0.004, η2=0.04; F=11.92, p < 0.001, η2=0.11; F=6.94, p < 0.001, η2=0.06) over seven days interval. CONCLUSIONS: The present study findings provided evidence for the effectiveness of integrating Milieu Therapy in psychiatric acute wards in reducing conflict behaviors among schizophrenia patients. Milieu therapy should be considered as an integral part of psychiatric care settings in these patients.

Clinician attitude and perspective on the use of coercive measures in clinical practice from tertiary care mental health establishment - A cross-sectional study.

BACKGROUND: Use of coercive measures in mental health care is an important issue for research. There are scarce data available on perception and attitudes toward coercion among Indian psychiatrists. AIMS: This study aims to study psychiatrists' attitude and perspectives on the use of coercive measure in clinical practice against the background of family and patients' opinion. MATERIALS AND METHODS: The study was conducted at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India. Psychiatrist in charge of the inpatients was asked about their general opinion on coercion and was administered Staff Attitude to Coercion Scale questionnaire. Findings were compared to previously published studies on patients' opinion and family opinion in the same sample. Data were analyzed using descriptive statistics. RESULTS: Coercion proved to be a common measure applied in nearly 70% of the patients studied. The 189 psychiatrists participating in the study almost all perceived coercion as care, protection and safety, and as protection from dangerous situations. About 66% of psychiatrists perceived physical and chemical restraint (sedation) as necessary and acceptable in acute emergency care. One-third of the psychiatrists felt their patients lost autonomy, dignity, and the possibility of interpersonal contact. The same amount agreed that some patients could have been treated with less restriction and fewer coercive measures. CONCLUSION: Psychiatrists felt that physical and chemical restraints are necessary and acceptable in acute emergencies. Most psychiatrists considered coercion as a caring protective and safety attitude but also acknowledged its potential negative impact on patient dignity and therapeutic relationships.

Caregivers' Attitude and Perspective on Coercion and Restraint Practices on Psychiatric Inpatients from South India.

BACKGROUND: Coercion and restraint practices in psychiatric care are common phenomena and often controversial and debatable ethical issue. Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients have received relatively less research attention till date. AIMS: Caregivers' attitude and perspective on coercion and restraint practices on psychiatric inpatients. METHODOLOGY: This is a hospital-based, a descriptive, cross-sectional study. A total of 200 (n = 200) consecutive patient and their caregivers were chosen between June 2013 and September 2014 through computer-generated random numbers sampling technique. We used a semi-structured interview questionnaire to capture caregivers' attitude and perspective on coercion and restraint practices. Sociodemographic and coercion variable were analyzed using descriptive statistics. McNemar test was used to assess discrete variables. RESULTS: The mean age was 43.8 (±14.9) years. About 67.5% of the caregivers were family members, 60.5% of them were male and 69.5% were from low-socioeconomic status. Caregivers used multiple methods were used to bring patients into the hospital. Threat (52.5%) was the most common method of coercion followed by persuasion (48.5%). Caregivers felt necessary and acceptable to use chemical restraint (82.5%), followed by physical restraint (71%) and electroconvulsive therapy (ECT) (56.5%) during acute and emergency psychiatric care to control imminent risk behavior of patients. CONCLUSION: Threat, persuasion and physical restraint were the common methods to bring patients to bring acutely disturbed patients to mental health care. Most patients caregivers felt the use of chemical restraint, physical restraint and ECT as necessary for acute and emergency care in patients with mental illness.

Factors influencing advance directives among psychiatric inpatients in India.

OBJECTIVES: Advance directives are documents stating treatment preferences in case of future lack of decision making capacity. In India, as in many other countries, legislators advocate Psychiatric Advance Directives (PADs), while evidence on its use is limited. This study examined factors influencing PADs by gathering inpatients perspectives on PADs at discharge and investigating patient characteristics associated with the expression of treatment wishes in PADs. METHODS: We conducted a hospital based descriptive study in Bangalore. 200 patients were included. The Mini International Neuropsychiatric Interview, CGI-S and CGI-I (Clinical Global Impression scales), the Insight Scale-2, and an Illness insight assessment were completed within 3days of admission. We used the Bangalore Advance Directive Interview (BADI) to assess attitudes towards PADs. 182 subjects were reassessed within 3days of discharge, along with an interview on their perspectives on PADs. RESULTS: 67% welcomed the need for PADs in India. 95.6% made their own PADs. 80% followed their doctors' advice in their PAD. Subjects lacking insight or remaining symptomatic at discharge opted significantly more often against ECT, antipsychotics, and inpatient care. Linear regression showed that low socio-economic status, unwillingness to stay in hospital, and having received ECT before were inversely associated with the expression of treatment wishes in PADs. CONCLUSIONS: This study's findings are relevant for India and Western countries alike while generating legislation including patients' perspectives. A majority of patients favoured PADs. Absent insight, severe psychopathology and incomplete recovery may negatively influence the way PADs are completed. Therefore, clinicians must assess patient's capacity to formulate PADs carefully, as capacity may significantly influence patients' views. The timing of when to formulate one's PAD within the illness process may be essential.

Psychotropic implant can be a new hope in psychiatry.

Non-adherence to oral psychotropic medications is common in patients with severe mental illness (SMI). This substantially limits the effectiveness of treatment and results in higher rates of relapse, rehospitalization, suicide, early mortality and disability in SMI. This is a major concern for professionals, caregivers and policy makers. The pharmacological, psychological, psychosocial models and interventions have been there since last few decades to address non-adherence. These have not made major changes in treatment adherence and outcome of SMI. Hence new powerful, long acting and novel psychotropic implant can be developed and could soon revolutionize the treatment in psychiatry.

Clinical correlates and predictors of perceived coercion among psychiatric inpatients: A prospective pilot study.

BACKGROUND: The current Mental Health Care Bill (MHCB) -2013 in India advocates least restrictive alternatives (LRA) in psychiatric treatment. However, we have little evidence on patient's perspectives of coercion and LRA. METHODOLOGY: This was a hospital-based prospective pilot study. 170 subjects chosen by computer-generated random number sampling were screened. In 83 eligible subjects, all assessments including coercion assessment were completed within 3 days of admission and in 75 subjects reassessment was done within 3 days of discharge. RESULTS: Perceived coercion as measured by the MacArthur Perceived Coercion Scale (MPCS) decreased significantly from 3.72±1.98 at admission to 1.77±1.8 (<0.001) at discharge. This was accompanied by significant increase in global functioning, insight score (from 1.5±1.0 to 3.8±1.1; p<0.001) and as well as decrease in symptom severity (CGI-S) (from 5.9±1.1 to 1.8±1.9; p<0.001). Coercion is predicted by family type, employment status, socio economic status, severity of illness and level of insight. 87% patients reported that their admission was justified even though many felt coerced during hospital stay. CONCLUSION: Coercion is a dynamic state and changes with treatment and care. Clinical care may result in an improvement in global functioning, insight as well as in reduction in severity of illness consequently leading to less coercion. During the time of discharge, majority of patients reported that their admission was justified, even though they felt coerced during hospital stay and agreed for treatment against their will within a safe, standardised coercive practice.

The mystery of reincarnation.

One of the mysteries puzzling human mind since the origin of mankind is the concept of "reincarnation" which literally means "to take on the flesh again." As the civilizations evolved, beliefs got discriminated and disseminated into various religions. The major division manifested was "East" and "West." The eastern religions being more philosophical and less analytical, have accepted reincarnation. However, the different eastern religions like Hinduism, Jainism, and Buddhism have differed in their faith on rebirth. Further, the Islam as well as the most dominant religion of the world, Christianity, having its origin in the west, have largely denied reincarnation, though some sub-sects still show interest in it. Also many mystic and esoteric schools like theosophical society have their unique description on rebirth. This article describes reincarnation as perceived by various religions and new religious movements as well as some research evidence.