Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth

Gender-specific pathways in mental health crisis in adolescents, from consultation to (in)voluntary admission: a retrospective study

BACKGROUND

A strong increase in mental health emergency consultations and admissions in youths has been reported in recent years. Although empirical evidence is lacking, gender differences in risk of admission may have contributed to this increase. A clearer understanding of the relationship, if any, between gender and various aspects of (in)voluntary care would help in more evidence-based service planning.

METHODS

We analysed registry data for 2008-2017 on 3770 outpatient emergencies involving young people aged 12 to 18 years from one urban area in the Netherlands, served by outreaching psychiatric emergency services. These adolescents were seen in multiple locations and received a psychosocial assessment including a questionnaire on the severity of their problems and living conditions. Our aims were to (a) investigate the different locations, previous use of mental health service, DSM classifications, severity items, living conditions and family characteristics involved and (b) identify which of these characteristics in particular contribute to an increased risk of admission.

RESULTS

In 3770 consultations (concerning 2670 individuals), more girls (58%) were seen than boys. Boys and girls presented mainly with relationship problems, followed by disruptive disorders and internalizing disorders. Diagnostic differences diminished in hospitalisation. More specifically, disruptive disorders were evenly distributed. Suicide risk was rated significantly higher in girls, danger to others significantly higher in boys. More girls than boys had recently been in mental health care prior to admission. Although boys and girls overall did not differ in the severity of their problems, female gender predicted admission more strongly. In both boys and girls severity of problems and lack of involvement of the family significantly predicted admission. Older age and danger to others significantly predicted admission among boys, whereas psychosis, suicidality and poor motivation for treatment predicted admission among girls.

CONCLUSION

There are different pathways for youth admission, which can partly be explained by different psychiatric classifications as well as gender-specific differences with regard to age, suicide risk, danger to others and the influence of motivation for treatment. Finally, for both genders, family desire for hospitalisation is also an important predictor.

Position Paper: fragmented youth healthcare services in the Netherlands endanger treatment of teenage boys with psychiatric disorders

For children who show strongly deviant behaviour in the Netherlands, a distinction is made between behavioural problems and psychiatric problems. As a result, two different domains have emerged over time, each with its own legal frameworks and inclusion and exclusion criteria. Consequently, there is no well-organized, coherent system for youth mental health care in the Netherlands. This strong dichotomy raises the question whether patients are being admitted to facilities where they are receiving appropriate care. In addition, referral bias can arise, because the type of complaint with which a young person presents is often dependent on the type of coping of the individual and thus, in turn, the gender of the patient. In this Position Paper, we examined the gender distribution at a youth psychiatric high and intensive care (HIC-Y) and other streams of youth care in the Netherlands to explore possible inequities in access to psychiatric care among children and adolescents. Results show that girls are significantly more likely than boys to be admitted to the HIC-Y for suicidal thoughts, self-harm and emotional dysregulation. In fact, girls account for 80% of all admissions, while boys account for only 20%. In contrast, regional and national reports from youth services and probation show a majority of boys being admitted (56-89%). The way care is organized (lack of cross-domain collaboration and the interplay between gender-dependent coping and exclusion criteria) seems to play a role in the underrepresentation of boys in acute psychiatry and their overrepresentation in secure youth care. Based on our research results, the concern is raised whether boys have a greater chance of undertreatment for psychiatric problems. Further research is needed to better understand the underlying factors that contribute to gender bias in psychiatric admissions, and to develop interventions that promote gender equality in healthcare.

Detention of children and adolescents under mental health legislation: a scoping review of prevalence, risk factors, and legal frameworks

BACKGROUND

For individuals with severe mental illness, involuntary assessment and/or treatment (hereafter detention) can be a necessary intervention to support recovery and may even be lifesaving. Despite this, little is known about how often these interventions are used for children and adolescents.

METHODS

This global scoping review set out to: (1) map the current evidence around mental health detentions of children and adolescents (< 18 years); (2) identify the clinical, sociodemographic, and behavioural factors associated with detention; and (3) document the views of professionals and young people on the implementation of mental health legislation.

RESULTS

After searching databases of peer-reviewed literature and citation chaining, 42 articles from 15 jurisdictions were included. About one fifth of psychiatric admissions in national register data were detentions, however trends were only available for a few high-income Western countries. The circumstances justifying detention and the criteria authorising detention varied between studies, with a mix of clinical factors and observed behaviours reported as the reason(s) warranting/precipitating a detention. Particular groups were more likely to experience detention, such as children and adolescents from minority ethnic communities and those with a documented history of abuse. There was a notable absence of qualitative research exploring the views of professionals or children and adolescents on detention.

CONCLUSION

Further research is needed to explore the impact of detention on those aged < 18 years, including national register-based studies and qualitative studies. This is particularly relevant in nations currently undergoing legislative reform.

Factors Influencing Emergency Department Staff Decision-Making for People Attending in Suicidal Crisis: A Systematic Review

BACKGROUND

Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group.

METHODS

MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies.

RESULTS

Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs.

CONCLUSION

Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention.

Emergency-related inpatient admissions in child and adolescent psychiatry: comparison of clinical characteristics of involuntary and voluntary admissions from a survey in Bavaria, Germany

Emergency inpatient admissions of children and adolescents are more difficult if the patient is admitted involuntarily and/or the caregivers or custodians of institutional care are absent. The present study aimed to clinically characterize involuntary versus voluntary admissions by examining the reasons for presentation and associated factors. We retrospectively analyzed patients who presented to the emergency department of a hospital for child and adolescent psychiatry in Bavaria, Germany, and were admitted as inpatients for crisis intervention in the 4th quarter of 2014-2018. Reasons for presentation, clinical and sociodemographic characteristics, and type of admission (voluntary versus involuntary) were analyzed for 431 emergency inpatient admissions. A total of 106 (24.6%) patients were involuntarily admitted. In a binominal logistic regression, presentation due to alcohol consumption, deviant social behavior, and psychosocial burden was positively associated, whereas difficulties at school and depression were negatively associated, with the likelihood of involuntary admission. 58.5% of the 123 unaccompanied patients were admitted involuntarily. Reasons for the presentation of unaccompanied and voluntary inpatient admissions were suicidal thoughts, psychosocial burden, and externalized aggression. A substantial number of child and adolescent psychiatric admissions represent emergency admissions. Involuntarily admitted patients and unaccompanied children/adolescents represent a non-negligible proportion of clinical routine and the clinical and legal background factors need to be further clarified in future studies. This study is registered in the German Clinical Trials Register (24 September 2019, DRKS00017689).

Early trajectory of clinical global impression as a transdiagnostic predictor of psychiatric hospitalisation: a retrospective cohort study

BACKGROUND

Identifying patients most at risk of psychiatric hospitalisation is crucial to improving service provision and patient outcomes. Existing predictors focus on specific clinical scenarios and are not validated with real-world data, limiting their translational potential. This study aimed to determine whether early trajectories of Clinical Global Impression Severity are predictors of 6 month risk of hospitalisation.

METHODS

This retrospective cohort study used data from the NeuroBlu database, an electronic health records network from 25 US mental health-care providers. Patients with an ICD-9 or ICD-10 code of major depressive disorder, bipolar disorder, generalised anxiety disorder, post-traumatic stress disorder, schizophrenia or schizoaffective disorder, ADHD, or personality disorder were included. Using this cohort, we assessed whether clinical severity and instability (operationalised using Clinical Global Impression Severity measurements) during a 2-month period were predictors of psychiatric hospitalisation within the next 6 months.

FINDINGS

36 914 patients were included (mean age 29·7 years [SD 17·5]; 21 156 [57·3%] female, 15 748 [42·7%] male; 20 559 [55·7%] White, 4842 [13·1%] Black or African American, 286 [0·8%] Native Hawaiian or other Pacific Islander, 300 [0·8%] Asian, 139 [0·4%] American Indian or Alaska Native, 524 (1·4%) other or mixed race, and 10 264 [27·8%] of unknown race). Clinical severity and instability were independent predictors of risk of hospitalisation (adjusted hazard ratio [HR] 1·09, 95% CI 1·07-1·10 for every SD increase in instability; 1·11, 1·09-1·12 for every SD increase in severity; p<0·0001 for both). These associations were consistent across all diagnoses, age groups, and in both males and females, as well as in several robustness analyses, including when clinical severity and clinical instability were based on the Patient Health Questionnaire-9 rather than Clinical Global Impression Severity measurements. Patients in the top half of the cohort for both clinical severity and instability were at an increased risk of hospitalisation compared with those in the bottom half along both dimensions (HR 1·45, 95% CI 1·39-1·52; p<0·0001).

INTERPRETATION

Clinical instability and severity are independent predictors of future risk of hospitalisation, across diagnoses, age groups, and in both males and females. These findings could help clinicians make prognoses and screen patients who are most likely to benefit from intensive interventions, as well as help health-care providers plan service provisions by adding additional detail to risk prediction tools that incorporate other risk factors.

FUNDING

National Institute for Health and Care Research, National Institute for Health and Care Research Oxford Health Biomedical Research Centre, Medical Research Council, Academy of Medical Sciences, and Holmusk.

Ethnic inequalities in involuntary admission under the Mental Health Act: an exploration of mediation effects of clinical care prior to the first admission

BACKGROUND

Studies show ethnic inequalities in rates of involuntary admission and types of clinical care (such as psychological therapies). However, few studies have investigated if there is a relationship between clinical care practices and ethnic inequalities in involuntary admission.

AIMS

This study investigated the impact of ethnicity and clinical care on involuntary admission and the potential mediation effects of prior clinical care.

METHOD

In this retrospective cohort study, we used data from the electronic records of the South London and Maudsley NHS Foundation Trust and identified patients with a first hospital admission between January 2008 and May 2021. Logistic regression and mediation analyses were used to investigate the association between ethnicity and involuntary admission, and whether clinical care, in the 12 months preceding admission, mediates the association.

RESULTS

Compared with White British people, higher odds of involuntary admission were observed among 10 of 14 minority ethnic groups; with more than twice the odds observed among people of Asian Chinese, of Asian Bangladeshi and of any Black background. There were some ethnic differences in clinical care prior to admission, but these had a minimal impact on the inequalities in involuntary admission. More out-patient appointments and home treatment were associated with higher odds of involuntary admission, whereas psychological therapies and having a care plan were associated with reduced odds of involuntary admission.

CONCLUSIONS

Ethnic inequalities in involuntary admission persist after accounting for potential mediating effects of several types and frequencies of clinical care. Promoting access to psychological therapies and ensuring that care plans are in place may reduce involuntary admissions.

Comparison of adolescent referred involuntarily or voluntarily to psychiatric hospitalization

PURPOSE OF THE STUDY

To study in an adolescent clinical inpatient population how clinical, background and psychological factors differ between adolescents referred voluntarily or involuntarily.

METHODS

In this prospective cohort study, we compared adolescents (age 13-17 years, n = 206) who had been referred to psychiatric hospitalization for the first time in their life either voluntarily (n = 144) or involuntarily (n = 62). We gathered from clinical records data on the source, mode and reason for referral as well as on whether after referral the subjects were admitted to the hospital voluntarily or not, and whether they were committed to involuntary hospitalization after the observation period. Diagnostics was based on Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) interview, supplemented by information from clinical records. Structured self-reports provided information on family background, depressive symptoms, substance use, defense styles, self-image and perceived social support.

RESULTS

The majority of referrals due to psychotic symptoms were involuntary, whereas self-harm was the primary reason for involuntary and voluntary referrals in comparable extent. After diagnostic evaluation, no significant difference in psychotic disorders was observed between the two groups, but anxiety disorders were more prevalent among inpatients referred voluntarily than involuntarily. Among adolescents referred involuntary, parents were more often unemployed and had mental health problems. In self-assessments, mature defense style and more positive self-image were associated with adolescents referred involuntarily compared with those referred voluntarily.

CONCLUSIONS

Not only psychiatric but also psychological and social factors were associated with involuntary referral for psychiatric hospitalization in adolescents.

'A Safe Place Where I Am Welcome to Unwind When I Choose to'-Experiences of Brief Admission by Self-Referral for Adolescents Who Self-Harm at Risk for Suicide: A Qualitative Study

Evidence is lacking on how to manage imminent suicidality in adolescents with self-harm. Brief Admission by Self-referral (BA) is a crisis-management intervention, developed for adults with self-harm at risk for suicide. Structured, individualized and based on responsible autonomy, BA aims to provide a respite while minimizing negative effects of hospitalization. This qualitative interview study illuminates adolescents' experiences of BA, adapted for this target group. Nineteen adolescents aged 14 to 19 years, described BA as helpful for timely rest and recovery to save themselves from impulses to self-harm. The individual contract, which is a prerequisite for access to BA, was perceived to give access to professional support in a safe environment, also among adolescents not using their contract. Being trusted with responsibility to self-admit was also hard work with struggles of self-doubt. Challenges included experiencing distrust from staff and fear of not being able to abstain from self-harm, which BA is conditioned upon. However, this condition was also perceived to induce self-motivation and growth. BA appeared well-adapted to the target group, fulfilling needs of predictability, autonomy, and opportunity for recovery to prevent self-harm. Suggestions for improvement included continually informing staff about important features of BA. To further evaluate benefits and challenges of BA, future research may evaluate clinical and health-economic outcomes and perspectives from parents and caregivers.

Clinical and social factors associated with involuntary psychiatric hospitalisation in children and adolescents: a systematic review, meta-analysis, and narrative synthesis

BACKGROUND

Disparities in involuntary psychiatric hospitalisation between population subgroups have been identified in adults, but little is known about the factors associated with involuntary hospitalisation in children or adolescents. We did a systematic review, meta-analysis, and narrative synthesis to investigate the social and clinical factors associated with involuntary psychiatric hospitalisation among children and adolescents.

METHODS

We searched MEDLINE, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials for studies of any type up to July 22, 2020, that compared the characteristics of voluntary and involuntary psychiatric inpatients (mean age of sample ≤18 years). We synthesised results using random effects meta-analysis on unadjusted data and by narrative synthesis. Heterogeneity between studies was calculated using I2. This study is registered on PROSPERO, CRD42020099892.

FINDINGS

23 studies from 11 countries were included in the systematic review and narrative synthesis, of which 19 studies (n=31 212) were included in the meta-analysis. On meta-analysis, involuntary rather than voluntary hospitalisation of minors was associated with a diagnosis of psychosis (eight studies; odds ratio 3·63, 95% CI 2·43-5·44, p<0·0001), substance misuse (five studies; 1·87, 1·05-3·30, p=0·032), or intellectual disability (four studies; 3·33, 1·33-8·34, p=0·010), as well as presenting with a perceived risk of harm to self (eight studies; 2·05, 1·15-3·64, p=0·015) or to others (five studies; 2·37, 1·39-4·03, p=0·0015). Involuntary hospitalisation was also found to be associated with being aged 12 years or older (three studies; 3·57, 1·46-8·73, p=0·0052) and being from a Black rather than a White ethnic group (three studies; 2·72, 1·88-3·95, p<0·0001). There was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 51·3% to 92·3%). Narrative synthesis found that more severe illness and poorer global functioning was associated with involuntary hospitalisation.

INTERPRETATION

Over-representation of involuntary psychiatric hospitalisation in certain groups might begin in childhood, potentially establishing a cycle of inequality that continues into adulthood. Further research into the systemic factors underlying these health-care inequalities and the barriers to accessing less coercive psychiatric treatment is urgently required, with specific consideration of racial and ethnic factors.

FUNDING

UK National Institute for Health Research and Wellcome Trust.