Involuntary Psychiatric Admissions Quadruple

Megan Brooks

February 27, 2018

In 2013, nearly three quarters of all psychiatric hospital admissions in Ontario were involuntary — a fourfold increase in the Canadian province since the 1980s, new research shows.

Involuntary psychiatric hospital admissions generally occur when individuals with mental illness are hospitalized against their will when it is thought that they are in imminent danger to themselves or others and are unwilling to stay in the hospital voluntarily.

"The issue with involuntary psychiatric admissions is that they can be disruptive to the patient-provider relationship and negatively impact the patient's perception of his or her care at the time of the admission and afterward," lead author Michael Lebenbaum, epidemiologist with the Institute for Clinical Evaluative Sciences (ICES) in Toronto, said in a statement.

Avoidable Events

Using the Ontario Mental Health Reporting System, researchers with the ICES and the Center for Addiction and Mental Health (CAMH) in Toronto assessed recent trends in the prevalence of involuntary admissions in Ontario (population, ~14 million).

Among 115,515 people hospitalized between 2009 and 2013, 74% were hospitalized involuntarily for psychiatric care. The prevalence of involuntary admissions increased steadily and significantly between 2009 and 2013, from 71% to 77% (P < .0001).

Given previous Ontario estimates of around 12% in the late 1970s and 19% in 1983, the current rates demonstrate a "dramatic 4-fold" increase in the prevalence of involuntary admissions, such that 3 of 4 psychiatric hospitalizations are involuntary at admission, the researchers note.

The study was published online February 22 in the British Journal of Psychiatry Open.

Today, patients spend less time being detained involuntarily than patients who were involuntarily admitted years ago. Prior to 1978, patients were admitted involuntarily for up to 1 month. In the current sample, roughly 34% of those who were involuntarily admitted were released and 17% were transferred to voluntary status within 72 hours of admission.

For individuals who have had contact with the police in the prior week, as well as for immigrants and persons aged 16 to 24 years, the likelihood of being involuntarily admitted was greater.

"Our findings show that some population groups such as immigrants and youth (age 16 to 24) are potentially facing inequalities, given they are experiencing a greater likelihood of involuntary admissions, despite controlling for many other factors," Lebenbaum told Medscape Medical News.

The study also found that individuals who had a mental health visit with a psychiatrist or family physician were less apt to be involuntarily admitted, a fact that is "concerning," in that it suggests that for persons with severe mental illness, access to psychiatrists is inadequate, the researchers say.

"This indicates to us that involuntary hospitalization may, to some extent, be an avoidable event if care provided in the community settings eases the psychiatric crises that lead to involuntary hospitalization," coauthor Paul Kurdyak, MD, PhD, from the ICES and the CAMH, said in a statement.

The sharp reduction in the number of psychiatric hospital beds per capita in Ontario may be one factor contributing to rising rates of involuntary admissions, the researchers say. From 1965 to 1980, the number of psychiatric beds in Ontario dropped from 219 per 100,000 population to 81 per 100,000 population. In 2015, it had dropped to 34.2 per 100,000 population — a decline of 84% durng the 50-year period, they point out.

"The reduction in the number of hospital beds may have resulted in the remaining beds being preferentially deployed for the most severely ill presentations, which would be highly correlated with the need for involuntary hospitalization," the researchers write.

"Our findings suggest that Ontario's current psychiatric hospitalization system, which has considerably less beds per population than in the past, may have to largely restrict admissions to individuals with high levels of severity, potentially resulting in delays in inpatient care for patients until they meet the criteria for involuntary admission," Lebenbaum told Medscape Medical News.

"Future research should further examine explanations for the high prevalence of involuntary admissions and determine what system level changes may be able to mitigate this undesirable trend," the researchers conclude.

Higher Than US Rates

This study from Ontario shows a "higher rate of involuntary admissions than most US systems," said Joe Parks, MD, medical director, National Council for Behavioral Health, who reviewed the study for Medscape Medical News.

Parks said it's noteworthy that 10% of involuntary admissions were to psychiatric hospitals and 90% were to general hospital psychiatric units. "That makes me wonder about the availability of psychiatric consultation in general hospital emergency rooms," Parks said.

"If general hospitals don't have psychiatric consultation available on site in their ERs, then they are going to end up admitting a lot of people, because the ER docs aren't trained, and they don't have a lot of patience, time, or interest in this area. They are worried about the next heart attack. Your average ER doc does not want to sit and talk with a psychotic or distraught patient, so they send them up to the psychiatric ward and let them deal with it."

This could be happening in the United States too, Parks said. In his view, "There is no excuse for any ER in Canada or the US not to have psychiatric consultation by telepsychiatry 24/7. There are so many companies out there offering telepsychiatry services, and if anybody needs telepsychiatry consultation, it's an emergency room, and we are seeing it more and more in US hospitals," said Parks.

Regarding mental health care in general, Parks said the situation today is "actually better than it was 20 years ago. It just doesn't feel that way, in part because demand is way up. People want more mental illness treatment than they wanted 20 years ago. Stigma is down, and the less stigma there is, the more willing people are to step forward and say, 'I need help.' "

The study had no commercial funding. The authors have no disclosed no relevant financial relationships.

BJPsych Open. Published online February 22, 2018. Full text

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