Risk factors for involuntary psychiatric hospitalisation
Authors: Lisa Brophy, Cath Roper, Kellie Grant
Journal: The Lancet Psychiatry (2019)

In The Lancet Psychiatry, Susan Walker and colleagues1Walker S MacKay E Barnett P et al.Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesis.Lancet Psychiatry. 2019; 6: 1039-1053Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar report findings of a systematic review, meta-analysis, and narrative synthesis of 77 studies from 22 countries, providing valuable data on risk factors for involuntary psychiatric hospitalisation. These findings will substantially contribute to addressing gaps in knowledge about international and intranational variations in use of involuntary psychiatric hospitalisations and to development of interventions to reduce these hospitalisations. Walker and colleagues identified that previous involuntary hospitalisation and diagnosis of a psychotic disorder present the greatest risks for further compulsory treatment, which is a very helpful finding because it highlights opportunities for preventive interventions. The experience of coercion, or being subjected to restrictive interventions associated with involuntary admission, can lead to disengagement with mental health services, setting up an ongoing cycle of involuntary admissions. Interrupting this potentially spirit-breaking2Deegan P Spirit breaking: when the helping professions hurt.Humanist Psychol. 1990; 18: 301-313Crossref Scopus (111) Google Scholar cycle demands attention. The UN Convention on the Rights of Persons with Disabilities recommends that involuntary treatment should be ceased because it constitutes discrimination on the basis of disability.3Maylea C A rejection of involuntary treatment in mental health social work.Ethics Soc Welf. 2017; 11: 336-352Crossref Scopus (19) Google Scholar Regardless of the rationale for its use, there is growing recognition that involuntary treatment poses a risk to the dignity, human rights, and equality before the law of those affected.3Maylea C A rejection of involuntary treatment in mental health social work.Ethics Soc Welf. 2017; 11: 336-352Crossref Scopus (19) Google Scholar Hooff and Goossensen4Hooff S Goossensen A How to increase quality of care during coercive admission? A review of literature.Scand J Caring Sci. 2014; 28: 425-434Crossref PubMed Scopus (22) Google Scholar analysed 22 reports on involuntary treatment, in which the views of detained patients were examined, and the most common theme of qualitative studies was that patients experienced feelings of not being listened to. They concluded that listening to patients and actively eliciting their views on treatment is essential. Attempting to understand how people experience their own involuntary treatment is not legislated as part of the involuntary treatment process, and this omission warrants reflection. Walker and colleagues report that risk of harm to others was associated with involuntary admission, despite inconsistency in how risk was assessed between studies (with many studies not reporting how risk was measured) and low use of formal scales. Although this lack of transparency poses a problem, we caution against the view that the solution lies in greater standardisation between studies and consistent use of formal risk assessment scales, particularly in the context of evidence to suggest that risk of harm to self and others cannot be usefully assessed.5Large M Ryan C Callaghan S Paton MB Singh SP Can violence risk assessment really assist in clinical decision-making?.Aust N Z J Psychiatry. 2014; 48: 286-288Crossref PubMed Scopus (20) Google Scholar, 6Mulder R Newton-Howes G Coid JW The futility of risk prediction in psychiatry.Br J Psychiatry. 2016; 209: 271-272Crossref PubMed Scopus (70) Google Scholar Bigger questions need to be addressed, such as whether a focus on risk prediction in psychiatry is truly beneficial.6Mulder R Newton-Howes G Coid JW The futility of risk prediction in psychiatry.Br J Psychiatry. 2016; 209: 271-272Crossref PubMed Scopus (70) Google Scholar In Walker and colleagues' study, poor adherence to treatment and poor compliance with medication before admission were associated with involuntary rather than voluntary admission in six of eight studies that reported on treatment adherence. Non-adherence to treatment can, arguably, be seen as a facet of insight: who decides what constitutes an acceptable treatment approach? Eight studies of moderate to high quality reported an association between lack of insight and involuntary hospitalisation. Of these, only half reported how insight had been measured, and variance in assessment approaches occurred. The idea of insight in clinical assessments has been critiqued on the grounds of imprecision and pathologisation of disagreements and non-medical understandings of people's experience, as pointed out in the lived-experience commentary by Rachel Rowan Olive and Patrick Nyikavaranda in Walker and colleagues' Article. When the concepts of insight and incapacity are used together they can instigate involuntary status and nullify an individual's own worldview—how they think, speak, and understand—if it does not accord with a clinical view.7Beaupert F Freedom of opinion and expression: from the perspective of psychosocial disability and madness.Laws. 2018; 7: 3Crossref Google Scholar Dispensing with the current concept of insight in favour of remaining curious and cultivating a lay sense of insight could be a fruitful way forward.8Hamilton B Roper C Troubling ‘insight’: power and possibilities in mental health care.J Psychiatr Ment Health Nurs. 2006; 13: 416-422Crossref PubMed Scopus (30) Google Scholar The perspectives raised in the lived-experience commentary were especially useful and authoritative. Co-production of research with people who have lived-experience is imperative, particularly when service users' rights are at stake.9Sunkel C Saxena S Rights-based mental health care.Lancet Psychiatry. 2019; 6: 9-10Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Involving people with lived-experience in the identification of problems and conduct of research is vital to developing high-quality and relevant solutions. Walker and colleagues' findings offer valuable perspectives that could guide population-level interventions. In view of what is known about the effect of structural-level inequalities in power, money, and resources within countries, it is worth pausing to consider whether tackling diseases or risk factors at the individual level is the best approach.10Friedli L Speaking allowed: the political voice of public health.Zdr Varst. 2012; 51: 5-7Google Scholar Walker and colleagues' findings suggest a need to target the social determinants of involuntary treatment, with three studies examining area-level deprivation and all finding that greater area-level deprivation led to increased rates of involuntary admissions. We concur that more fine-grained research is needed in this area. We declare no competing interests. Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesisPrevious involuntary hospitalisation and diagnosis of a psychotic disorder were factors associated with the greatest risk of involuntary psychiatric hospitalisation. People with these risk factors represent an important target group for preventive interventions, such as crisis planning. Economic deprivation on an individual level and at the population level was associated with increased risk for involuntary hospitalisation. Mechanisms underpinning the risk factors could not be identified using the available evidence. Full-Text PDF Open Access