Variations in involuntary hospitalisation across countries
Authors: Brendan D Kelly
Journal: The Lancet Psychiatry (2019)

In 1817, the UK House of Commons set up a Select Committee to study the plight of “the lunatic poor in Ireland”.1Select Committee on the Lunatic Poor in IrelandReport from the Select Committee on the Lunatic Poor in Ireland. House of Commons, London1817Google Scholar The evidence they heard, in the language of the era, was stark: “There is nothing so shocking as madness in the cabin of the peasant […] When a strong young man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin not high enough for the person to stand up in, with a crib over it to prevent his getting up, the hole is about five feet deep, and they give the wretched being his food there, and there he generally dies.” Subsequent laws led to the construction of psychiatric institutions in many countries during the 1800s and 1900s, rooted in the idea that if some of the people who were mentally ill were to be deprived of liberty, this deprivation was best done in accordance with explicit public legislation, rather than privately by families. The resultant history of psychiatry is a complicated story of custody and care.2Kelly B Hearing voices: the history of psychiatry in Ireland. Irish Academic Press, Dublin2016Google Scholar Even today, two centuries later, whether mental health laws fulfil their original objective—ie, to facilitate treatment in a fashion that maximises liberty, minimises suffering, and is equitable, accountable, and fair—is still unclear. Luke Sheridan Rains and colleagues3Rains LS Zenina T Dias MC et al.Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study.Lancet Psychiatry. 2019; (published online April 3.)http://dx.doi.org/10.1016/S2215-0366(19)30090-2Google Scholar add substantially to the literature on this topic by showing large, unexplained variations in patterns of involuntary hospitalisation in 22 countries across Europe, Australia, and New Zealand. The differences are great, varying from 282 involuntary hospitalisations per 100 000 people per year in Austria to 14·5 per 100 000 people per year in Italy. Although these findings are both convincing and consistent with previous literature, it is worth remembering that comparison across countries is difficult. In Italy, many people with mental illness are treated in residential facilities rather than hospital units, and these facilities are commonly excluded from bed-counts; when they are included, the number of beds in Italy is similar to that in the UK and elsewhere.4Burns T Franco Basaglia: a revolutionary reformer ignored in Anglophone psychiatry.Lancet Psychiatry. 2019; 6: 19-21Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 5Guaiana G Bastiampillai T Allison S O'Reilly R Basaglia's impact.Lancet Psychiatry. 2019; 6: 94-95Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar However, Rains and colleagues3Rains LS Zenina T Dias MC et al.Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study.Lancet Psychiatry. 2019; (published online April 3.)http://dx.doi.org/10.1016/S2215-0366(19)30090-2Google Scholar focus on involuntary hospitalisation and present a compelling case for substantial variations both across countries and over time, with annual rates increasing in some jurisdictions (eg, Spain) and decreasing in others (eg, Italy). These divergent trends lead to substantial variations between countries that appear comparable in other ways: the annual rate of involuntary hospitalisation in England is double that of Ireland—why?6Gilhooley J Kelly BD Return of the asylum.Br J Psychiatry. 2018; 212: 69-70Crossref PubMed Scopus (11) Google Scholar Rains and colleagues3Rains LS Zenina T Dias MC et al.Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study.Lancet Psychiatry. 2019; (published online April 3.)http://dx.doi.org/10.1016/S2215-0366(19)30090-2Google Scholar suggest that “overall there is no association between differences in legislation and rates of involuntary hospitalisation.” Their extremely useful comparison of legislation across jurisdictions certainly supports the idea that law as written cannot explain these differences, but it is, of course, the day-to-day operation of specific elements of law that has the greatest effect. For example, some patients find statutory mental health review panels so intensely unpleasant that they ask for their status to be changed from involuntary to voluntary hospitalisation solely to avoid the review process. In addition, most clinicians will be aware of colleagues with differing thresholds for applying legislation; not everyone who fulfils legal criteria for involuntary care is subjected to it and legal definitions can be difficult to apply in real-world settings. These variations in clinical practice are probably relevant to differences both within and between countries.7Gilhooley J Umama-Agada E Asghar M McManus S Whitty PF Kelly BD Voluntary and involuntary psychiatric admissions in a suburban area: comparison with national rates, diagnosis and other correlates of involuntary admission status.Ir J Psychol Med. 2017; 34: 243-249Crossref PubMed Scopus (7) Google Scholar Therefore, what are the take-home messages from this Article? The authors conclude that “these large variations do not seem to have clear relationships with any differences in clinical need” and suggest that possible explanations include “what alternatives to detention can be offered in the community or in the family, and societal responses to people with mental illness.” Rains and colleagues3Rains LS Zenina T Dias MC et al.Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study.Lancet Psychiatry. 2019; (published online April 3.)http://dx.doi.org/10.1016/S2215-0366(19)30090-2Google Scholar are correct; psychiatry, throughout its short history, has always had a strong social dimension, and the net of involvement and responsibility is broad. The key message for practitioners and policy makers is that involuntary admission can possibly be avoided in certain cases, if services, such as community clinics, outreach teams, and peer-led support, are available. We need more of these services. The key message for researchers is that we need greater understanding of the operation of law in clinical practice, rooted firmly in patient and family experiences. Finally, legislators should realise that mental health legislation is not immutable and needs regular review to reflect its evolving evidence base.8Wessely S Lloyd-Evans B Johnson S Reviewing the Mental Health Act: delivering evidence-informed policy.Lancet Psychiatry. 2019; 6: 90-91Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 9Kelly BD Dignity, mental health and human rights: coercion and the law. Routledge, Abingdon2015Google Scholar, 10Duffy RM Kelly BD India's Mental Healthcare Act, 2017: content, context, controversy.Int J Law Psychiatry. 2019; 62: 169-178Crossref PubMed Scopus (42) Google Scholar In 1891, the Committee on Lunacy Administration wrote, in the language of the times, that “good lunacy laws should make it possible to obtain care and treatment in asylums with ease, but they should make unnecessary detention difficult”.11Committee on Lunacy Administration (Ireland)First and second reports. Neill & Co for Her Majesty's Stationery Office, Edinburgh1891Google Scholar More than a century later, we still need to do better. During the conduct of their study, Rains and colleagues consulted me to clarify points regarding Ireland's mental health legislation. Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative studyVariations between countries were large and for the most part unexplained. We found a higher annual incidence of involuntary hospitalisation to be associated with a lower rate of absolute poverty, with higher GDP and health-care spending per capita, a higher proportion of foreign-born individuals in a population, and larger numbers of inpatient beds, but limitations in ecological research must be noted, and the associations were weak. Other country-level demographic, economic, and health-care delivery indicators and characteristics of the legislative system appeared to be unrelated to annual involuntary hospitalisation rates. Full-Text PDF Open Access