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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 68-73

Profile of male forensic ward patients in the state of Telangana, South India, and the challenges faced


Department of Psychiatry, Institute of Mental Health, Hyderabad, Telangana, India

Date of Submission21-Jun-2022
Date of Decision19-Jul-2022
Date of Acceptance30-Jul-2022
Date of Web Publication16-Dec-2022

Correspondence Address:
Dr. Ravikishore Sadula
Department of Psychiatry, Institute of Mental Health, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjp.tjp_22_22

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  Abstract 


Background: Clinical profiling helps to identify the common psychiatric problems that would result in psychiatric referrals and admissions and helps to develop protocols to counteract common psychiatric problems.
Aim: The study aims to identify the profile of forensic ward patients in terms of sociodemographic, clinical, and criminal profiles; evaluate the challenges faced while treating them; and to come up with certain recommendations to the concerned prison authorities to how to deal with them.
Materials and Methods: Retrospective chart reviews of 90 male forensic ward inpatients were done and the details as per the semi-structured intake pro forma were taken, and the data were analyzed using descriptive statistical methods.
Results: Majority of the patients were single, uneducated, unemployed, and belonged to low socioeconomic status. Referral letters from the concerned prison medical officer were absent in half of the cases. Majority of the patients had personality disorders as the main diagnosis, and antisocial personality disorder was seen in majority (34.4%), followed by substance disorders (32.2%), psychosis (30%), and mood disorders (22.2%). 12.2% of convicted murder individuals diagnosed as schizophrenia. Most common crime committed by the individuals with Anti-social personality disorder was theft (15.6%).
Conclusion: In many patients, the information about the reasons for referral and behavioral observation reports was lacking. This lack of information makes it difficult for the psychiatrist to accurately diagnose and treat. Sensitization and creating awareness of prison authorities are of paramount importance to deal with these challenges.

Keywords: Forensic, legal, profiling, psychiatry


How to cite this article:
Rayirala A, Molanguri U, Thupkar N, Sadula R. Profile of male forensic ward patients in the state of Telangana, South India, and the challenges faced. Telangana J Psychiatry 2022;8:68-73

How to cite this URL:
Rayirala A, Molanguri U, Thupkar N, Sadula R. Profile of male forensic ward patients in the state of Telangana, South India, and the challenges faced. Telangana J Psychiatry [serial online] 2022 [cited 2023 Feb 4];8:68-73. Available from: https://tjpipstsb.org/text.asp?2022/8/2/68/363970




  Introduction Top


Studies done previously in prison settings have shown that psychopathology in the prison population is higher than the general population.[1],[2],[3],[4] Some studies have found that personality disorders were very common in the prison population, followed by mood disorders, psychotic disorders, and substance use disorders being the most common accompaniment.[5],[6],[7],[8],[9],[10] In most jurisdictions, forensic psychiatric patients suffer primarily from psychotic symptomatology, but comorbidities are very common, especially personality disorders, neurodevelopmental disorders, and substance-related disorders.[5]

It is a common understanding that psychiatric admissions through prisons can only happen when the criminals are harmful to themselves or others and also there is a lot of literature that aggressive or violence is very high in the prison population and manipulative, parasuicidal behavior is also common.[1],[2],[3]

Planning and administration of a treatment plan consisting of both medical and psychosocial support, interventions intended to enable patients to live independent, will fulfill lives and will reduce the likelihood of reoffending in the prison population.[11],[12]

However, there are very few studies done in India in forensic psychiatric hospital settings. Moreover, there are even less studies done to evaluate specifically the clinical profiling of forensic ward patients. Somsundram (1974)[4] had studied 53 criminal patients admitted to the Government Mental Hospital. They were acquitted of their criminal charges by reason of insanity at the time of the commission of the crime under Section 471 CrPC. It was found that 40 of them suffered from schizophrenia, 10 from affective disorders (3 – mania and 7 – depression), 1 – epilepsy, and 2 – “temporary insanity.”

A retrospective record review of patients admitted to a forensic unit in South Africa had shown high rates (57.14%) of substance use disorder.[13] Another study done in South Africa investigated the demographic, clinical, and forensic characteristics of alleged offenders referred for forensic assessment. A data collection form was used to gather information from 155 offenders' clinical records. The most common diagnoses were substance-related and addictive disorders and schizophrenia spectrum and other psychotic disorders. A sizeable number of offenders were diagnosed with an intellectual disability. The comorbidity of other medical conditions such as epilepsy and HIV/AIDS was also noteworthy. The results highlighted the effect of substances on mental illness and crime.[10]

Clinical profiling helps us to identify which psychiatric problems commonly would result in psychiatric referrals and admissions. Thereby, we can also develop specific protocols to counteract such common psychiatric problems.

This study intends to profile sociodemographic, clinical, and legal aspects of patients in the forensic ward. It also intends to identify common psychiatric illnesses resulting in admission, to address them during treatment. This study also intends to show the challenges we faced during the admission of patients and certain recommendations that can be followed.

Need for the study

Only few studies were done in India regarding the profile of male forensic psychiatric patients. Our study will help to identify the profile of forensic ward patients and guide us to provide proper care to the patients.

Aim

Profile of Forensic Psychiatry patients of male ward and the challenges Psychiatrists face in the state of Telangana, South India.

Objectives

  1. To study the sociodemographic, crime, and clinical characteristics of male forensic ward patients
  2. To study the challenges faced during the admission and discharge of such patients.



  Materials and Methods Top


Inclusion criteria

  1. Male forensic ward patients
  2. 18–65 years
  3. Convicted trial prisoner under trial prisoner and remand prisoners.


Exclusion criteria

  1. >65 years of age
  2. Persons with medical comorbidities


Study tools and design

  1. Semi-structured intake pro forma
  2. Referral letters from prison medical officers
  3. Reception orders (honorable courts)
  4. Hospital records.


Study subjects

Male forensic ward patients at IMH were enrolled.

Total Sample

The total sample size was 90.

Period of study

The study period was 3 months.

Place of study

This study was conducted at Institute of Mental Health, Hyderabad. Institute of Mental Health is a tertiary referral center, situated in the state of Telangana. It is the only center in the whole state, which has a forensic ward setup. Forensic patients from various prisons in Telangana, who require admission, will be admitted to the forensic ward.

Methodology

After obtaining Institutional Ethics Committee approval, case records of 90 forensic ward patients were collected from the hospital with admission from January 2020 to December 2021. A convenient sampling method was used, and all the patients with available records were included. The case sheet of the hospital contains all the relevant information pertaining to the patient, such as identification data, presenting complaints, history of presenting illness, history, family history, premorbid personality, personal history, criminal history, serial physical examinations, serial mental status examinations, and case formulation. Various characteristics of patients such as sociodemographic profile, crime, and clinical characteristics were collected as per semi-structured intake pro forma from hospital records, referral letters of medical officers of prison, and reception orders from the magistrate or superintendent of prison. The patients were diagnosed clinically as per the International Classification of Diseases-10 criteria.[14] All the details were compiled and evaluated. Written informed consent was not taken as this was a retrospective chart review and no direct contact with the patient was made.

Statistical analysis

The analysis was performed using SPSS software version 22 IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.


  Results Top


Sociodemographic profile

Majority of the patients (36.7%) fell between the age groups of 26 and 35 years. Almost two-third of the patients (63.4%) were below 35 years. Majority (70%) belonged to rural areas. Forty percent of the patients were illiterates. Unmarried (52.2%) people were high in number compared to married as majority of the patients were below 35 years. Higher were from the low socioeconomic status (97.8%), and no person was from higher socioeconomic status. Seventy-five patients were from nuclear families [Table 1].
Table 1: Sociodemographic profile

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Criminal profile

Majority of the patients were referred by the superintendent of the prisons, as the sample had the high representation of convict prisoners, who will be referred by the superintendent of the prisons. Except for one patient who got referred for fitness to stand trial, all other patients were referred from treatment only. Almost half of the patients did not have referral letters by the prison medical officer and the complaints for which they were sent were not available [Table 2].
Table 2: Criminal profile

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Most of the patients were found to be violent offenders (58.9%) and most of them got convicted of murder (38.9%) and a significant amount of them were booked for theft cases (16.7%). In 19 individuals, the crime committed by them was not mentioned in the referral letters [Table 3]. Among the violent offenders, 11.3% were sexual offenders. The convicted prisoners were 62.2%, and most of the patients received (38.9%) life imprisonment. Previous crime record was not mentioned for majority of the patients (76.4%), and the reasons for the crime were not mentioned in most of the patient records (56.70%). Substance dependence (14.4%) followed by domestic causes and mental illnesses accounted for reasons for crime in the provided records.
Table 3: Indian penal code section and crime

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Clinical profile

Majority of the patients had personality disorders (37.7%) as the main diagnosis, and antisocial personality disorder was seen in majority (34.4%), followed by substance disorders (32.2%), psychosis (30%), and mood disorders (22.2%) [Figure 1] and [Table 4].
Figure 1: Diagnosis

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Table 4: Clinical profile frequency

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Diagnosis versus crime

Of individuals who were convicted of murder, majority of them had schizophrenia as a diagnosis (12.2%). In antisocial personality disorder (ASPD) individuals, the most common crime committed was theft (15.6%) [Table 5]. In sexual offenders, both substance use disorders and mood disorders constituted 33.3% each; however, as the number of sexual offenders is very less (6), the findings cannot be generalized [Table 3].
Table 5: Diagnosis and criminal profile

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In ASPD individuals, majority had substance use disorders [Figure 2]. Mostly, they were convicted under Section 379 [Table 5].
Figure 2: Comorbid substance use. ASPD: Antisocial personality disorder

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Based on the percentages, it was derived that previous crime record was high in ASPD individuals when compared to other diagnoses [Table 6].
Table 6: Frequency previous crime record

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Based on the descriptive statistics of the sample, it was found that persons with no formal education had high crime rate [Table 7], especially violent (302) than other crimes.
Table 7: Education level and crime

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  Discussion Top


In our study, almost two-third of the patients (63.4%) were below 35 years. Majority (70%) belonged to rural areas, and most of them (40%) of the patients were illiterates. Unmarried (52.2%) people were high in number compared to married as majority of the patients were below 35 years. Higher were from the low socioeconomic status (97.8%), and no person was from higher economic status. Seventy-five patients were from nuclear families, and these findings were consistent with studies done previously.[2],[3],[6],[10],[15],[16]

On criminal profiling, it was found that most of the patients were found to be violent offenders (58.9%) and most of them got convicted of murder (38.9%). As violent behavior is a common attribute to both mental illness and criminality, the admission rates of violent offenders were high in our study. Similar to other Indian studies convicted prisoners were higher in number (62.2%) in our sample[17] could be because of their long stay in prison. Most of the patients received (38.9%) life imprisonment and convicted prisoners were high in our sample and the most common crime was murder. Except for one patient who got referred for fitness to stand trial, all other patients were referred from treatment only. It was evident from these results that most of the patients required treatment rather than certification. It was surprising to note that none had First Information Report surrounding the crime, and almost half of the patients did not have any referral letter by the prison medical officer and the complaints for which they were sent were not at all available. This lack of adequate information about the previous history and behavioral report which were crucial in making the diagnosis would make it difficult for the treating psychiatrist to correctly diagnose and treat them, as most of the patients either deny illness or were not in a position to give a proper history.

As almost all these patients were admitted for treatment purposes only, all these patients had a psychiatric diagnosis in accordance with many studies.[15],[17] The most common diagnoses were personality disorders, antisocial personality disorder being more common, substance use disorders, and psychosis and mood disorders. High rates of substance use were seen in other studies.[15],[18] Some other studies found higher rates of psychotic disorders.[5],[14] These differences could be because of different methodologies used in different studies. Many of the studies done in the past had shown high rates of personality disorders and substance abuse disorders even in the prison population and high rates of substance intoxication at the time of the commission of the crime.[13],[18] Majority of the patients in our study did not mention the reason for the crime, but whoever mentioned had high rates of substance use in their history.

In psychotic disorders, the most common disorder was schizophrenia. Polysubstance abuse was the most common presentation, rather than single substance abuse, mainly in ASPD individuals. The most common crime committed by schizophrenia patients was murder, whereas in ASPD individuals, the most common crime committed was theft. Previous crime record was found to be high in ASPD individuals when compared to other diagnoses as criminal behavior and risk of reoffending would be high in this group. Majority of the patients were kept on antipsychotics and mood stabilizers.

Challenges faced in the treatment of patients in the male forensic ward

No proper information about the history and reason for referral were given at the time of admission for some patients. Some of the admissions were not accompanied by proper referral letters and behavioral observation reports from the prison medical officer. No patient had First Information Report surrounding the crime. We had to rely on the information given by the patients no corroborative information was available in majority. Compliance issues of patients with major or longstanding illnesses could not be established. Comorbid medical illnesses are difficult to handle in a pure psychiatric setup.

Recommendations

  • Psychiatrists must be present in the prison setup as psychiatric morbidity in inmates is very common
  • Inpatient treatment should be made available at the prison to control acute behavioral disturbances and to prevent suicides
  • Screen individuals immediately after entering into the prison to rule out any psychiatric disorders; because antisocial personality disorder, schizophrenia, and substance abuse are more common in forensic population
  • Any behavioral disturbances noted in the prison should be documented properly
  • During referral to the mental health establishment, all the details and history of the patient should be made available to the treating psychiatrist
  • The referral form should be made compulsorily available. The reasons for referral should be clearly mentioned
  • Discharged patients should be sent for follow-up regularly to avoid disease recurrence and revolving door phenomena
  • Directly observed treatment should be given to patients with long-standing illnesses in the prison to avoid frequent relapses
  • A counselor should present in prison to provide counseling and to manage minor issues
  • Sensitization and awareness should be created to prison authorities.


Strengths

  1. Very few studies done in a psychiatric hospital setting
  2. No evidence from Telangana geography.


Limitations

  1. As it is a retrospective chart review, some of the important data can be missing
  2. A semi-structured intake pro forma was used and no scales were administered.



  Conclusion Top


There was high psychiatric morbidity in the inpatient prison sample at our institute, and the patients will be referred to psychiatric hospitals for inpatient treatment when they are highly violent and harmful to themselves or others. In most of the patients, the information about the reasons for referral and behavioral observation report was lacking. This lack of information makes it difficult for the psychiatrist to accurately diagnose and treat. Sensitization and creating awareness of prison authorities are of paramount importance to deal with these challenges.

Acknowledgment

We would like to thank my teacher, Professor Raj Shekhar sir, for his constant guidance and support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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  [Full text]  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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