Characteristics associated with change in the legal status of involuntary psychiatric patients

Preventing involuntary admissions: special needs for distinct patient groups

BACKGROUND

Coercive measures in psychiatry are a controversial topic and raise ethical, legal and clinical issues. Involuntary admission of patients is a long-lasting problem and indicates a problematic pathway to care situations within the community, largely because personal freedom is fundamentally covered by the UN declaration of human rights and the German constitution.

METHODS

In this study, a survey on a large and comprehensive population of psychiatric in-patients in the eastern part of North Rhine-Westphalia, Germany, was carried out for the years 2004-2009, including 230.678 treatment cases. The data were collected from the dataset transferred to health insurance automatically, which, since 2004 is available in an electronic form. In addition, a wide variety of information on treatment, sociodemographic and illness-related factors were collected and analysed. Data were collected retrospectively and analyses were calculated using statistical software (IBM SPSS Statistics 19.0^®). Quantitative data are presented as mean and standard deviation. Due to the unequal group sizes, group differences were calculated by means of Chi-square tests or independent sample t tests. A Bonferroni correction was applied to control for multiple comparisons.

RESULTS

We found an over-representation of involuntary admissions in young men (<21 years) suffering from schizophrenia and in female patients aged over 60 with a diagnosis of dementia. Most of our results are concordant with the previous literature. Also admission in hours out of regular out-patient services elevated the risk.

CONCLUSION

The main conclusion from these findings is a need for a fortification of ambulatory treatment offers, e.g. sociopsychiatric services or ward round at home for early diagnosis and intervention. Further prospective studyies are needed.

Characteristics associated with involuntary versus voluntary legal status at admission and discharge among psychiatric inpatients

BACKGROUND

The objective of this analysis was to determine the ways in which patients' legal statuses at hospital admission and discharge are associated with select sociodemographic and clinical variables. This study specifically investigated differences between patients who were voluntary during both admission and discharge, patients who were involuntary on admission but voluntary on discharge (having converted to voluntary status during hospitalization), and patients who were involuntary during both admission and discharge.

METHOD

Data were collected from the charts and treating clinicians of 227 consecutively discharged patients from two psychiatric units in a large, urban, county hospital in the southeastern United States. Based on results of bivariate tests, sociodemographic and clinical factors were entered into a polytomous logistic regression model to determine effect estimates (adjusted odds ratios).

RESULTS

In the bivariate analyses, 15 variables were significantly associated with the trichotomous legal status. In the model, three factors were independently significantly associated with legal status, while controlling for four potential confounders: (1) whether or not the patient was experiencing psychotic symptoms at discharge, (2) whether or not the patient had documented medical problems requiring medication at discharge, and (3) the number of psychiatric medications.

CONCLUSIONS

A generalized lack of treatment engagement and adherence among involuntary patients likely underlies significant differences between the groups in terms of psychotic symptoms, diagnosed medical problems requiring medications, and number of psychiatric medications at discharge. Studying legal status (and the process of legal status conversion from involuntary to voluntary) and its correlates is an important topic for further research.

Characteristics associated with legal status change among psychiatric patients

Typically research on civil commitment has simply compared voluntary and involuntary psychiatric patients and has ignored the process of legal status change. The present study examined patient characteristics associated with legal status change during different points of patients' hospital stays. Results indicated that patients with greater improvement, patients with more severe diagnoses, and non-minority patients were more likely to transition to voluntary status, but only when these transitions occurred early in the hospitalization. Later in the hospitalization, the presence of living arrangements involving family and friends was associated with higher rates of transition to voluntary status.