Unlocking the mentally ill in Indonesia: An empirical study of the effectiveness of a “Bebas Pasung” program in Central Java

Background Locking or confinement of persons with severe mental illness has been common in Indonesia. In 2010, the Ministry of Health declared a policy that persons who were locked ( pasung ) should be unlocked or freed ( bebas ) from confinement and provided mental health services. This study is an empirical evaluation of the effectiveness of one Bebas Pasung program in Indonesia at two-year follow-up. Methods From medical records in Soerojo Mental Hospital, Magelang, Central Java, 114 persons with severe mental illness who had been unlocked, treated, and returned to the community from four districts served by the hospital were identified. At two-year follow-up, 62 caregivers were able to be contacted and willing to participate in a study. Data were collected from hospital records about condition of the patient at time of ‘unlocking’ and at discharge, and primary caregivers were interviewed about the previous locking and care of the patient since return, as well as experiences of caregiving. Results We provide descriptive data concerning history of illness, reasons for locking, type of confinement, and care of the individual since return. 58% of those unlocked were men, 80% had diagnoses of schizophrenia, and mean age was 35. At follow-up, 24% of this sample had been re-locked; only 44% took medications regularly, including 33% of those re-locked and 47% of those not relocked. A majority cared for themselves, half were partially or fully productive, and the quality of life of family caregivers improved significantly since their family member was unlocked, treated, and returned home. Conclusions This program successfully unlocked, treated, and returned to their homes persons with severe mental illness living in pasung or restraints. Findings suggest such unlocking programs need to be linked more closely to community-based mental health and rehabilitation services, maintain care of the patient, and provide a path toward recovery. ### Competing Interest Statement The authors have declared that no competing interests exist. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the ethics review boards of Harvard Medical School Protocol#: IRB13-0191 Submission#: CR13-0191-02 and the Soerojo Mental Hospital Ethical Clearance Number TEC/005/IV/2012. The study also gained the permission from the District of Integrated Licensing Services of the research sites. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable For approved reasons, some access restrictions apply to the data underlying the findings. Given the sensitivity of the data and the fact that data are not formally de-identified owing to on-going research, sharing of the data requires IRB approval for researcher who meet the criteria for access to confidential data. Data on the specific variables in this study are available upon request and requests may be sent to the corresponding author.