Involuntary Hospitalization More Likely With Psychosis Diagnoses and Few Resources

New study links involuntary hospitalization with psychotic diagnosis, previous involuntary hospitalization, and economic deprivation.

Micah Ingle, MA
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A recent study published in Lancet Psychiatry explores associations between involuntary hospitalization and factors at the patient and area levels. The authors conducted a systematic review, a meta-analysis, and a narrative synthesis to better understand these associations. Among the findings were links between involuntary hospitalization and individuals receiving diagnoses of psychotic disorders, having had previous hospitalizations, and having experienced economic deprivation.

“Involuntary admission to hospital for psychiatric care can be lifesaving and perceived as beneficial in the long term for some people. Yet, the experience of involuntary admission can be traumatic, frightening, stigmatizing, and lead to long-term avoidance of mental health support and increased risk for further coercion as an inpatient,” explain the authors, led by Dr. Susan Walker.

“Rates of involuntary hospitalization vary greatly worldwide and, in several European countries (including the UK), the number of people detained in psychiatric hospitals has risen substantially in the past three decades. The reasons for these international variations and increases in rates of involuntary hospitalizations cannot be accounted for fully by legislative diversity or differences in rates of severe mental illness, and remain largely unexplained.”

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Some psychiatric professionals have questioned the ethics of involuntary hospitalization, and it has been posed as a human rights violation by UN officials. Involuntary hospitalization has been linked to increased risk of suicide. Hospitalization, in general, has also been indicated as a factor in increased risk of suicide. Previous research has found associations between involuntary hospitalization and “being a young man, homeless, unemployed and affected by schizophrenia or by an organic mental disorder.”

The current article adds to existing literature that examines associations between involuntary hospitalization and clinical as well as social factors. The authors searched multiple databases, from January 1, 1983, to August 14, 2019, to catalog the attributes of individuals who have undergone voluntary as well as involuntary hospitalization. A total of 77 studies from 22 different countries were included in the review. The data from these studies were analyzed using random-effects meta-analysis as well as narrative synthesis procedures.

The authors note that this article should be considered in tandem with a companion piece that looks at ethnic grouping and involuntary hospitalization. The results of that study report that black, Asian, and minority ethnic groups and migrant groups in the US and UK are at a higher risk for psychiatric detention.

“Some factors that have been implicated in the risk for involuntary psychiatric hospitalization include a diagnosis of psychosis, male gender, risk of aggression, absence of alternative community services, and socioeconomic deprivation. However, research to date has been inconclusive and the factors associated with involuntary hospitalization remain poorly understood. To our knowledge, no international systematic review or meta-analysis of the risk factors for involuntary psychiatric hospitalization has been done. We aimed to assess the current evidence for the associations between clinical and social factors (with the exception of ethnic origin, which we have reviewed previously) and involuntary psychiatric hospitalization.”

This study included individuals from 18 “high-income countries” such as Australia, Canada, Israel, the U.S., and several European nations. Four “middle-income” countries were represented: Brazil, China, India, and Turkey. A total of 975,004 patients were represented in the meta-analysis, and 23% (228,239) had been committed involuntarily.

Several demographic characteristics were discovered for those who experienced involuntary psychiatric hospitalization. These included being male, being unemployed, being on welfare services, renting rather than owning a home, being single or previously married, and most significantly, having a diagnosis of psychosis or bipolar disorder as well as having had a previous involuntary hospitalization.

Both of these factors, more than doubled the chances of involuntary hospitalization. The exact reasons for the association between psychosis and involuntary hospitalization remain unclear. With previous hospitalization, the authors suggest that these experiences can be traumatic and may “negatively affect future engagement with mental health services.”

“This factor might mean that people who have previously been detained do not seek help until the point of crisis, when a further involuntary hospitalization might be needed.”

The authors suggest some evidence-based remedies to these issues, such as increased crisis-planning interventions for those diagnosed with psychotic and bipolar disorders. In contrast, psychiatric diagnoses such as depression, mood disorder, anxiety, personality disorder, or neurosis were associated with voluntary hospitalization.

Eight studies found that lack of insight was also strongly associated with involuntary hospitalization, though only two of these studies reported on how insight was measured. “Poor treatment compliance” was linked to involuntary hospitalization in six of the studies, while two studies found no effect.

“Risk to self” was widely reported to be a significant factor in involuntary hospitalization. It was unclear how risk to self was determined, i.e., whether this related to previous self-harm or suicide attempts or rather expressions of suicidal ideation. Nine of the studies linked suicidal behavior to voluntary rather than involuntary hospitalization. Five studies found a correlation between the risk to self and involuntary admission, while 17 studies found no association.

Eighteen studies reported risk to others as a positive association with involuntary hospitalization. Still, again, assessment of “risk to others” was inconsistent across the studies, with many failing to use formal methods of evaluation.

Seven studies reported an association between social support and involuntary hospitalization, although these studies measured social support in different ways. One study used a formal measure of social support, the Oslo social support scale. It discovered that “higher levels of perceived social support were independently linked to a lower probability of involuntary hospitalization.” Other studies relied on self-report of perceived social support or number of family visits during hospitalization. Five studies in total found an association between limited social support and involuntary admission, while two found no effect.

The logistics and quality of community care were analyzed in a handful of studies. One German study found a link between the availability of in-home care and lower rates of involuntary hospitalization. A study in the UK found that the availability of “alternative, less restrictive forms of care” was a major factor in determining the necessity of involuntary hospitalization. However, an additional population-based study in England found that areas with highly rated community services also had a higher number of involuntary admissions, muddying the waters in terms of this association.

Four studies examined the relationship between area-level economic deprivation and involuntary hospitalization. Findings from three of the studies, performed in the UK, showed that the “greater the level of area deprivation, the higher the rate of involuntary psychiatric hospitalization.” The fourth study, from Germany, also found an elevated risk of involuntary hospitalization in areas with significant unemployment, high population density, and greater wealth inequality.

The authors note several limitations to their article. Most of the findings come from high-income countries, limiting the ability to generalize to other settings, although the studies do represent a diversity of different legal and healthcare systems. Additionally, the authors restricted their search to quantitative studies, leaving out potentially insightful qualitative findings on “clinical decision-making processes and service-user and carer experiences of inpatient psychiatric care and pathways into it.” Relatedly, the data analyzed were focused on population-based characteristics rather than individual experiences.

Furthermore, many patients who undergo voluntary admission to psychiatric hospitals feel coerced as well, while some who undergo involuntary hospitalization do not, which complicates the overall picture.

The authors conclude:

“We have identified potential target groups for interventions to prevent or reduce use of involuntary care. This targeting is imperative as the importance of liberty and autonomy over paternalism and authority is increasingly recognized and prioritized within mental health policy and practice internationally. Further research needs to focus on confirming prospectively in current cohorts the risk factors for involuntary hospitalization; elucidating the mechanisms that underpin these risk factors at individual, group, service and area level; and using this evidence to inform the development and implementation of targeted strategies to reduce the use of involuntary treatment and to improve equity of access to mental health care.”

“This work should occur alongside fine-grained research into the processes implicated in clinical decision making around involuntary hospitalization, including assessments of risk and insight, and the experiences of individuals subject to involuntary psychiatric hospitalization.”

 

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Walker, S., Mackay, E., Barnett, P., Sheridan, R. L., Leverton, M., Dalton-Locke, C., Trevillion, K., Lloyd-Evans, B., Johnson, S. (2019). Clinical and social factors associated with increased risk for involuntary psychiatric hospitalization: A systematic review, meta-analysis, and narrative synthesis. Lancet Psychiatry, (6)12, 1039-1053. (LINK)

 

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Micah Ingle, MA
MIA Research News Team: Micah Ingle is a doctoral student in Psychology: Consciousness and Society at the University of West Georgia. He has published on therapeutic approaches centering the person-in-context, as opposed to the individualizing medical model, and on the characteristics of people high in empathy. His current interests include the intersection of sociopolitical/economic structures and mental health, individualism in psychology, gender, liberation psychology, and mythopoetic perspectives inspired by Jungian thought.

7 COMMENTS

  1. Suffice it to say that I would never bow to authority, because I do nothing wrong on a legal level. The UN should be ashamed of themselves. They remain pretty much useless. Suicide is a pretty extreme escape but people will often act upon what choices they have left and they have rights to make those choices. If you provide no choice and basically rule society, something has gone very wrong. A man shows up at psychiatry in distress, does psychiatry say “You have two options, you can come here to be safe until it blows over”, or , you are sick and now we ‘diagnose’ and medicate, because we don’t believe in a get better system, and before you leave, we need to tag you, and send you home with meds that will hurt you. But best you stay here for a few days so we can give you an antipsychotic, after which we may keep you longer. We need you to get insight into your “illness”. You might feel suicidal, but the meds are not what caused it, but don’t talk about that because then we keep you longer. But don’t be afraid of being caged and drugged. Pretty soon we will have you docile. When you leave, don’t ever have anxiety or any other upsets, but if you do, you can come back for your safety and compassion.

  2. My son works as a student support for an alternative school. His job requires him to pick the kid/kids up to bring them to their school. Just the other day he went to pick up a child in a low income neighbourhood, and as he parks in front of the side by side house, a van pulls up behind him. A teenage girl jumps out of the van and frantically pounds on his car window. My son rolls down the window and the girl says “my brother is beating up me and my gram, call 911”. So my son calls 911 and as he is on the phone, the son who is in the house, slams his head through the glass window. My son is still talking to 911 and 911 heard the shattering of the window. Then the family gets into the van and my son says they are leaving, so 911 asks my son to get the licence which my son did. My son was just hoping that his kid wasn’t going to come to his car while all this was going on. He then proceeded to get his kid to take him to school. My son said someone obviously HAD to intervene, as people were at risk. I asked how old the person in distress was and it appeared to be a teen, maybe 14 but big for his age. No one had an alternative, and we know where he is going to deal with his distress. The only place a teen should ever wind up is in a safe place without drugs. If he is aggressive, they could easily put him in a safe room. I absolutely disagree with forced drugs. In so many people’s lives the acting out in anger is either frustration or street drugs or a combo. You can’t solve it by more drugs. It needs intervention but not a violence (which forced drugging is) in return. It is nothing more than temporary and does nothing to keep anyone safe. It should definitely be a human rights concern. To be a teen and be so frustrated and angry, and with his mind still growing, society can’t just drug and pretend the problem goes away. It could get much worse. The money spent could be spent in much better ways.
    My son tells me that some foster parents make 9,000 per month for a high needs kid. Why? It lures pretend do gooders to foster. Why not spend that money and pay a trained person to work from inside the kid’s home? Pulling families apart most often just results in more pain. The systems in place are aware it fails, so why stick to it without change? The sign of insanity is doing the same crap over and over, even though it is not working. Kids/adults are poisoned by drugs and diagnosis only to end up on disability which again is funded. Our whole system is designed for failure. That teen who pounded his head through the window, now has a good description of being “unpredictable”. But that is only ONE part of him. The other parts are not looked at and fostered. So it always becomes about treating the unwanted thing, but not about bringing out the desired to the forefront, yet psychiatry touts neuroplasticity and create drugs that kill that ability. It is an ABSOLUTE that nothing is stagnant. They have the ability to make it better for people, but they lack insight into human experience and everything in it’s path becomes a pathology. If reasoning exists, a psychiatrist would have the insight into problems. His lack of options, show how narrow his views are. Psychiatry adopts rigid behaviour and I am really starting to believe that it is because of an inability to think and create without pathologizing. To be rigid in thought, creates rigid societies, that stay the way they are despite evidence that people suffer. Psychiatry needs to either go away or become human enough to realize that we really cannot overpower others nor label them as somehow being faulty, because looking for fault has no end within a society where each one of us is deeply unique. Psychiatry knows that to pretend that they are the sane who need to suggest that the opposite of them is “sick’, is a sick and grandiose view.