most poor people seek help at public run hospitals where services are free , and those from families below the poverty line ( bpl ) are exempted from payments for medicines and investigations . while this is helpful , there are other hidden costs which the family has to bear .
patients often need to buy medicines which are unavailable in the hospital , meet the expenses for food , transport , etc .
the total costs usually workout to be well beyond the means of those coming from bpl households .
in fact , health care costs often lead to further impoverishment and sets off a vicious cycle of ill - health and poverty , one fuelling the other .
this had been investigated in maternal health and it is relevant for scaling up of mental health care too .
the financial impact of hospitalization for psychoses needs to be evaluated , especially on the poorer sections of the society .
this study aims to assess the treatment related expenses of patients admitted to a government general hospital with psychotic illness .
the present study was conducted after getting approval from institutional research board of government medical college , thrissur .
patients who meet the international classification of diseases ( icd)-10 criteria for schizophrenia , bipolar mood disorders , and other psychotic conditions were prospectively identified from the psychiatry wards of government medical college , thrissur .
they were interviewed after getting informed consent ( written ) and we used specially designed study proforma for data collection . these in - depth interviews were aimed to explore the financial burden experienced by the family during hospitalization .
the major components of expenses during the hospital stay were categorized as cost of medicines , investigations , food , travel , and other incidental expenses .
the details of medication and investigations were collected from the case records on the last day of hospitalization .
we also analyzed the different categories of expenses and calculated the total expenses incurred during hospitalization .
all those who had a bpl card issued by the revenue department of kerala were considered as poor .
we used descriptive statistics such as mean , median , range , and standard deviation to explain the results .
mann  whitney u - test was used to compare costs among bpl and above poverty line ( apl ) patients .
spearman 's rank correlation coefficient was used for finding out the correlation between study variables .
there were 104 cases who received an icd-10 diagnosis of psychosis during the 6-months study period .
four cases had to be excluded due to lack of consent and inability to schedule the interviews on the day of discharge .
only 3% of the subjects were illiterate while 34% had primary level education , and the rest had education up to high school or more .
the number of earning members in each family ranged from 1 to 4 while the average family size was four .
pension benefits were available to 29% of the families , but the average pension was only inr 300/month .
about a half of all patients ( 49% ) were engaged in skilled , semiskilled or unskilled work , often for daily wages , before the onset of illness .
about 21 of them stopped working less than a month prior to admission whereas 13 patients were not working for the last 1 - 6 months . during the hospitalization ,
about 49% of the caregivers had to cut back work resulting in an average loss inr 1500 from the caregiver income during the hospitalization period alone .
nearly half ( 45% ) of the families had availed loans for different purposes , and a significant proportion ( 22.2% ) of them took loans to meet the expenses of hospitalization for psychosis .
the expenses incurred during hospitalization included cost of medicines , laboratory investigations , food , travel and other incidental costs .
though most patients ( 76% ) received free medicines from the hospital , some drugs had to be purchased .
almost a quarter ( 24% ) had to purchase all the necessary medicines from elsewhere .
both bpl and apl patients spent almost same amount for purchase of medicines ( z = 0.469 , p = 0.639 ) .
more hospital days meant more money spent on medication ( r = 0.442 , p = 0.00 ) .
while most patients ( 94% ) needed laboratory investigations , only a minority ( 19.2% ) could get all the investigations done in the hospital itself .
many ( 41.5% ) patients had to pay and use other facilities for some investigations . among 94 patients who needed investigations ,
patients from bpl households spent significantly less amount of money for investigations ( z = 2.682 , p = 0.007 ) and this expense did not depend on the duration of hospitalization ( r = 0.101 , p = 0.320 ) . even though , food was available at free of cost for inpatients from bpl families , the quantity was insufficient .
the average cost of food during the hospitalization was inr 1200 , and this increased with the duration of hospital stay ( r = 0.619 , p = 0.00 ) . among the 100 patients admitted in the hospital , 65% hailed from thrissur district and the remaining 35% were from the neighboring districts such as palakkad , malappuram , and ernakulam .
majority of patients ( 60% ) made use of vehicles such as car , auto or ambulance for conveyance .
the number of persons accompanying the patient on their journey to the hospital was 1 - 5 while 1 - 3 persons accompanied the patient after getting discharged from the hospital .
an average cost of travel per patient was inr 396 for their journey to and fro the hospital .
the total direct expense of hospital stay was calculated as the sum of cost of medicine , laboratory test , food , travel , and other miscellaneous expenses .
the average total expenses including indirect expenses was inr 3975 and this increased with the duration of hospital stay ( r = 0.515 , p = 0.00 ) . almost half of the families ( 46% ) had received financial support from relatives outside their household and this averaged inr 500 .
majority ( 67% ) of patients treated for psychosis in a government - run medical college came from low - income households living below the poverty line .
the average out of pocket expense was more than 1200 rupees and averaged inr 100/day .
the average cost of hospitalization rose to about inr 4000 when indirect expenses are added on .
we did not find a significant difference between apl and bpl families in the expenses related to hospitalization except that the patients from bpl families spent less on investigations that were free for them .
many families had to rely on hired vehicles for bringing the patient to the hospital .
there are schemes that allow reimbursement of the expenses for transport during emergency obstetric care .
there is no provision to reimburse the cost of transport of a person who needs hospital admission and care for psychosis .
government should extend such schemes to include those who need hospitalization for a psychotic illness .
almost half ( 45% ) of the families had availed loans , a clear indication of their strained financial status . about a fifth of these families borrowed money to meet the expenses for the current hospitalization and treatment .
this is a matter of great concern as health care costs , especially out of pocket expenses and is a major cause for further impoverishment of poor households .
lack of support would lead these families to take more loans and get into a debt trap .
our study shows that health care cost , especially the costs associated with management of psychosis is well beyond the financial capability of low - income families .
government should recognize this and offer financial support to meet the treatment related expenses of people with psychosis .
the model of janani suraksha yojana can be adopted for financing expenses of psychiatric hospitalization .
many families are laboring under serious financial strain while they are engaged in the treatment of psychosis .
the governments should seriously consider financial support for treatment of poor people affected by major health conditions like psychoses .
support should extend well beyond free services and should include strategies to finance the direct and indirect costs of treatment . to the best of our knowledge ,
this is the first study from india to report the costs associated with hospitalization for people with psychotic illness in a general hospital setting .
the treatment of mental illness involves significant expenditure , frequent , and considerable use of health care resources .
health care financing in india is vastly different from western countries and some developed economies where in health insurance plays a very large role .
even there , the situation is bad , if the provision for third party payment is unavailable .
there are schemes like rashtriya swasthya bima yojana ( rsby ) and other health insurance policies under government of india that are running essentially for inpatient service for people from bpl families .
people with psychiatric illness were kept out of the benefits of rsby scheme till recently .
. a special scheme to support management of psychotic disorders like schizophrenia and bipolar disorders would be helpful to many families .
good access to effective treatment and adherence to long - term prophylactic treatment is important in the management of schizophrenia and recurrent bipolar disorder .
poverty is a barrier that denies access to good quality mental health care for them .
governments and policy makers should design and implement schemes to finance treatment of psychosis that eventually will help to improve outcomes .
the cost of care leading to further impoverishment is a real problem , especially in low - income settings .
we need to adopt an intervention which goes well beyond the conventional management of illness to prevent this .
 background : combination of ill health and poverty poses special challenges to health care providers . mental illness and costs are linked in terms of long - term treatment and lost productivity , and it affects social development . 
 the purpose of the present study is to assess the economic burden of poor families when a family member needs hospitalization due to psychosis.materials and methods : the information was gathered from caregivers of 100 psychotic inpatients of medical college hospital of kerala during a period of 6 months . 
 data regarding components of expenses such as cost of medicine , laboratory investigations , food , travel , and other miscellaneous expenses during their inpatient period were collected by direct personal interview using specially designed proforma . 
 the data were analyzed using epi - info software . 
 the patients below the poverty line ( bpl ) were compared with those above poverty line ( apl).results : there was no significant difference between patients from bpl and apl in respect of amounts spent on the studied variables except for laboratory investigations during the hospital stay.conclusions:the results showed that the studied subjects are facing financial difficulties not only due to hospitalization , but also due to the recurrent expense of their ongoing medication . 
 the study recommends the need of financial support from the government for the treatment of psychotic patients . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION