Hospital dependency in mental illness is a popular phenomenon but it has been woefully less addressed in literature. Chronic patients in mental hospitals are a burden on hospital administration, but on humanitarian grounds, such patients remain in the hospital for an indefinite period of time. After long periods of residence in mental hospitals, these patients tend to develop an institutionalizational syndrome and show reluctance to be discharged from the hospital. To address this problem there should be a holistic approach from all concerned including mental health professionals, caretakers, policy makers and society at large.

Keywords: dependency, institutionalization, mental hospital

In the 19th and early 20th century, due to lack of effective treatment, patients with severe mental illness were admitted to asylums for prolonged periods of time. Goffman coined the term “total institution” to describe the problematic effects of asylums, from a sociological perspective.¹ He defined ‘psychiatric institutions’ as a closed system apart from the rest of society, where patients received custodial care. All activities of the patients were tightly scheduled and their lives were dictated by institutional routine with limited access to the outside world. Goffman perceived psychiatric hospitals as prison like institutions where the mentally ill were admitted although they had not broken the law.¹ Institutionalism, or institutional neurosis, is defined as “the impoverishment of feelings, thoughts, initiative and social activity” initially identified in psychiatric hospitals, may also be found among inmates of prisons and boarding homes.²

Many patients suffering from mental illnesses, especially the chronic patients, over a long period of their stay in mental hospital, often develop a tendency towards hospital sickness and express anxiety during the process of their discharge even when they are fit for discharge. There are substantial numbers of cases which suggest that such chronic mental patients gradually develop an attitude of apathy demonstrated by an absence of emotional reactions towards events outside the hospital.³

An empathetic care and congenial hospital atmosphere often develop a sense of attachment and at the same time they develop a pessimistic attitude towards outer world, especially in chronic patients.⁴ Wing mentioned the term syndrome of ‘institutionalism’ in context of chronic mental patients. Such patients often refuse or express resistance to be discharge from mental hospital.³ As described by Downing, “many mental patients are not motivated to leave the hospital which contains them’’.⁵ This leads to hospital dependency and further adds to the burden on the hospital in terms of unnecessary occupancy of hospital beds, financial burden, unnecessary manpower engagement in care of such patients, etc. The impacts of these problems multiply when there are inadequate emotional attachments and dumping attitude is found from the side of the caretakers. It was advocated that there should be enough opportunity for mentally ill patients to be treated in free environment where they belong to and all rehabilitation programmes and policies for such patients should be designed in concordance with their community requirements in order to discourage the unnecessary mental hospital stay of patients.^6,7 We present a chronic patient with schizophrenia who developed institutionalism.

Index patient was 46 years old illiterate, unmarried, male, suffering from chronic schizophrenia. He belonged to lower socio-economic class, with no past and family history of mental illness. He was admitted to a tertiary care teaching institute and psychiatric hospital for the last 27 years. As per the case records after he was stabilised on psychiatric treatment, he could not be discharges as a fake address was recorded in the file at the time of admission and patient relatives were not traced at the village which he named. It was quite obvious that this patient was admitted by the family with an intention to dump him in the mental hospital. After several unsuccessful attempts of discharge, hospital administration was left with only one option, to keep the patient engaged in various hospital activities like others patients. As years rolled by, patient and accustomed to his life in the hospital and over the years rarely expressed any concern for his family affairs, which was observed in the early years.

His routine psychiatric treatment is taken care of by treating team. Patient is currently in remission phase but surprisingly expresses no enthusiasm to get discharged from the hospital. Over the years, many counselling sessions were conducted with the patient, and several sessions were conducted to motivate him to be shift at least to a day care-centre where stable patients were kept. Every time when an attempt was made to shift him, he would make excuses or create some inconvenient situation that forced the authorities to keep him in the same ward along with his other patients with whom he had developed friendly relations. In the ward the patient rarely expressed any behavioural or interpersonal problems but was always cooperative and helpful, followed all the instructions given by the ward staff and volunteered to distribute food and other ward work. He also attended occupational therapy unit and performed some chores which required little supervision and in lieu of that he earned some incentive. In ward too, he was found engaged with settled patients and took part in recreational activities. Regular mental status examinations revealed no active psychopathology with partial insight into his illness. He strictly followed his activity scheduling and was always found well adjusted with hospital routine and milieu. Considering his disciplined behaviour, hospital staff also gave him some responsibilities in the wards, which required little supervision.

The term hospital dependency was initially narrated by Downing in 1958.⁵ Chronic mental patients may develop an attachment towards congenial and protected environment like mental hospital where basic human requirements i.e. food, shelter and clothes are easily available in a stable social milieu which in the real world are very difficult to attain, especially for mentally ill patients. This might be one of the reasons, why many chronic patients show unwillingness to be released in their own community. The other reason could be that, after being rejected by their relatives, such patients are restrained to a highly protected mental hospital. As a result, such patients are found completely dependent on the hospital milieu and the free services are provided to them and thus show reluctance to be discharged from such a comfortable environment.⁸ Moreover, such patients tend to develop negative or pessimistic images about outer world which prevent them to be released from the mental hospital.⁴

Many inpatients, particularly those who live for prolonged periods in restricted environments of mental hospitals, become dependent on the institution for everything, lose their confidence to make decisions and consequently become institutionalized.¹ Moreover, depersonalization and the loss of one’s identity have been suggested as key features of institutionalism. Institutionalization has been linked to “social breakdown syndrome” (SBS) that manifests as the loss of normal role functioning along with exclusion from family or community roles. SBS can result from any treatment that removes the patient from his or her regular social environment. The author claimed that in the final stage of SBS the patient accepts the chronic sick role and identifies with the other sick patients around him.⁹

Considering humanitarian prospective, hospitals also have to adopt a flexible approach towards such patients and have no option other than to retain them in hospitals at their own cost with significant human efforts, and unnecessary occupancy of hospital beds which otherwise could have been given to other needy patients. Such patients also exhibited intense anxiety and apprehension when being discharged or shifted to their community. Other possibilities for such behaviour could be that many of such patients get a kind of satisfaction and recognition of becoming an active member of hospital community. Their persistent sick role attracts the attention of hospital staff and other patients also. Such patients try to find out some parental figure in the hospital staff and use ego defences to compensate their parental loss or such a long detachment from their parents.

Thus, we can conclude that the most urgent task for all mental health professionals is to cater the actual needs of such chronic mental patients i.e. to reintegrate them in their own community with affordable psychiatric treatments, rather than designing and customizing more favourable situation inside the walls of mental hospitals.

None.

The author declares no conflict of interest.

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