Pullepady Incident: 5 lessons for mental-health-care system strengthening.
What is 'Pullepady Incident'?
The Hindu reports it as “Boy stabbed to death by neighbour” with details as excerpted below
The police, meanwhile, maintained that Aji had been mentally unstable and added that the exact reason for the attack was yet to be ascertained. “On a complaint from Aji’s mother, about his becoming violent towards her, we had earlier admitted him to a mental hospital at Thrissur. He was released only a week back,” said M.P. Dinesh, Commissioner of Police, Kochi city.However, local people claimed that the accused was addicted to liquor and drugs.
More sensational reporting in the vernacular press went with screaming headlines like “പത്തു വയസ്സുകാരനെ ലഹരിക്ക് അടിമയായ അയൽവാസി റോഡിൽ കൊലപ്പെടുത്തി” (Malayalamanorama); “പത്തു വയസ്സുകാരനെ മയക്കുമരുന്നിന് അടിമയായ മാനസ്സികരോഗി കുത്തി കൊന്നു” (Mangalam) and also the-Times-of India which said “Smarting over insult, man stabs neighbour’s kid 17 times” . The Times adds..
Before admitted at Thrissur health centre for the last time, Aji had reportedly been treated for mental disorder at five different psychiatric institutions across the state for the last 10 years.
In summary the 'Pullepady incident' is one where a 10 year old boy was stabbed repeatedly to death at road side by his neighbour who has drug dependence and possible mental illness. The entire state was gripped with shocking grief after hearing the tragic news.The incident raises issues of dangerousness of the mentally ill, adequacy of their treatment, stigmatizing and sensational aspects of reporting by media.
This write-up shall focus only on matters related to adequacy/inadequacy of treatment aspects of such people in our current mental-health-care system. The following are five observations which is aimed at strengthening (modernising) the mental health service infrastructure as it exits today in Kerala.
1. Role of disasters and untoward incidents in mental-health system reform.
Reform in mental-health system has generally lagged behind the general health-care system. Many reasons like low priority for mental-health in health policy, inability of patients or family caretakers to form pressure-groups to lobby due to illness related stigma and friction among professional groups regarding medical-care vs social-care can be implicated.The general culture of change in our system is also reactive and often forced-from-outside than through internal proactive considerations. A ready testimony to this fact can be seen in the disproportionate influence that incidents like the ‘Erwady incident’, ‘Nirbhaya’ and the more recent furore in Kerala over compromised dignity of suicidal patients; has had on system reform. Therefore it is pertinent that we dwell on any lessons that the ‘Pullepady incident’ can teach us.
2. Need to provide custodial-care services for mental-health and substance-use treatment in every district:
Pullepady is a place in Ernakulam district. This patient has taken treatment in psychiatric institutions (both government and private) in places as far as Thiruvanathapuram, Trissur and Idukki. The last admission, through an order of the district magistrate of Ernakulam was to the government mental health centre Trissur. Facilities for high security wards are probably not available in Ernakulam district to accommodate such admissions which need custodial care. Services for custodial care for mentally ill patients at all district headquarters have to evolve.
3. If families do not have the capacity to take the burden of care after successful inpatient (custodial) care, the system need to start thinking about what alternatives to provide.
Though family-support is a great boon which absorbs most of the responsibilities of after-care after hospital admission, in recent times we are seeing families who have diminished capacity to deal effectively with the care-burden. Tension between the formal service providers and family care givers (informal) are bound to arise in such cases.In this case forced admission of the patient who had created trouble at home was possible because the mother approached the police and the court for getting admission-order (news-report)
ഏറ്റവുമൊടുവിൽ വീട്ടിലെ ഉപദ്രവം സഹിക്കാതെ വന്നപ്പോൾ സിറ്റി പോലീസ്സ് കമ്മിഷണറെ കണ്ട് പരാതി പറഞ്ഞു.
There was tension at time of discharge also as is reported in the news report.
….. ഇയാളെ ഒരു മാസം കഴിഞ്ഞപ്പോൾ കൂട്ടികൊണ്ട് പോകണമെന്ന് ആശുപത്രി അധികൃതർ അറിയിച്ചു. ആരും വന്നിലെങ്കിൽ സ്വന്തം ജാമ്യത്തിൽ വിട്ടയക്കുമെന്ന് പറഞ്ഞു. ഇതെ തുടർന്ന്… കൊണ്ട് വന്നു. വീട്ടിൽ വന്ന ശേഷം മരുന്ന് കഴിക്കുന്നത് അജി പൂർണ്ണമായും നിർത്തിയതായി തങ്കമ്മ പറഞ്ഞു.
This illustrates not only a diminishing capacity among nuclear families to shoulder the burden of care in cases with overwhelming/complex needs, but also a lack of preparedness of the formal care system – which is attuned to care of patients with good family support – to be responsive to needs of such cases. Community based assessment of such patients with models of care delivered by field professionals adopting “case management” has to be developed.
4. Need for facilities for step-down care trough transitional facilities that are based on level of care-needs at the time for discharge.
Discharge planning in our system is predicated on an availability of a secure family support for the patient; who shall take the patient home, supervise drug administration and bring patient for regular follow up. We need to realise that many families in the modern world either do not have such resourcefulness or the needs of the patient are overwhelming to the available resources of the family. The mental hospitals often report that they face difficulty to discharge such patients as current default option available is only discharge-under-care-of-family. In the incident case too the patient who was admitted involuntarily due to violent behaviour at home was also discharged under care of the family after hospital stay. The need has risen for step-down transitional facilities for discharge, supported housing facilities to discharge patients who do not have families to return to.
5. Need to provide community-based after care options.
The mother report that soon after discharge patient stopped medicines. There is currently no formal system in place to inquire about drug adherence after a patient is discharged. Home-visits by dedicated field professionals who could take an ‘assertive’ approach to track patients with little chance of family supervision is a solution from the services-side. Care would have reached this patient if such a system of ‘active’ follow up was made available. Such community based after-care options have to evolve.
(views and opinion are personal)
(also publised as peer reviewed article in kerala journal of psychiatry)
30.12.2019: 3 yrs later, now, sentence has been declared for this case. see reports in thenewindianexpress, manoramaenglish, manorama.
One of the key contention in the case was that accused Aji has an unsound mind and should be exempted as per IPC section 84. However, the court after examining doctors and witness ruled out any exemption under IPC section 84 to the accused. Before the murder, Aji underwent treatment at Thrissur Mental Health centre. In February 2016, a medical board was constituted to assess the mental condition of Aji. The board found that he was not suffering from any mental illness. He is capable of understanding the nature and consequence of the act. The abuse of alcohol, cannabis, IV injections and heroin was the reason for mood change in him.
Apart from it, the court also noted that he had concealed the knife while proceeding towards the victim before stabbing him. According to the court, the concealment of the weapon explained that Aji was sane and knew that what he was going to do to the boy was against the law.
“From the analysis of the whole material let in from the part of prosecution and the accused coupled with the legal principles, the ensuing corollary is that the accused was not suffering from legal insanity at the time of stabbing of the boy and he is not entitled to benefit from the general exception contained in section 89 of IPC,” the court observed. (TNIE, 25th Oct, 2019)
25.12.2020 : In a webinar by IPS on rehabilitation, a question was raised from the floor on the role of community in treatment of mental disorders. Learned speaker responded with many things , one among them was that the community has a role in helping family in crisis situation i.e. helping family to get person admitted during a relapse or such situation. Infact this role is so ubiquitous that we take it for granted. However the Pullepady incident may suggest an adverse affect for community members who involve in such role.
Community Psychiatry in India 