Investigating the Prevalence and Causes of Escape in Mental Patients

Veronica Ciocan¹, Manuela Dora Gyorgy²*, Daniela Margareta Varga³, Felicia Marc³, Florica Voiță-Mekeres³

¹Department of Forensic Medicine, University of Medicine and Pharmacy ’’Victor Babes’’ Timisoara, Romania.

 ²Department of Psychology, Dimitrie Cantemir University of Targu Mures, Romania.

³Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania.

*Email: [email protected]

ABSTRACT

This study summarize and evaluate the articles that have been done in the field of mental patient escape to provide a clearer picture of the prevalence, causes, and factors of escape. Electronic resources were searched in the the period from 2008 to 2023. A combination of Abscond of mental patient, Abscond of mentally ill, Abscond, Escape of mental patient, and Escape was used to search electronic resources. The results of this review study showed that the highest number of escapes from the hospital are in Australia, England, America, India, and Ireland, respectively. A rate of over 25% absconding has been reported in forensic psychiatry in South Africa. Also, young male patients, single, addicts, people diagnosed with bipolar mood disorder, depression, and schizophrenia and patients who have not been admitted for a long time showed more desire to run away. A review of the conducted studies showed that the prevalence of absconding occurred in which countries, in which age group, with which disease, and which gender. According to the results of the research, it is possible to identify the patients at risk of escaping by taking into account the characteristics of hospitalized patients and preventing them from escaping by monitoring them and taking special measures. Encouraging families to visit and support their patients, reducing the feeling of limitation and deprivation in patients, can help reduce the rate of absconding. The results of this research can be used in planning and designing appropriate measures to prevent mental patients from escaping.

Key words: Escape, Mental patients, Abscond of mental patient, Abscond

INTRODUCTION

Mental illnesses have existed since the beginning of mankind, and no person is completely immune to them, and this is a danger that threatens mankind regularly [1]. Providing continuous care and support to patients with mental illnesses is challenging. Mental patients overshadow the social functioning of themselves and their families from the social and educational aspects. One of the important factors in supporting these patients is preventing them from escaping [2, 3]. Escape is an important health and security concern, which causes unfortunate consequences for patients and their families, health professionals, and society, and increases the responsibility and workload of hospital personnel and the executive director to return the patient to the hospital [1, 4].

Escaping includes any case of leaving the hospital without permission or not returning from leave at the agreed time and leaving the hospital against medical advice [5]. Patients who leave the hospital without the permission and order of the doctor and before the treatment is completed may harm themselves and others [6-8]. Runaway patients are at greater risk of self-harm, violence, non-adherence, relapse, drug use, and negative media attention [5, 9-11]. Escaping can potentially lead to risks to the patient himself, public safety, legal and legal consequences. Absconding can also lead to missing the treatment program, which leads to a longer rehabilitation period and as a result, consumes more resources and costs and expends more energy [1, 6, 12]. Also, from a legal point of view, it can create responsibility for the hospital and harm the image of the hospital and the health system [13, 14], one of the important consequences after escaping is suicide. Suicide in hospitalized patients and escape from hospitalized patients at risk are important challenges for all medical fields, especially psychiatry [15-18].

Suicide is highly correlated with mental illness. Old studies show that about 10% of schizophrenic patients die by suicide. Recent analyses estimate this figure at around 5%. Paranoid phenomena are also related to suicide. Fear and anxiety are associated with an increased risk of suicide. People with schizophrenia and panic attacks are five times more likely to commit suicide than people with panic attacks without schizophrenia. Furthermore, when schizophrenia is accompanied by panic attacks, patients have significantly more paranoid symptoms. Disappointment of mind or mental suffering leads to suicide. The effects of unbearable guilt, humiliation, self-loathing, desolation in abandonment, loneliness, overwhelming anxiety, and hopelessness have all been associated with suicide [19-21]. Suicide prevention by mental health services requires awareness of suicide antecedents among high-risk groups such as psychiatric patients. The findings of studies have confirmed that a significant part of patient suicides happen after escaping from the ward. Any patient suicide can reflect the quality of service. Necessary measures to prevent suicide in patients may include regular risk assessment during recovery and before granting leave, adequate monitoring of patients, staff training programs in the field of risk management, and improving staff communication [22].

Patient absconding depends on various factors such as the hospital environment and the type of illness, and the rate of absconding from mental hospitals is higher than other hospitals [6, 23-25]. Patients run away to find peace and regain strength and control over their lives [26, 27]. The rate of absconding in mental health departments differs from 25 to 34% of admissions in general hospitals. Some of the reasons for patient absconding include the following: impatience and boredom, lack of appointments, communication problems, irritability, peer influence, active symptoms such as command hallucinations, trying to obtain drugs, dislike of staff, and dissatisfaction with the ward or hospital food, the feeling of not accepting them, the feeling of restriction and deprivation from leaving or being released, the feeling of fear, separation, homesickness, worry for the family, family responsibilities, lack of privacy, delay in examinations and treatment, defects in the treatment process, expenses Treatment and lack of insurance coverage, lack of insight or correct understanding of the patient or his family about the disease and the complications and consequences of non-treatment, stressful factors, feeling confined in prison, feeling insecure, and doing household responsibilities [5, 28].

Considering the importance of patient absconding, the purpose of this study is to summarize and evaluate the articles that have been done in the field of mental patient absconding to provide a clearer picture of the prevalence, causes, and factors of absconding.

MATERIALS AND METHODS

Electronic resources were searched in the Scopus, Science Direct, ISI Web of Science, Google Scholar, and PubMed databases in the period from 2008 to 2023. A combination of Abscond of mental patient, Abscond of mentally ill, Abscond, Escape of mental patient, and Escape was used to search electronic resources. The article selection process was done in order and based on the protocol. First, the mentioned title was searched in the databases, then the articles were reviewed according to the study criteria. The criteria for inclusion in the study included: all articles related to the escape of mental patients in the period from 2008 to 2023 and at least one diagnosis of a mental illness, and the exclusion criteria included articles that had incomplete information.

After completing the above steps, the articles that covered the criteria of the rate of escape of mental patients and the factors affecting the escape of mental patients were included in the study.

RESULTS AND DISCUSSION

A mental disorder is a clinically significant psychological or behavioral syndrome or pattern associated with distress or disability. The person does not show a consistent, predictable response to specific events, and the person's relationship with society is limited [1]. Running away is a potentially dangerous phenomenon for all stakeholders in mental health and society [2, 29].

A patient is considered an absconder when he leaves the ward unexpectedly and before the treatment is completed, without notifying the clinical staff [15]. Patient absconding from the hospital is an important healthcare issue with economic, social, and health costs. Runaway patients from the mental hospital are examined in terms of etiology and major social and economic consequences. According to Gowda's study in 2019, the best definition of escape is enjoying life without permission from the hospital or not returning from leave [9, 30]. A better understanding of the factors that influence patients to abscond can reduce the number of these events [31, 32]. This can increase the continuity of care for patients and increase the trust of families and society towards hospital protocols for safe treatment [33].

Escaping causes fear and uncertainty and makes psychiatric services look negative [34]. Incidents after the escape can also cause distress and anxiety to relatives and staff, can lead to the deterioration of relations between staff and relatives of patients, divert nurses from other responsibilities, and cause feelings of guilt, hopelessness, lack of success, and fear of safety. Career, self-blame, and fear of punishment by the hospital become in nurses. The rate of escape is higher on weekends when changing shifts, and in the evening and night hours, because there is the least control over patients during those hours. Leaving the hospital may be easier during the day because at that time more people move or visit almost every hospital [13]. Measures such as establishing consistent therapeutic relationships with patients, patient-centered care, using minimum mandatory punishments, minimizing restrictive environments, and training nurses and families regarding the consequences of running away and more monitoring of patients at risk, can reduce The escape rate of patients should be effective. Relatives of patients should be aware of their essential role in bringing patients back. Nursing staff and social workers play an essential role in this psychological education. Such an approach not only helps to reduce absconding but also improves the overall quality of patient care and reduces medical and legal issues as well [27].

Consequences of running away include physical injuries, prolonged treatment duration and discontinuation, high treatment costs, self-neglect, exposure to violence, aggression and irritability, homicide, loss of communication and self-confidence, suicide, and sexual abuse [35]. Nursing staff and social workers play an essential role in this psychological education [32]. In another study, the most important reasons for fleeing from Yemen included the following: treatment failure (50 percent), family problems (17 percent), alcohol addiction (12 percent), being influenced by other patients (8 percent), and Economic problems were (4 percent) [35, 36]. The existence of hospital wards whose entry and exit are uncontrolled or have so-called open doors is also one of the factors of escape [37].

Consequences of running away include physical injuries, prolonged treatment duration and discontinuation, high treatment costs, self-neglect, exposure to violence, aggression and irritability, homicide, loss of communication and self-confidence, and suicide [35]. In the study of Ajalli et al. 21.5% of people aged 15 and above in urban areas of Tehran had mental disorders [38]. Previous studies have shown that running away is more common among men (5.94%), single people (58.9%), and patients with schizophrenia (41.9%) [39, 40].

Also, the escape rate from the emergency department is higher than that from inpatient departments [41]. The highest number of hospital escapes is in Australia with 20.82, England with an average of 16.45, America with 8.62, India 5.58, and Ireland or 4.28 people per 100 hospital admissions. A rate of more than 25% absconding has been reported in forensic psychiatry in South Africa [42, 43]. In a study in a hospital in Tehran, the escape rate was reported as 2.4% [44]. In the study of Memarian and colleagues in Tehran Hospital, the escape rate was 1% and in a study in Shiraz, this rate was reported as 5%. A study in Hong Kong also mentioned the absconding rate of patients at about 0.3% [45, 46]. The escape rate among male patients is 64-94%; also, in another study in Hong Kong, 84% of absconding patients were men. The average age of absconding patients in this study was about 31 years, and similar results have been obtained in different studies [38, 47]. In Khammarnia study, a significant relationship between the rate of escape and the place of residence has been obtained. It seems that the lack of accommodation facilities outside the hospital for non-native patients is one of the reasons for the low prevalence of this behavior among this group [40]. In Verma's study in 2020, it was found that the highest rate of escape happened in the early morning and at night, and the patients were from the young age group and had schizophrenia [33].

Considering the high prevalence of escape and its consequences, it is necessary to reduce this occurrence by making correct decisions and plans.

CONCLUSION

In this study, the prevalence of escape in mental patients was shown, and the dangers that threaten them after escape were investigated. The results of this review study showed that the highest number of escapes from the hospital are in Australia, England, America, India, and Ireland, respectively. A rate of over 25% absconding has been reported in forensic psychiatry in South Africa. Also, young male patients, single, addicts, people diagnosed with bipolar mood disorder, depression, and schizophrenia and patients who have not been admitted for a long time showed more desire to run away. A review of the conducted studies showed that the prevalence of absconding occurred in which countries, in which age group, with which disease, and which gender. This study has some limitations. Our search was limited to the contents of only a few databases, so we may have missed publications that were not indexed in these databases. At the same time, the search was conducted only in the English language, which can prevent the achievement of all the studies conducted in the field of the prevalence and reasons for the escape of psychotic patients.

According to the results of the research, it is possible to identify the patients at risk of escaping by taking into account the characteristics of hospitalized patients and preventing them from escaping by monitoring them and taking special measures. Encouraging families to visit and support their patients, reducing the feeling of limitation and deprivation in patients, can help reduce the rate of absconding. The results of this research can be used in planning and designing appropriate measures to prevent mental patients from escaping.

ACKNOWLEDGMENTS : None

CONFLICT OF INTEREST : None

FINANCIAL SUPPORT : None

ETHICS STATEMENT : None