Management of the wandering mentally-ill roadside destitute

Dr Bharat Vatwani

Volume 12 Issues 11 November, 2022 

Continuation of the article publishes in previous issue i.e. Volume 12, Issue 10, October 2022 ….

A wandering, mentally ill destitute poses a different set of complex psychiatric and medical problems requiring other skills for successful solutions. 

Medical Challenges Post Rescue:

The destitute go through extremes of Heat/ Cold/ Rain/ Starvation/ Sexual Abuse/ Anaemia/ Hypoproteinaemia/ Kochs/ Enteric fever/ Sexually-transmitted Diseases/ Seizures/ Grave Body and Scalp injuries/ Severely-infected Wounds with Maggots-Infestation/ Fractures/ Impacted Rings in Fingers, all restricting administration of appropriate treatment.

Because no objective data is available, there is no information on the ration of illness, history of prior episodes and treatment/ family history of mental illness/ presence of concomitant medical/neurological disease. Finally, treatment becomes signs/symptoms based. There is no validity no the patient’s history. 

The presence of co-morbid organicity (Dementia/ Paralysis/ Cerebrovascular episodes/ Epilepsy/ Borderline Intellectual Functioning) and the ds to difficulty getting good improvement and clear family details/addresses. Untreated Hypertension/Diabetes and co-morbid Cardiovascular Decompensation may curtail desired drug dosages.

Need for a Culturally and Linguistically Diverse Rehabilitation Team:

Communication has many language issues; different dialects are impossible to comprehend, and the patient remains symptomatic and irrelevant for months. In case the destitute have negative symptoms or are catatonic, it is challenging to establish rapport. The reluctance/refusal to eat, the reluctance/refusal to take oral medicines/allow fluid administration, and the Tendency towards violence because of inherent illness/lack of comprehension of what is going on are all stumbling blocks to treatment. The issues with food preferences/tastes because destitute hail from different regional/cultural backgrounds impede rapport development.

Psychiatric and Medical Medication Regime:

Medication has to be introduced insidiously. Given the patient’s weak, debilitated, hypo-proteinemia state, Olanzapine is the best drug. It has a feel-good factor and helps increase appetite and weight. 5-7.5 mg is more than adequate. Trifluoperazine (15 mg daily dose) is ideal for paranoid delusions and auditory hallucinations. Agitation/Tendency for violence responds to Haloperidol 5 mg oral or intramuscular. Since the previous history of seizures is unknown and the patient is in a weak debilitated state, it is better to start with a low dose of medication. Prophylactic Sodium Valproate (600 mg in divided doses) helps prevent seizure onset and allows effective control. Clobazam as an add-on helps augment anti-seizure propensity, helps suppress emotional outbursts and has a feel-good factor. Other drugs often used in Shraddha for negative symptoms are Flupenthixol, Pimozide, Amoxapine, and Aripiprazole. Again, dosages must be low, with 5-10 mg of Aripiprazole often sufficient. Lithium continues to be the time-tested best drug for Bipolar Illness. From day one, we start Trihexyphenidyl (4-6 mg daily) for EPS prevention. Quetiapine and Amisulpride, even if used, are in low doses, as both are relatively expensive and not readily available in rural areas. Carbamazepine beats Oxcarbazepine in efficacy but could give rise to allergic reactions. Both Oxcarbazepine and Lamotrigine are expensive mood stabilizers, and we use them relatively lesser than Sodium Valproate. Risperidone long-term elevates blood sugar levels. Blonanserin, Iloperidone, Ziprasidone, and Lurasidone are decent antipsychotics, with Lurasidone having a definite edge in affective symptomatology. Drug-induced BP drop, oversedation and consequent hypoglycaemia need constant guarding.  

Vitamin D3 and all vitamin levels are low in roadside destitute and need Injectable Vitamin D3 and often IV supplementations of vitamins. Two boiled eggs daily for non-vegetarians help boost protein levels. For vegetarians, a high pulses diet helps. Routine CBC, ESR, FBS, HIV, and UPT in all patients are mandatory. Anaemia will require de-worming, Injectable Folic Acid, and, if necessary, parenteral Iron diluted in appropriate solutions. A very low haemoglobin of 2-3 gm % may require a couple of blood transfusions. For Fever, one has to rule out Enteric, Koch’s, Malaria and Dengue (both endemic in our area). Widal, Chest X-Ray, Smear for Malarial Parasite etc., are needed. In our NGO, a reasonable medical opinion is not that readily available, and one has to be prepared to be a psychiatrist-physician rolled into one. Diabetes and Hypertensin detection require correctly-titrated anti-diabetics and anti-hypertensives. But our experience has been that while chronic patients may take months to respond, overall dosage requirements are low in destitute.

Difficulties faced – During Reunions

• Tribal patients (females more), uneducated with poor general knowledge, know only the name of their village. They do not understand the words of their District/State or even the nearest railway station. These tribals, even upon recovery, are very difficult to reunite.
• Recovered destitute throws a seizure or develops a medical complication (fever/diarrhoea/vomiting) during the journey or accompanying SW themself develops medical contingency.
• Destitute with a physical handicap/challenge has to be dealt with hands-on.
• Long-distance Reunions – e.g. Assam/Arunachal Pradesh.
• Female destitute picked up occasionally with their offspring—uncertainty whether the child is marital or from sexual exploitation on roads.
• The inherent intensity of the schizophrenic illness fluctuates with time, causing the most-cooperative docile, recovered-destitute, to disappear and get off the train during night travel or when SW has gone to the restroom.
• Recoveries of the destitute are incomplete. Correspondingly knowledge of antecedents/address details is also incomplete, hampering final reunions.
• Non-acceptance by relatives is more likely (1:30) when relatives traced out are distant relatives, the near-and-dear ones having passed away.

Ultimately, it is not a separated loved one that Shraddha reunites with their family. It is the debunking of the Stigma that surrounds mental illness at the individual, family, and societal levels, which Shraddha accomplishes, albeit in bits and pieces, in a fragmented journey across the length and breadth of India. And it does this with an all-pervasive Compassion/Empathy for the plight of the ordinary, grossly-misunderstood, wretched, neglected mentally-ill man. And this perseverant Empathy kindles further Empathy for the mentally ill within the sufferers themselves, their families, their villages & surrounding societies at large.

Ending on a note of prayer & hope for the wandering mentally-ill

Note: The article is the continuation of the article published in the previous issue, Volume 12, Issue 10, October 2022