Findings were classified into six categories including the patient’s insistence, miss the beloved one, sense of improvement, financial and family concerns, dissatisfaction with the quality of medical care, and worries about the hospitalization consequences.
“Patient’s insistence” was the most frequent content given by patients’ families/relatives for DAMA. Some families knew their patients’ reasons for insisting, but many did not. Therefore, researchers found it necessary to interview the patients who insisted on discharge. The contents of this category were derived from a combination of contents, given by both families/relatives and patients themselves. But other categories were merely extracted from families/relatives’ statements.
Major contents of this category include “Fear of being injured by other patients,” “A sense of being fully cured,” “A feeling of being stuck,” “A feeling of monotony,” and Discontent of care.” In explaining these issues, it should be borne in mind that psychiatric patients may feel prone to harm under the influence of symptoms like delusions or hallucinations. Moreover, some inpatients may have unusual or aggressive behaviors which may cause a feeling of fear in other patients. The content of “fear of being injured by other patients” may root in these facts.
Some patients after a few days of being away from the stressful environment and improving their vegetative symptoms like insomnia or anorexia will feel well. They might think that continuing the hospitalization is not necessary. However, doctors may prefer to make the hospitalization longer due to subsiding the signs and improving insights. This may explain the content of “A sense of being fully cured.”
Closed wards, old buildings, and facilities of Roozbeh Hospital in addition to strict regulation of wards may cause “A feeling of being stuck in a tight space” and “A feeling of monotony.”
Since psychiatric medications work gradually and last for several days and non-pharmacological treatments at Roozbeh Hospital are associated with limited facilities, patients may feel that they are not receiving enough care and not much is being done for them. This may be the root of the content of “Discontent of care.”
Some statements by patients or their families are as follows:
P1: He insisted to be out. We did not want DAMA at all. We had brought him to be treated, but he was constantly calling and telling us: take me out, I would not be changed in hospital. I'm not crazy ... He threatened me one day and said: you did not rescue me, I am bored and got nervous and could not endure this situation. I said to myself: "Let him go, let him be out and do whatever he wants", but I promised myself not to live with him anymore."
P25: I think that there was no need for hospitalization at all because I have been arguing with my sister since we were children, and I was just angry that day because of her. I thought I would have a simple routine visit by a doctor. I was completely fine. A physician talked with me and admitted me. If I knew I would be hospitalized, I did not go to the hospital at all, or my mother did not let me. I do not have any certain disease. I just was angry"
Miss the beloved one
According to limited facilities and resources, visiting the patients by their relatives in Roozbeh Hospital always have been confined to special times and situations. Moreover, due to the COVID-19 pandemic, face-to-face visits became further limited. These conditions made families/relatives and patients miss each other, and experiencing guilt feeling for hospitalization was the root of some DAMA. Some examples of statements made by the participants are as follows:
P4: "COVID-19 is bothering everyone. For example, if you could visit your son every day and spend hours with him, it would be a better process. Be fair! I really had bad feelings not to visit him and I was more bothered than my son".
P19: "It's a motherly feeling. She cries a lot and says "take me out, I'm upset, I have a stomachache. I cannot eat well". I decided to take her out this time for showing my kindness. It is a motherly feeling. She has been hospitalized here several times, and doctors eventually discharged her even if I disagreed. Therefore, I prefer to prioritize motherly feelings and emotions this time."
Sense of improvement
This category explains that the patient’s families/relatives may feel that the patient is relatively well and can be controlled at home, but the physician has not yet reached the conclusion for discharge. Caregivers often feel that they are able to manage the patient at home with a relative improvement in symptoms. They believe they know their loved ones better than the doctors. Sometimes they do not expect much from the patient, and as soon as the acute symptoms such as aggression decrease, it is enough for them, and want the patient to be discharged. Sometimes it is difficult to find an agreement on discharge time. Here, there are some examples of statements:
P2: “I think he is better. I have to take him home and assess how things are going ... now he recognizes good and bad and is not aggressive, now it is the time to go home I think."
P17: “I think she is fine, she is not that ill, she was confused and forgot the pills. We decided to hospitalize her and now she is fine. That night he was very ill when we brought her but now, she is ok. "
Financial and family concerns
This category refers to the issues that occur outside the hospital and may be the reason for DAMA. In recent years, poverty has increased due to the financial crises in Iran, the devaluation of the national currency, and inflation. In this regard, it should be noted that some mentally ill people help provide for the family, which is cut off when they are hospitalized. Moreover, hospitalization itself is costly. Therefore, some families discharge the patients due to financial conditions. Some patients have a relative or a baby outside the hospital that needs their care. Hence, they want to be discharged early. Some examples of interviewees’ statements are as follows:
P3: "I gave my consent because his insurance booklet was not ready. I cannot pay without insurance."
P15: "Both the child and she were impatient. I saw that she became better and her child was impatient, and she was homesick, so I did it for her".
Dissatisfaction with the quality of medical care
This category refers to the fact that sometimes patients feel they were not well cared for. It may be related to an adverse event in the hospital or medication side effects. Furthermore, inappropriate communication can produce these feelings. This inappropriate communication may be due to a lack of communication skills such as active listening and empathy in the staff, or it may be rare due to the patient’s paranoid symptoms. Feelings of not being well cared for may be passed on to the patient’s families/relatives who are usually more concerned about care than the patients themselves.
The following statement is related to the mother of a lady whose daughter had superficially self-harmed in the hospital. This has happened despite routine nursing care.
P12: I brought my daughter to the hospital so that she could not conduct self-injurious behavior. If she was going to self-harm, our home would be a better place! I came to see her and I see that his hands and face are bloody. I was not given a convincing explanation
Worries about the hospitalization consequences
Some families/relatives are worried that the hospitalization of their patients will have consequences for them. They worry that their relationship with the patient will be damaged after discharge because the patient considers them responsible for involuntary hospitalization. They worry that their patient’s hospitalization in a psychiatric hospital will tarnish the family or the patient’s reputation in the community, making it difficult for them to find a job or a spouse. Some statements are as follows:
P18: “If the news of my brother's hospitalization in a mental hospital spreads, it does not matter to anyone what was the reason. Our reputation will be ruined. And most of all, it's bad for my sister, who is not married yet. She may miss the good options for marriage...
P7: "I felt that he had a bad attitude towards me. ‘You are cruel. You are bothering me. I will get worse if I stay here,’ he kept saying yesterday. I'm afraid our relationship will be ruined. "