From folk therapy to evidence-based psychiatry practice: The benefit of evidence-based psychiatry in treatment-naive psychotic patients

Background: As Taiwan’s Mental Health Act (MHA) clearly states that the human rights and legal rights of psychotic patients should be respected and guaranteed; however, a temple asylum violates the law in the 21st century. Hundreds of patients were constrained in the asylum for years without consent. Because of outbreak of infectious diseases, patients were evacuated from the asylum by the official intervention. Aims: To evaluate the outcomes of these patients from folk therapy to conventional treatment. Method: The study recruited the drug-naive psychotic patients constrained in an asylum for decades. Before and after the formal treatment, 253 patients were diagnosed with schizophrenia and other psychotic disorders with assessment of using the Mini Positive and Negative Syndrome Scale (Mini-PANSS) and Comprehensive Occupational Therapy Evaluation (COTE) scale. In addition, family function, self-care ability and nutritional status were also evaluated. Results: The initial data show the improvement in psychotic symptoms and occupational function in these patients. Furthermore, the ratio of patients who were classified as being at risk for malnutrition was decreased by 21.7% after treatment. There was no statistically significant difference in self-care ability before and after treatment. Conclusion: The psychotic symptoms and occupational function of these patients were improved after the formal treatment compared to the folk therapy. The care model for the psychotic patients in the temple asylum should be more thoroughly discussed in consideration of the medical ethics principles.


Introduction
Many patients with mental illness were locked up with the iron chains over hundred years in the past. In 1793, Philippe Pinel unchained the patients, and many of them had been restrained for decades (Hergenhahn & Henley, 2013). 'Dementia praecox' was used by the German psychiatrist Emil Kraepelin that eventually relabeled as schizophrenia (Tandon, 2012). In 1952, chlorpromazine was confirmed to be more effective for controlling agitation and excitement on the patients than any previously used drugs, including insulin coma and morphine and scopolamine (hyoscine) combinations (Leon, 2011). Afterward, other first-generation antipsychotics (FGA) and secondgeneration antipsychotics (SGA) were provided to alleviate the psychotic symptoms, caregiver loading and neurocognitive deficits, and antipsychotics improve brain function in schizophrenia patients (Leucht et al., 2013).
There were approximately 1.17 million people with physical and mental disabilities in Taiwan in 2018. Among them, 10.9% patients were diagnosed with mental illness (Ministry of Health and Welfare, 2018a). The length of hospital stay for the psychotic patients is known to be even longer than the length for physical illnesses (Moreno et al., 2013). In the 1970s, many psychotic patients in Taiwan were applied with the folk therapy in asylum because there was no effective treatment at the time (H. Y. Wang & Chou, 2019). The National Health Insurance (NHI) in Taiwan has been on board since March 1995 and covers over 99% of the Taiwanese citizens (Lee et al., 2018). As time goes by, the resource for the psychiatric care has shown an upward tendency in Taiwan. There were 89 intensive care unit beds, 7,399 acute beds and 13,661 chronic beds in hospitals in Taiwan in 2017 (Ministry of Health and Welfare, 2017). In 2017, the Psychiatrist-population ratio is 7.19 per 100,000 population in Taiwan. Briefly speaking, the psychiatrists and beds currently in Taiwan are adequate. In Asia, the doctor-to-patient ratio in Taiwan is only inferior to the ratio in Japan (Ministry of Health and Welfare, 2018b). In 2014, the HSBC Expat Explorer Survey showed that almost 7 in 10 expats in Taiwan said that they spent less on health care than they did before migration. In this regard, Taiwan is superior to Japan, France, Belgium and Germany in affordability and quality (HSBC, 2014).
However, there was an asylum accepting up to 1,000 psychotic patients in Taiwan. Most of the patients were neither offered with any antipsychotic medications nor other medication regularly. In 1971, a monk recruited a patient with pyromania and confined his body with a straw rope and such method surprisingly led to a result that the patient gradually improved (Chang & Lai, 2002). At the time, the psychiatric care remained inadequate in Taiwan. In the largest city in Taiwan, a new mental hospital with 60 acute beds was newly established. There were only four psychiatric specialists in the second largest city in Taiwan. The shortage of psychiatric beds and psychiatrists was obviously then. Moreover, the NHI had not been put into effect. Therefore, only patients with high socioeconomic status (SES) could receive the conventional treatment. Most patients could not obtain the regular antipsychotic medications and instead could only receive the folk treatments commonly used in Taiwan then.
The temple asylum asserted that patients did not need to take any antipsychotic medications. Instead, the temple used an iron chain to confine patients with vivid psychotic symptoms at the waist with good function patients. The temple further asserted that the patients could take care with each other in this way. However, the physical violence frequently occurred over the past years. The risk of patients being attacked by another patient was neglected by the temple management (H. Y. Wang & Chou, 2019).
There were more than 500 patients confined on a single floor in the temple asylum in 2017. There were only seven workers and only one nurse to provide medical care without regular visits by the psychiatrist. Besides, the sanitation was insufficient in the building. In 2017, there was an outbreak of amoebic dysentery and pulmonary tuberculosis in the asylum. With the official intervention, the 503 nearly treatment-naive patients were evacuated from the temple. The patients were assigned to hospitals and started regularly receiving antipsychotic medications. Since early treatment is important in schizophrenia (Murru & Carpiniello, 2018), we wondered that if antipsychotics is still effective to these patients in the asylum for decades. This is a naturalistic study designed to evaluate the treatment outcomes of these patients evacuated from the folk therapy to conventional treatments.

Participants
The patients constrained in the temple asylum were recruited in the study. Most of the patients in the asylum did not regularly take antipsychotic medications (H. Y. Wang & Chou, 2019). Due to the outbreak of amoebic dysentery and pulmonary tuberculosis, these patients were evacuated from the asylum. After the official intervention, these 503 patients were assigned to many hospitals across the country and few of them returned home. The assignment of these patients is shown in Figure 1. These 253 patients were transferred to several hospitals in Kaohsiung city where the temple asylum is located. According to the official record, 253 patients were diagnosed with schizophrenia and other psychotic disorders with illness duration for more than 20 years. And they began to receive evidence-based antipsychotic medications and occupational training.
This study was approved by the Institutional Review Board (IRB) of Kaohsiung Municipal Kai-Syuan Psychiatric Hospital (KSPH-2018-05). All participants provided informed consent.

Outcomes
The following measures were assessed when admission and after 4-week treatment: the Mini Positive and Negative Syndrome Scale (Mini-PANSS), Comprehensive Occupational Therapy Evaluation (COTE) scale, self-care ability, cognitive function, activities of daily living (ADL) and Mini Nutritional Assessment (MNA).  Figure 1. The assignment of these patients evacuated from the temple asylum.
and Negative Syndrome Scale (PANSS) is a widely used scale for measuring symptom severity in schizophrenia (Kay et al., 1987). These patients were assessed with the Mini-PANSS in this study (Lin et al., 2018).
Occupational function was assessed with the COTE scale. The scale was graded with general behavior, interpersonal behavior and task behavior. Higher scores on the COTE scale showed the higher patient function (Chiu et al., 2019).
The self-care ability was assessed with the Self-care Ability Scale. This scale was evaluated with the areas of personal hygiene, eating habits, life in ward, medication adherence and money processing (Yang et al., 1996).
The MNA was used for evaluating the nutritional status of a patient. The MNA consisted of six items and was widely used to provide a single, rapid assessment of nutritional status in elderly patients at outpatient clinics, hospitals and nursing homes. A higher score manifested that the patient had a better nutritional status (Vellas et al., 1999).
The Mini-Mental State Exam (MMSE) is a widely used test for cognitive function. It was applied to screen the cognitive defects of the patients with psychosis (Ong et al., 2016).
The Family APGAR is a 5-item questionnaire and been used to evaluate the family function. The scale evaluated the support of family with the dimensions of 'Adaptability', 'Partnership', 'Growth', 'Affection' and 'Resolve'. It was used to evaluate these patients' family function (Sprusińska, 1994).

Data analysis
All statistical tests were presented with two-tailed tests, and the significance level was set at .05. All analyses were performed with SPSS software, version 17.0.

Results
After 4-week treatment, the 253 patients had statistically significant improvements in psychotic symptoms, occupational function and nutritional status. However, the selfcare ability made no difference after 4-week treatment compared to the ability when the patients were first admitted. The results mentioned above are shown in Table 1 to 3.
The psychotic symptoms of these patients were assessed by the Mini-PANSS. The mean score was 26.40 ± 7.48 when admitted. The score decreased to 24.84 ± 6.62 after 4-week treatment (p < .001). The results indicate that antipsychotic medication is still responsive to the chronic patients even though they had been nearly drug-naive.
The score of the COTE scale was 42.04 ± 20.08 when admitted and 44.91 ± 18.55 after 4-week training (p < .05). Although these patients had lived under a limited environment for decades, they showed improvements in occupational function after the regular training.
The score of self-care ability was 21.64 ± 7.87 when admitted and 21.97 ± 7.69 after 4-week treatment (p < .576). No obvious improvement in self-care ability after treatment was shown in the results.   With the application of the MNA, the score was 8.92 ± 1.77 when admitted. Such finding indicates that these patients were malnourished. The score was 9.66 ± 1.87 after 4-week hospitalization (p < .001). It is noteworthy that 129 patients were at risk for malnutrition initially and after 4-week treatment, only 101 patients were at risk, showing a 21.7% decrease. Similarly, 24 patients were severely malnourished initially, and after treatment, the number was lowered to 16, showing a 33.3% decrease.
The scores for the cognitive assessment were 15.17 ± 9.77 when admitted and 15.41 ± 10.06 after 4-week treatment, respectively; however, the difference was not significant (p = .615). The score of family function by APGAR was 1.58 ± 2.77 when admission and 1.67 ± 2.52 after 4-week treatment; nevertheless, the results were not statistically significant.

Discussion
The duration of untreated psychosis (DUP) is defined as the time from onset of the first psychotic symptom to the initiation of an adequate dose of antipsychotic treatment. It has been postulated that through some unknown mechanism, untreated psychosis has a toxic effect that patients with a longer DUP have poorer prognosis (Farooq et al., 2009;Marshall et al., 2005;Murru & Carpiniello, 2018). To some extent, the illness course of nearly drug-naive patients for decades is similar to dementia praecox, and such patients are rarely found in the developed country today. The significant finding of the study is that nearly drug-naive patients had statistically significant improvements in psychotic symptoms as assessed with the Mini-PANSS after receiving evidence-based psychiatric service for 1 month, even though they were untreated for decades. A longer follow-up continues to confirm such finding.
The Family APGAR score in this study suggested a severely family dysfunction of these patients. Severe mental illness such as schizophrenia may cause a variety of psychosocial challenges such as increased emotional burden and decreased quality of life of the patient's caregivers. When these patients were referred to the assigned hospitals for conventional treatment, the caregivers of these patients experienced shock and anger to the official and the assigned hospitals, because the caregivers had paid a considerable donation to the temple asylum in advance for lifetime care for these patients. The situation interfered the process that clinicians, patients and caregivers work together to make decisions and choose treatment options.
Only a few patients received training, such as folklore training or marching band training in the temple asylum. Other patients participated in activities with labor works, such as pig farming, chicken raising or clothing manufacturing. However, regular occupational trainings, such as attention training, hand-eye coordination or daily activities, are deficient. Nevertheless, there was a significant difference in occupational function (COTE scale) showing that these patients' conditions improved in occupational function after treatment.
There were no significant differences in MMSE in these patients. Cognitive impairment is an important clinical feature in many schizophrenic patients who may be influenced by many factors, such as sex, premorbid adjustment and education (Amminger et al., 2002;M. Y. Wang et al., 2016). It is a pity that the workers in the temple asylum were uncooperative in the intervention, and therefore, the premorbid information collection is obstructed. It further affects the interpretation of MMSE.
Contrary to our expectation, there was no statistically significant difference in self-care ability before and after treatment. One possible reason is that functional deterioration occurred in the chronic course of the illness. Furthermore, the patients were constrained under militarylike management in the temple asylum. Long-term institutionalization may also be interfered with the function impairment of self-care ability. It may take more time to train and improve self-care ability. An alternative reason may be the poor prognosis due to the duration of lack of treatment. Early treatment in psychotic patients may not only reduce the acute psychotic symptoms but also improve long-term outcomes (Murru & Carpiniello, 2018).
Most of these patients were malnourished for unknown reason when admitted to hospitals. Factors include (1) these patients had poor life management skills and missed the meal times; (2) the food supply was insufficient; and (3) these patients were vegetarians in the temple asylum out of religious concerns. Moreover, when the official intervention occurred, there were only seven workers and one nurse for these patients. The shortage of manpower may have exacerbated the poor meal intake because of the negative symptoms of chronic schizophrenia. A meta-analysis showed that patients with schizophrenia died earlier than the general population while men died earlier than women (15.9 vs 13.6 years). The factors of the shorter lifespan included life pattern disturbances and lack of means at regular times (Galletly, 2017). There was a significant improvement in MNA after 4-week treatment. The potential damage from malnutrition needs to be followed up for a longer period of time.
Proportionally of these patients were diagnosed with anemia, latent tuberculosis infection (LTBI) and hypoalbuminemia when admitted. Half of these patients suffered from Hepatitis A. The high prevalence rate of Hepatitis A confirmed that lack adequate sanitation in the temple asylum or poor hygiene practice of these patients.
Medical ethics provide principles and guidelines for the practice of clinical medicine and scientific research. 'Four principles' is a common framework and widely used in the analysis of medical ethics, including (1) autonomy, (2) beneficence, (3) non-maleficence: 'first do no harm', (4) equality (justice) (Beauchamp & Childress, 2012). The care model of the temple asylum is discussed with the above four principles. In another aspect, the outbreak of infective diseases illustrates the inadequate sanitary equipment and poor physical condition in the temple asylum. In 1982, a psychiatrist conducted a survey of the temple asylum with the official funding. The survey revealed that 60% of the patients had skin lesions, 40% had abnormal physical examinations and 30% had abnormal neurological examinations. In addition, a high ratio of patients had died of the infectious disease (Wen, 1990). The disputes regarding the temple asylum include the shortage of manpower, the inadequate sanitary equipment, the patient malnourishment and the outbreak of infectious diseases. The violation of medical ethics such as 'do no harm' is noteworthy. These patients were cared by licensed employees after admission instead of being cared by seven high functioning patients in the temple asylum. These patients were provided with treatment according to the treatment guidelines when admitted to the hospitals. While ethical issues involved, a case discussion would be held for determining the treatment manner.
The regulations and procedures of involuntary hospitalization vary in many countries. Generally, involuntary commitment regulations are based on the risk of the patient himself/herself or others (O'Brien et al., 2018). Patients with involuntary hospitalization often have an 'active psychotic state', they are 'incompetent to make decisions' and they are at 'risk of suicide or violence'. Even if a patient was hospitalized, the duration of inpatient treatment should be limited to the shortest possible period of time. It is provoked that in the temple asylum, most of the patients had lived in a controlled and limited building for decades. In addition, almost none of these patients provided with express hospitalization consent. The Mental Health Act (MHA) was enacted in 1990 in Taiwan and amended in 2007. According to the amendment of the MHA, a committee consisting of specialists in addition to psychiatrists is assigned to verify the compulsory admissions (Shieh et al., 2016). The number of involuntary admissions was reduced by 83% after the amendment of the MHA (Hsu et al., 2017). The patients had been constrained in the temple asylum for decades without informed consent, and they were not allowed to leave even when their psychotic symptoms subsided (H. Y. Wang & Chou, 2019). This situation is legally controversial.
Moreover, these patients had apparent psychotic symptoms and were therefore sent to the temple asylum by their family caregivers. The temple asylum was notorious for using a metal chain called 'emotional chain' (Chang & Lai, 2002). Even if the metal chain has a pleasant name, it is dangerous and deprives the basic human rights of the patients. It is reported that when patients escaped from the temple asylum, they were forced to return to the temple asylum and repeatedly chained. In 1984, a high-profile event occurred. A patient handcuffed with a metal chain escaped from the temple asylum and was misidentified as a fugitive. A residence nearby called the police, and the police force team was dispatched to pursue and capture the patient. The event aroused the social attention. Meanwhile, several lawmakers claimed that the temple asylum must exist because of inadequate medical resources. Such events accelerated the progress of the legislation of Taiwan's MHA and further contributed the increase in the acute beds and medical manpower.
There were some limitations in the present study. This is a cross-sectional study, and therefore, the causality cannot be well explained. There may be interrater differences. The psychotic symptoms of these patients were assessed by different psychiatrists, and interrater differences occurred. Due to the performance of the hospitals with pressure and bulk-loading, it is a pity that some data are not available. Moreover, the data in the study were based on data uploaded to official department by the assigned hospitals, and divergence of data submission. For example, one hospital provided data of Mini-PANSS but data of diagnoses were missing. More importantly, these patients were evacuated from the temple asylum by the public force without cooperation of the workers in the temple asylum. It is difficult to obtain the comprehensively premorbid information, function and clinical symptoms.

Conclusion
These psychotic patients were nearly drug-naive for decades and had significant improvements in psychotic symptoms, occupational function and nutritional status after evidencebased treatment for 4 weeks. There was no significant difference as anticipated in self-care ability after treatment, and such outcome may result from the chronic course of the disease with functional deterioration over time. Also, medical ethics need to be taken into consideration when the temple asylum did not offer the adequate manpower and sanitary equipment. It is continuously controversial that most of the patients had being living in this controlled and limited building for decades without their informed consent.

Author Contributions
H.Y.W. is the main writer of the manuscript and research project design and data management performer; J.J.H. is the policy maker and responsible person of the project; S.F.S. is the policy performer and partial data collection performer; S.H.H. is the data collector and patient evaluation performer; L.S.C. is the data collector and patient evaluation performer; and F.H.C. is the designer and responsible person of the research project, data manager and manuscript reviewer.

Availability of data and materials
The patients included in the trial were based on the evacuation program from the Department of Health, Kaohsiung City Government. This trial is not involved in blood sample storage.

Ethics Statement
The data involve collection of sensitive information; thus, any requests for access to the data must first be approved by the Institutional Review Board (IRB) of Kaohsiung Municipal Kai-Syuan Psychiatric Hospital (KSPH-2018-05).

Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.