From asylums to bedless hospitals: Will COVID-19 catalyse a paradigm shift in psychiatry care in India?

Sir,

Psychiatry practice in India, was initially confined to mental asylums in the 18th & 19th centuries. The asylum concept, originally propagated by the British, gradually shifted towards a mental hospital setup. The Indian Lunacy Act, 1912, catalysed the shift from asylum to hospital. The number of psychiatry hospitals also increased (Sax, 2014), & the scope of services extended to inpatient, outpatient, & rehabilitation services (Saraceno et al., 2007). General hospital psychiatry completed this paradigm shift (Daund et al., 2018), and integrated psychiatry into mainstream healthcare. The community-based care started through the National Mental Health Program (1982), and the District Mental Health Program (DMHP), with the objective of providing access to mental health care for all (Gupta and Sagar, 2018).

Mental health care faces challenges, with 10.8 % of the population in India affected by mental illness, and a treatment gap of 83 % as per National Mental Health Survey (NMHS) 2015–2016 (Gautham et al., 2020). The burden on tertiary care continues to remain high, and the available hospital beds are insufficient to meet this demand. This calls for different measures to be implemented to reduce the treatment gap.

‘Bedless hospital’ means that the patient does not stay overnight. The concept originated in day care surgeries, where patients were discharged within 24 h. In North America, cancer surgeries, and mastectomies are performed in bedless hospitals, and patients get discharged within hours of the procedure (“Are ‘bedless’ hospitals the wave of the future?, ” n.d.; “Bedless hospitals treat patients and send them home the same day,” 2016). This reportedly reduces the cost of stay, and more importantly, the risk of infection.

The ongoing corona virus disease – 2019 (COVID-19) pandemic necessitated a lockdown throughout India, and patients were not able to access tertiary care hospitals. Emergency care continued to remain available, and patients were encouraged to access services locally. In NIMHANS, bed occupancy dropped from the usual 85 % to less than 40 % per day during the lockdown. Contrary to what was expected, the emergency services were not overburdened, and the utilization of this service dropped by 40–50 %. Only 11.46 % (147/1282) of the patients who availed emergency services were advised Inpatient care during the months of April, & May 2020.

The remaining patients were admitted for a brief period of less than 24 h, and discharged.

The patients were evaluated in detail and treated for emergencies like aggression, substance related withdrawal and were discharged following stabilization. The patients were advised to continue medications and followed up in person or through telemedicine. Some patients were referred to a nearby psychiatrist where feasible.

The utilization of the DMHP services, and Tele Psychiatry services rose during this period, due to travel restrictions & quarantine rules preventing access to tertiary care. As per Mental Health Care Act (MHCA), 2017, the patients with mental illness with capacity to take treatment decisions cannot be admitted, if the patient is not willing to get admitted. In such cases, patients can be evaluated in the emergency set up in detail and can be discharged within 24 h, besides assessing the capacity of the patient to consent in terms of mental health related treatment decisions. The concept of ‘bedless hospitals’ would be applicable under the MHCA, 2017. This may not apply for wandering persons with mental illness, who might require a longer period of inpatient stay.

Will COVID-19 trigger a paradigm shift towards ‘bedless hospitals’ in tertiary care psychiatry? Tandon (2020) has rightly pointed out the importance of learnings and perspectives of mental health after COVID-19 (Tandon, 2020). One such perspective is the concept of ‘Bedless hospitals’. This concept can help the patients access care in the nearby hospitals at the level of community, avoid unnecessary travel, and costs of inpatient stay at tertiary centres. Another advantage is the risk of COVID-19 infection is also minimized if patients stay only for short period, while allowing patients to be evaluated, initiating treatment, and discharge, or referral to a local facility. Adding to the advantage, this concept also allows for treatment of more patients on the same day, without necessitating an increase in infrastructure, or human resources. More inpatient beds can be designated for day-care, and the number of emergency care beds can be increased to provide high intensity treatments for vulnerable populations. However, the after-care in the community needs to be strengthened, like the DMHP programmes, to successfully implement the concept of bedless hospitals. This is likely to empower community-based treatment centres, and enable the tertiary care centres to function as referral centres. This shift was forced on the mental health system in view of reducing the transmission of COVID-19. This can be one of the indirect measures to help reduce the treatment gap. If the change to a bedless hospital does happen, COVID-19 would have catalysed another paradigm shift in mental health service provision.

Author’s contributions

All authors have contributed equally to the conceptualisation of the manuscript.

Funding

None.

Declaration of Competing Interest

The authors report no declarations of interest.