Epidemiology of Behavioral Emergencies in India

In India, approximately 15 million people are estimated to have serious mental disorders.Reference Reddy and Chandrasekhar¹³ In their estimation of the cost of mental illness in India, Math et al reported that the total cost required is 1,950 crores INR (Indian Rupee) per month and 23,400 crores INR per year (US$430.1 million and 5,161 million, respectively). If these issues are neglected, the indirect costs in terms of loss of wages by the patient, disability, and the social isolation, burden, stigma, and psychological strain facing them and their families will be enormous.Reference Math, Chandrashekar and Bhugra⁵ However, the cost of mental health does not take into account the burden to caregivers that accompanies behavioral emergencies.

The suicide rate in India is approximately 11.4/100,000 males and 8.0/100,000 females.Reference Chavan, Singh, Kaur and Kochar¹⁴ Although the first study on behavioral emergencies was in 1973,Reference Ramachandran and Menon¹⁵ it provided inadequate information. The next study followed nearly 10 years later, and described the pattern of emergency psychiatry referrals over a period of 35 days in a tertiary care general hospital.Reference Kelkar, Chaturvedi and Malhotra¹⁶ An emergency psychiatry referral rate of 5.4% (suicide attempts (13%), excitement and violence (10%), and altered sensorium (9%)) constituted 32% of the total referrals. Neurotic complaints (51%) and functional psychoses (13%) comprised the major psychiatric diagnoses among the emergencies.Reference Kelkar, Chaturvedi and Malhotra¹⁶

Trivedi and Gupta also reported on the pattern of psychiatric patients presenting to the emergency psychiatric services of a post-graduate teaching hospital during a 90-day period.Reference Trivedi and Gupta¹⁷ They observed a referral rate of about 2.20 cases per day from the general emergency department (204 patients), and 3.47 cases per day at the psychiatric emergency department (132 patients). Epilepsy and associated disorders (37%), attempted suicide by poisoning (28%), and psychosomatic illnesses (19%) were the major psychiatric diagnoses attended to in the general emergency department, while acute psychoses (68%) was the major psychiatric illness in the emergency psychiatric department. The male:female ratio was approximatley 1.6:1, with the most patients in the 17–25 year (32.9%) and 26–40 year age groups (25.7%).Reference Trivedi and Gupta¹⁷

However, a separate study reported that nearly one-fifth of all patients who presented to psychiatric emergency services did so with social problems that only required social rather than psychiatric intervention.Reference Mohan and Wig¹⁸ Psychiatric emergencies constituted only 2% of all emergency visits, with males outnumbering females 2:1. Patient self-referrals constituted approximatley 77% of the sample, while 21% of patients were brought by police. Two-thirds of the patients were transported due to the severity of their clinical condition and the remaining one-third for medico-legal and social reasons. In the most recent study, which probably is the first study in the country to comprehensively document behavioral emergencies, a total of 40,541 behavioral emergencies were recorded in the states of Gujarat and Andhra Pradesh, in which the male:female ratio was 1.3:1.Reference Saddichha, Vibha, Saxena and Methuku¹⁹ Most victims were in the 20–30 years age group (42%), from a poor socio-economic background (93%), from a rural area (74.3%), and backward caste (42.6%). Suicidal attempts, whether in the form of poisoning (60.5%) or otherwise (30.7%), were the most common emergency, followed by acute psychotic episodes (4%), and alcohol intoxication (3%).

Subsequently, there have been several studies that have reported on different behavioral emergencies. Since these reports did not study patterns as a group, they are reported below as individual behavioral emergencies.

Suicide—Suicide is a major public health problem not only in India, but worldwide. The developing countries bear a huge burden, as their suicide rates are very high. Suicide is the 13th leading cause of death worldwide, and it is predicted that by 2020, the current rate of one death every 40 seconds will increase to one death every 20 seconds.² The number of suicides in India also has increased 33.9% from 88,241 in 1996 to 118,112 in 2006.²⁰ With respect to suicides committed, currently, India occupies the 45^th position globally, and the 2^nd position in the Southeast Asia region with respect to suicides committed.²

Suicide rates in India vary across the country, with states such as Kerala having the highest suicide rate of 30.8/100,000 population. Suicide rates are higher in urban settings than in rural settings.Reference Sudarsanan, Chaudhury, Pawar, Salujha and Srivastava⁹ One study reported that the southern states of Kerala, Karnataka, Andhra Pradesh, and Tamil Nadu have a suicide rate of >15/10,000 population, while in the Northern States of Punjab, Uttar Pradesh, Bihar and Jammu, and Kashmir, the suicide rate is <3/10,000 population. This difference has been stable for the last 20 years. Higher literacy, a better reporting system, lower external aggression, higher socio-economic status, and higher expectations are possible explanations for the higher suicide rates in the southern states.Reference Vijaykumar²¹

Mental illness has been a major risk factor for suicide in India, especially depression followed by alcohol abuse and schizophrenia.Reference Vijaykumar^21,Reference Roy, Sadock and Sadock²² Two case control studies using psychological autopsy techniques have been conducted in Chennai and Bangalore. Among those who died by suicide, 88% in Chennai and 43% in Bangalore had a diagnosable mental disorder. However, diagnostic evaluations were not done in the Bangalore study.Reference Vijaykumar²¹ Violence and psychological distress also have been observed to be independently associated with suicidal behavior among young people in India; with women from rural India more likely to commit suicide.Reference Pillai, Andrews and Patel²³ Most suicides in India are impulsive and related to stress.Reference Prasad, Abraham and Minz²⁴ Childhood sexual and physical abuse, witnessing domestic violence, parental separation or divorce, and living with substance-abusing, mentally ill, or criminal family members are other factors that may trigger a suicide attempt.Reference Pillai, Andrews and Patel^23,Reference Sharma and Taneepanichskul²⁵

The most common methods used for committing suicide in India are hanging and poisoning.Reference Vijaykumar^21,Reference Kanchan and Menezes^26–Reference Joseph, Abraham, Muliyil and George²⁸ Data on suicide in India indicate that the majority of suicides occur among those <30 years of age, which further imposes huge social, emotional, and economic burdens on society,Reference Vijaykumar²¹ since the general productive age of an individual is between 15–34 years.Reference Fleischmann, Bertolote and Wasserman²⁹

Deliberate Self Harm—Deliberate self harm contributes substantially to global mortality. In 2002, the WHO reported an estimated 877,000 deaths by suicide.² Studies on parasuicide or deliberate self harm from India have reported risk factors associated with attempted suicide as: being male, low level of education, low socio-economic status, illness, and family problems.Reference Parkar, Dawani and Weiss^30,Reference Nagendra Gouda and Rao³¹ A study from Manipal on 52 people who survived suicide, reported that men were more vulnerable than women in regard to deliberate self-harm.Reference Arun, Yoganarasimha, Palimar, Kar and Mohanty³² Urbanites (80%) outnumbered rural dwellers (20%), and more than one-third of those studied were in their third decade of life. More than half had at least a secondary school education, with manual laborers (23%) being the most vulnerable group when compared to skilled laborers and professionals. Married individuals (52%) and those from a lower-middle class sector (70%) attempted suicide more often than other groups. Another study identified personality disorders to be associated with deliberate self harm in two different age groups (15–24 years and 45–74 years).Reference Nath, Patra, Biswas, Mallick and Bandyopadhyay³³ The authors reported a higher percentage of personality disorders among the elderly age group (64%) compared to the younger (58.5%). In the younger group, the most common disorder was emotionally unstable personality disorder (28.6%), and in the elderly group, the most common was anankastic type of personality disorder (36%). Schizoid, dissocial, histrionic, and anxious avoidant personality disorders were found in a small percentage of cases. Another recent study reported hanging and insecticide poisoning (72%) as the most common methods used.Reference Saddichha, Prasad and Saxena³⁴ Males preferred hanging and insecticide poisoning, while females preferred self-immolation and hanging. Self-immolation and insecticide poisoning had the highest mortality (41.6%). Estimates of attempted suicides for the year 2008 revealed a mean of 3.2–3.8 per 1,000 population for males, 3.3–3.7 per 1,000 population for females, and 6.4–7.6 per 1,000 population combined.

Substance Dependence, Abuse, Intoxication, and Withdrawal—Another common psychiatric emergency is psychoactive substance use, which poses a significant threat to the health, social, and economic dimension of any country. The global burden of tobacco, alcohol, and illicit drugs combined, contributed to 12.4% of all deaths worldwide in 2000.Reference Rehm, Room, Monteiro, Ezzati, Lopez, Rodgers and Murray³⁵ Beyond the dangerous behavioral changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation, and violence. Chronic alcoholics also may suffer from alcoholic hallucinosis, whereas the cessation of prolonged drinking may trigger auditory hallucinations, all of which may result in a behavioral emergency.

Alcohol-related problems made up 17.6% of the caseload of psychiatric emergencies in an Indian General Hospital.Reference Adityanjee, Mohan and Wig³⁶ A psychiatric co-morbidity was present in 40% of the cases. Alcohol abuse also contributed to approximately 78% of the total substance abuse-related emergency attendance in another study.Reference Bhalla, Dutta and Chakrabarti³⁷ In addition, about 25% of road traffic crashes are alcohol-related, and 20% of accident-related head injury victims seen in emergency rooms consumed alcohol prior to the accident.Reference Chagas, Gaunekar and Patel³⁸ A retrospective chart reviewReference Bhalla, Dutta and Chakrabarti³⁹ of emergency services users reported that out of 54 patients seeking emergency services with substance abuse (1.16% of all psychiatric consultations), alcohol abusers comprised 77.8% and other opioid abusers, 14.8%.Reference Bhalla, Dutta and Chakrabarti³⁹ The prevalence of injection drug users was 16.7%. Alcohol withdrawal was the most common cause (57.4%) of emergency department visits. Psychiatric co-morbidity was found among 7.4% of the population. At the time of injury, alcohol involvement also is known to be present among 15% to 20% of persons with traumatic brain injuries.Reference Gururaj⁴⁰ Furthermore, alcohol also significantly contributes to one-third of suicide attempts.Reference Vijayakumar and Rajkumar⁴¹ Most importantly, the annual economic loss due to alcohol-related problems in work places in India is between Rs 70,000 to 80,000 million (US$1,543–1,764 million).⁴²

Agitated and Violent Behavior—Aggression can be the result of internal and external factors that create a measurable activation in the autonomic nervous system and became manifested in symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with wrists, or being easily startled.Reference Hillard and Zitek⁴³ Literature suggests that agitated or violent behavior occurs mostly as a result of either serious mental illness or substance misuse,Reference McAllister-Williams and Ferrier^44,Reference Raveendran, Tharyan, Alexander and Adams⁴⁵ and it constitutes approximately 10% of the total causes for use of emergency services worldwide.Reference Raveendran, Tharyan, Alexander and Adams⁴⁵

In India, studies on agitated and violent behavior as a cause of emergencies are non-existent, although violence has been noted to be associated with suicidal behavior.Reference Pillai, Andrews and Patel²³ Factors associated significantly with violence were: male gender, diagnosis of personality disorder, psychotic symptoms, substance- and alcohol-related disorders, low income, suicidal risk, and increased stay in the hospital, while factors significantly associated with aggressive behavior were: female gender, diagnosis of depression, and alcohol abuse.Reference Sharma and Taneepanichskul²⁵

It is pertinent to understand methods of reducing agitation in violent patients; however, guidelines and clinical practices vary widely on the choice of drugs to manage violence in psychiatric emergencies.Reference Hillard⁴⁶ A comparison of intramuscular olanzapine with intramuscular haloperidol plus promethazine on the rapid tranquillization of agitated or violent people with mental illness (n = 300) in behavioral emergencies reported that intramuscular olanzapine and intramuscular haloperidol plus promethazine were equally effective at rapidly tranquillizing or sedating agitated or violent patients with mental illness, but the latter combination resulted in fewer additional medical interventions within four hours of intervention.Reference Raveendran, Tharyan, Alexander and Adams⁴⁵

Disasters and Post-Traumatic Stress Disorder—Disasters are another major cause of psychiatric emergencies leading to psychological stress, which in the long run, may give rise to the post-traumatic stress disorder (PTSD). Disasters caused by natural and/or human-made hazards can cause severe psychological stress. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, and/or confused. The WHO recognizes that exposure to extreme stressors is a risk factor for mental health and social problems.⁴⁷ Events such as earthquakes, tsunamis, terrorism, bombings, and hijackings erode the senses of safety and security. The psychological impact of disasters can be more subtle and can bring shock and distress not only to the community and the state, but to the entire nation.⁴⁸ The psychological suffering from an act of terrorism usually is more extensive than that related to the physical injuries.⁴⁹ Patients suffering severely from this disorder often are admitted to psychiatric hospitals for stabilization.Reference Bassuk and Birk⁵⁰

India is among the world's most disaster-prone areas with a population of more than one billion. It has been witness to several major disasters in the last few decades, including the Bhopal gas tragedy in 1984, earthquakes in Uttar Kashi in 1991, Latur in 1993, Gujarat in 2001, the tsunami in 2004, the earthquake in Kashmir in 2005, and the terrorist strikes in Mumbai in 2008. Chadda and colleagues compiled a comprehensive report on the earthquakes occurring in Kashmir in October 2005 and the subsequent mental health problems encountered in those communities.Reference Chadda, Malhotra, Kaw, Singh and Sethi⁵¹ They reported the most common psychiatric disorders in the population to be adjustment disorders (39.6%), depressive episodes (22.6%), and other stress disorders (21.8%). Only 10 (3.3%) patients were found to suffer from PTSD, though PTSD-like symptoms were reported by more than two-thirds of the patients. Kar and colleagues reported on children after a super-cyclone in Orissa in 1999, and observed that a considerable proportion of children and adolescents exhibited post-traumatic symptoms.Reference Kar, Mohapatra, Nayak, Pattanaik, Swain and Kar⁵²

Anxiety and Panic Attacks—Anxiety disorders are common worldwide,⁴⁸ with the resource-poor countries face a high burden.Reference Khan, Kalia and Itrat⁵³ Anxiety disorders constitute a substantial proportion of the global burden of disease, and are projected by 2020 to form the second most common cause of disability while panic disorders are estimated to be the 27^th leading cause of non-fatal burden in the world.Reference Murray and Lopez⁵⁴ A panic disorder is described as one of the most intensely frightening, upsetting, and uncomfortable experiences of a person's life.Reference Bourne⁵⁵ Both anxiety disorders and panic attacks are common reasons for availing of psychiatric emergency services in India.Reference Kelkar, Chaturvedi and Malhotra^16,Reference Trivedi and Gupta¹⁷

Post-Partum Psychosis—Post-partum psychosis is another area of concern and is a serious mental illness that can affect a new mother. The episode of psychosis usually begins within one to four weeks of delivery. A woman with post-partum psychosis may lose touch with reality, and have auditory hallucinations, delusions, insomnia, agitation, anger, and irrational guilt. Sit and colleagues observed that women who have postpartum psychosis need prompt treatment with rapid and accurate diagnosis to reduce the risk of harm from this behavioral emergency.Reference Sit, Rothschild and Wisner⁵⁶ However, this has been a neglected area, with emergency medical services being seldom aware of its presence.Reference Agrawal, Bhatia and Malik^57,Reference Chandra⁵⁸

Acute Psychosis—Acute psychosis is classified as a medical emergency requiring immediate and complete attention, the lack of identification of which can result in suicide, homicide, or other violence.Reference Bassuk and Birk⁵⁰ Since acute psychoses form the most common reason for emergency department visits, there have been several studies that have examined this kind of emergency. A study from India compared two groups of patients—acute remitting vs. non-remitting or schizophrenic psychoses, and reported that acute remitting psychoses showed an over-representation of females, a higher frequency of associated stress preceding the onset of psychosis, more often had an onset during the summer months, and/or had fever and childbirth preceding the onset of psychosis in a significantly higher proportion of patients.Reference Malhotra, Varma, Misra, Das, Wig and Santosh⁵⁹ In addition, antecedent fever also has been found to be an important biological correlate of acute brief psychosis in one case control study from Chandigarh.Reference Collins, Varma, Wig, Mojtabai, Day and Susser⁶⁰ When the short-term course and outcome of acute psychotic illnesses in a cohort of 91 patients—affective as well as non-affective, were studied over a 12-month period, non-affective (mainly schizophrenic) patients were found to be the predominant group (51%), followed by manic (26%), and depressive (19%) patients.

Overall, the acute psychoses group had an excellent short-term course and outcome, a result that held across all diagnostic groups and across both rural and urban settings.Reference Varma, Malhotra, Yoo, Jiloha, Finnerty and Susser⁶¹ In another study, acute psychoses formed approximatley 9% of all emergencies, requiring the emerging role of emergency psychiatric services in India.Reference Saddichha, Vibha, Saxena and Methuku¹⁹ Such ambulatory services already have proven to be useful on a pilot basis in a couple of metropolitan cities.Reference Chandrashekar, Prashanth, Naveenkumar and Kasthuri^62,63

Other Psychiatric Emergencies—Similarly, an overdose with barbiturates or benzodiazepines may cause ventilatory arrest, while antipsychotic drugs, at therapeutic as well as toxic doses, can cause acute, extra-pyramidal, adverse effects including dystonia, oculogyric crisis, torticollis, and akinesia. Akathisia is another common adverse effect of high-potency antipsychotic agents, resulting in an emergency. Neuroleptic malignant syndrome and serotonin syndrome are some other toxic conditions for which patient require immediate attention.Reference Hillard⁶⁴

Current Status of Management of Psychiatric Emergencies in India

Existing emergency services in India have failed to handle psychiatric emergencies adequately, primarily because of ignorance, and secondarily, due to lack of trained manpower. Sometimes emergency services have been misused to settle legal scores leading to gross violation of human rights.Reference Math, Nagaraja, Nagaraja and Murthy⁶⁵ Unlike other medical emergencies, the biggest barrier to the provision of specialized psychiatric emergency services seems to be the lack of clear-cut legal provisions for dealing with such patients. The compulsory detention and treatment of patients with acute manifestations of a behavioral disorder in India is governed by the Mental Health Act, 1987.⁶⁶ This act replaced the Indian Lunacy Act of 1912, which had earlier replaced the Indian Lunatic Asylum Act of 1858. Chapter IV of the Mental Health Act, 1987 deals with the procedures of admission and detention of the mentally ill in psychiatric hospitals. There are two provisions of admission detailed in this Section. The first provision is a voluntary admission, by request by the patient or the guardian of the patient, and when deemed necessary, by the attending psychiatrist. The second provision is more relevant for emergencies, as it deals with admissions under special circumstances; it provides for admission against the patient's will if an application is made by a relative of such a person in a prescribed format accompanied by two medical certificates by two medical practitioners deeming such an admission necessary. A similar application to a Magistrate for detention and treatment of the mentally ill person is an alternative.

Although there are rules that govern the admission of such patients who require treatment, the ground realities are quite different. Unfortunately, there are no guidelines or provisions under the Mental Health Act for crisis intervention to help those families who request emergency ambulance services to escort or shift a violent patient to a psychiatric hospital. It has been noted that families often approach the nearest police station to help them transfer the disturbed person to a hospital, but often are ignored. In such instances, families are forced to file complaints against the individual for petty crimes, after which, police arrest the mentally ill person and have him/her referred to a psychiatric hospital.⁶⁶ This complicated and often inhumane approach only serves to increase the stigmatization of psychiatric illnesses. Fortunately, the use of specialized psychiatric emergency services can reduce and sometimes eliminate such approaches toward the management of behavioral emergencies.Reference Chandrashekar, Prashanth, Naveenkumar and Kasthuri⁶² As noted, a pioneering effort in this regard was initiated by Banyan, a non-governmental organization (NGO) working in Chennai, India.⁶³ The “Dial 100” service, in partnership with the city police, help to provide treatment to homeless mentally ill persons. However, this service was limited in accessibility and approach. The only other psychiatric emergency service in India is operated by the Karnataka State Mental Health Authority (KSMHA), Bangalore in association with several NGOs in the city.Reference Chandrashekar, Prashanth, Naveenkumar and Kasthuri⁶² This also is a small operation. It is operated by professionals with trained personnel. However, a state and nationwide emergency service that can cater to psychiatric emergencies on a scale similar to that of cardiovascular or traumatic, is required.

Limitations

This study is perhaps the first attempt to accurately document the emerging scenario of behavioral emergencies in India and the need to develop a specialized psychiatric emergency service. Although the authors have tried to include all pertinent studies in this review, it is possible that certain published or unpublished (but important) material may have escaped the attention of the reviewers. However, the authors believe that this number may be small and does not, in any way, change the focus of the paper—the current need for a psychiatric emergency service.