Involuntary hospitalization in contemporary mental health care. Some (still) unanswered questions

Abstract

Background: Published figures on civil commitment rates in Europe show large differences between countries. All such rates are based on public register data, and it has been questioned to what extent such data can be trusted.

Aims: To present an update on our current knowledge about involuntary hospitalization, with special emphasis on research issues related to time trends in its use, the impact of legislation, and that of service structure and ideology on variations in involuntary hospitalization rates.

Methods: Literature review.

Results: How civil commitment rates have been computed is rarely accounted for in the literature, and rates will vary substantially according to the methods used. The quality of public register data does also vary, and few studies have looked at the quality of public registers.

Conclusions: We still have insufficient knowledge about the use of involuntary hospitalization. Given the varying quality of the data, it is problematic to draw any firm conclusions about the extent, time trends and variations in the use of civil commitment. Comparison of civil commitment rates between countries should for this reason be interpreted with caution.

Keywords:

• Service delivery issues
• involuntary hosiptalization

Notes

1 This author is a member of this network. We did a wide PubMed search using the key words coercion and/or mental health, coercion and outcome, and coercion and/or treatment. The search was limited to papers published after 1990. We further supplemented papers identified from reference lists in original papers and from the MacArthur Coercion Study publication list (updated August 2006). This produced 52 papers that were then screened according to pre-set quality criteria; ending up with six papers on outcome of involuntary hospitalization and the two papers on outpatient commitment included in the Cochrane review. These eight papers were subjected to a thorough and detailed assessment by eight researchers in a plenary session lasting for two days.

2 In this paper involuntary hospitalization and civil commitment are used interchangeably.

3 All rates presented in this paper refer to number of civil commitments per 100,000 population per year.

4 This may also include the use of other coercive measures like forced treatment, the use of restraint, seclusion etc that contribute to the total burden of being coerced. As the discussion in this paper is restricted to civil commitment (in the sense of deprivation of liberty), the significance of these other coercive measures will not be discussed.

5 Such problems include what to do if patients change their minds in the acute situation and if statements made in the directive can be regarded as a valid consent for treatment even if the patient ultimately objects in the actual situation.

6 This unsurprisingly common conclusion in the scientific literature is partly driven by the need for researchers to increase funding in their specific field. However, when it comes to research on coercion in psychiatry, the need is independently manifest.