The rate at which Americans are held against their will and forced to undergo mental health evaluations and even state-ordered confinement – lasting anywhere from a few days to years – has risen sharply over the past decade, according to a new study by researchers at the UCLA Luskin School of Public Affairs.
The analysis, published online today in the journal Psychiatric Services, shows that in the nearly half of U.S. states for which data was available, involuntary psychiatric detentions outpaced population growth by a rate of three to one on average in recent years.
The study is the most comprehensive compilation of data on involuntary detentions to date, the researchers say, an undertaking made more challenging by the lack of a national data set on the topic and longstanding inconsistencies in reporting across states and jurisdictions.
“This is the most controversial intervention in mental health – you’re deprived of liberty, can be traumatized and then stigmatized – yet no one could tell how often it happens in the United States,” said David Cohen, a professor of social welfare at the Luskin School, who led the research. “We saw the lack of data as a social justice issue, as an accountability issue.”
While each state has its own laws governing these detentions, nearly all specify that people who have not been accused of a crime but who may pose a danger to themselves or others or can’t take care of themselves – because of mental illness or substance abuse – can be detained in an authorized facility, usually a hospital, Cohen said.
An initial evaluation can last several days, but detention can be extended at the discretion of mental health professionals.
Cohen and his co–lead author, Gi Lee, a social welfare doctoral student at the Luskin School, scoured health and court websites for all U.S. states and were able to cull usable counts on emergency and longer-term involuntary detentions from just 25 of them for the period from 2011 to 2018.
In those 25 states, they found, annual detentions varied from a low of 29 per 100,000 people in Connecticut in 2015 to a high of 966 in Florida in 2018.
Twenty-two of those states had continuous data from 2012 to 2016, and the authors found that during this five-year span, the average yearly detention rate in these states increased by 13%, while their average population grew by just 4%, the authors say Further, using data from 24 states that make up 52% of the country’s population, the researchers calculated a rate of 357 emergency involuntary detentions per 100,000 people in 2014 – a total of 591,000 detentions.
“If you think that coercion is necessary in mental health, then a rise in detention rates may be welcome news, a sign that society is doing whatever it takes to help people in crisis and keep order,” Cohen said.
“But if you think that coercion is punishment, that we need services to prevent or defuse crises in families and society before they get out of control, then a rise is a bad sign.”
One of the most common triggers for a detention is a threat of suicide, said Cohen, who noted that the detentions often involve law enforcement personnel.
“The process can involve being strip-searched, restrained, secluded, having drugs forced on you, losing your credibility,” Cohen said. “For people already scarred by traumatic events, an involuntary detention can be another trauma.”
The rate of suicide is high for people recently released from psychiatric hospitalization, but how many of these hospitalizations are involuntary is not known, nor is it clear whether such detentions may play a protective or risk-increasing role in suicide.
Likewise, while former involuntary detainees interviewed in previous studies have expressed both gratitude and resentment, data on the lasting effects of being coerced into a facility for psychiatric treatment is scarce, the authors say.
“These studies have mostly focused on subjective experiences of psychiatric detention, which are important to understand,” Lee said. “However, not much is known about more objective outcomes of psychiatric detention—on employment, education, contact with the criminal and juvenile justice systems, and others.”
Still, the authors stress that their study is not about whether involuntary psychiatric detention helps or hurts but about determining precisely how often it occurs in the U.S. in the hopes of spurring a national discussion on these issues. That, say Cohen and Lee, will come with more data.
Despite the current limitations, the researchers gleaned several other important findings from the available data:
Among the eight states that provided data on longer-term detentions, average annual rates over time ranged from lows of 25 (Oklahoma) and 27 (Missouri) per 100,000 people to highs of 158 (Virginia) and 159 (California).
These longer-term detentions were, on average, 42.2% of the eight states’ rate of all emergency detentions.
24 of the states studied comprised 52% of the U.S. population in 2014.
Five of them – Florida, California, Massachusetts, Texas and Colorado – accounted for 59% of the population of those 24 states but were responsible for 80% of the total detentions that year.
While only six states provided information on the detention of minors, the researchers believe even this partial data is the most complete glimpse yet of the involuntary detention of minors in the U.S.
“Greater transparency in data would not only lead to a better understanding of the epidemiology of psychiatric detentions in the U.S.,” Lee said, “but could help determine to what extent commitment is a last resort.”
Involuntary hospitalization and other coercive measures are highly critical aspects of mental healthcare. They are used to handle acute situations of danger to the patients themselves or to others. However, coercive measures themselves can cause severe harm to patients and staff [1].
There is broad societal, ethical and medical consensus that the use of all kinds of coercion should be restricted as far as possible in mental healthcare [2–4].
A recent study reported a high variation in involuntary hospitalization rates across 22 European countries, Australia and New Zealand [5]. Countries with higher health care spending per capita, lower absolute poverty and a larger proportion of foreign-born individuals in the population appeared to have higher detention rates.
Germany had roughly the third highest rate of involuntary hospitalization among the countries included in this study [5].
In order to target preventive interventions against involuntary admission and other coercive measures, it is important to identify modifiable risk factors, which exist on different levels and encompass patient-related clinical and sociodemographic as well as socioeconomic factors, quality of mental health services and emergency services, factors related to the social environment, and laws and the way how municipal courts and police services are organized.
On the individual level, there has been consistent evidence for people with schizophrenia or other psychotic disorders [6–8] and people with previous experience of detention [9, 10] to be at high risk for involuntary admission. There is some indication that risk may be also high for people with bipolar disorder, dementia and other organic mental disorders [11, 12], although this evidence has been less consistent.
Low motivation for treatment, marked severity of symptoms, low insight into the disorder and being a danger to others were shown as common risk factors for detention among the different diagnostic groups [6, 13–16].
In terms of sociodemographic factors, male gender and migratory background have been most commonly associated with involuntary admission [6–8, 12, 17]; however, the evidence for the impact of male gender has been inconsistent across studies in different countries and continents and may depend on societal factors [13, 18].
Evidence for the impact of other sociodemographic and socioeconomic characteristics on the patient-level has been even less consistent. Altogether, there is some indication that being unemployed or homeless, receiving disability pension or social benefits, being a member of a lower social class and having a lower level of education and poor social support may be associated with higher risks for involuntary hospitalization [9, 12, 19–21].
On the level of social environment, living in urban regions with high population density and living in socially deprived areas with a high unemployment rate, small household size and high percentage of immigrants were identified as risk factors for detention [7, 9, 22, 23].
On the organizational level of mental health services, longer waiting times for regular services and lower levels of service integration were shown to increase the risk of being hospitalized involuntarily [22, 24].
Furthermore, being admitted outside of regular service hours, i.e. at night or during the weekend, was associated with compulsory admission [11, 20, 25]. Finally, on the level of legal frameworks and regulations, the mandatory involvement of a legal advisor in the procedure of detention was shown to be associated with fewer involuntary admissions in EU countries [6].
According to a recent meta-analysis, the two most important predictors for involuntary admission were a history of previous detention and a diagnosis of a psychotic disorder [10]. Other risk factors were receiving welfare benefits, being diagnosed with bipolar disorder, single marital status, unemployment and male gender (in order of effect size).
Furthermore, a higher degree of socioeconomic deprivation of the living area was found to be associated with higher rates of involuntary treatment [10].
Most studies used a retrospective design and analyzed preexisting, routinely collected data from medical case and/or administrative files of one or more hospitals. Few studies analyzed data from public sources, e.g. Mental Health Act registers, or national health reports.
Some studies used prospective designs analysing data from consecutively admitted cases [9, 13–16, 20, 26–28] and they included non-routine data such as ratings on symptom severity or insight and patient self-reports on perceived social support and other relevant aspects. Hence, studies using different data sources and study designs focused on different possible risk factors.
To our knowledge, only one recent study of our group used machine learning (ML) procedures in order to explore the hierarchy and possible interactions between different risk factors for involuntary hospitalization [17].
In our previous retrospective study, we analyzed the health records of all persons treated as in-patients under the Mental Health Act in the four psychiatric hospitals of the metropolitan City of Cologne in Germany in the year 2011. We compared these records with the records of voluntary cases from the same hospitals and the same time period [17].
We extracted medical, sociodemographic and socioeconomic data from the records of 5764 cases and constructed a prediction model employing a decision tree method (chi-squared automatic interaction detection (CHAID)).
The patient’s main diagnosis upon hospital admission was found to be the strongest predictor of involuntary hospitalization, indicating high risks for people with dementia or other organic mental disorders (ICD10: F0), schizophrenia and other psychotic disorders (ICD10: F2), and mental retardation (ICD10: F7).
Other predictors were lack of outpatient treatment prior to admission, previous suicide attempts, suicidal behavior upon admission, admission outside of regular service hours, and the hospital that patients were admitted to. In addition, migratory background, marital status and professional education were also identified as risk factors for detention.
The highest risks of involuntary hospitalization were found for patients with a diagnosis of organic mental disorders (ICD 10: F0) who were married or widowed, and for patients with a non-organic psychotic disorder (ICD10: F2) or mental retardation (ICD10: F7) who had a migratory background.
There was some impact of the individual sociodemographic and socioeconomic factors on the risk for involuntary admission, but this impact was lower compared to the impact of the psychiatric diagnosis. The impact of environmental socioeconomic factors was not assessed, as the data set did not include any characterization of the patients´ living areas [17].
The goal of the present study is to improve the predictive decision tree model for involuntary psychiatric in-patient treatment by optimizing ML techniques and by broadening the data set to not only include factors on the individual level, but also environmental socioeconomic data (ESED) as factors that may contribute to the rate of involuntary psychiatric hospitalization.
An improved predictive model should lead to more robust findings, which may be more valid. The insight derived from this analysis may help to formulate a more comprehensive risk model for involuntary psychiatric hospitalization and to design better-targeted preventive measures to reduce the rate of involuntary admissions to psychiatric hospitals.
reference link : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414567/
More information: Gi Lee et al. Incidences of Involuntary Psychiatric Detentions in 25 U.S. States, Psychiatric Services (2020). DOI: 10.1176/appi.ps.201900477
