Socio-demographic and clinical characteristics of adults under involuntary hospitalization in the acute mental health services of Cyprus


 Background: The clinical and demographic characteristics of the adults involuntary admitted for compulsory mental health treatment have not been reported adequately. Purpose: Investigation of the socio-demographic and clinical characteristics of the adults who are involuntary hospitalized in the acute Mental Health Services in Cyprus. Method: A descriptive correlation study with cross-sectional comparisons was applied. Data collection was performed from December 2016 to February 2018 via a structured questionnaire including demographic and clinical variables. Each questionnaire was accompanied by a consent form, which was assigned by the participants before their discharge. Results: The sample consisted of 406 people, of whom 262 were male and 144 were female. The vast majority were Greek-Cypriots. The largest age groups were 45-65 years (33%) and 25-34 years (31.8%), respectively. 172 of the participants reported current substance use and 117 of them fulfilled the criteria of dual diagnosis. The most frequent diagnosis was schizophrenia or a relevant psychotic disorder (86.4%). The main cause of relapse and subsequent admission was medication non-adherence along with lack of insight (57.1%). 52% of the sample had been previously involuntary hospitalized in a psychiatric hospital. Conclusions: A high percentage of involuntary hospitalizations was noted due to non-adherence to pharmacotherapy. Re-evaluation of the effectiveness of relevant community interventions is suggested, as well as implementation of structured educational programs on therapy adherence during hospitalization. The goal is the limitation of the frequency of relapse while being in the community. Also, education on substance use prevention is also suggested for clinical populations. Keywords: demographic characteristics, compulsory hospitalization, involuntary admission, mental illness, neurobiological disorders

on substance use prevention is also suggested for clinical populations. Keywords: demographic characteristics, compulsory hospitalization, involuntary admission, mental illness, neurobiological disorders Introduction Although there is longstanding evidence showing that the incidence of mental disorders in the general population is increasing globally 1 , data on the factors triggering severe mental health disturbances leading to compulsory treatment have not been addressed adequately 2 . Involuntary or compulsory treatment is a procedure mainly applied to people with mental disorders lacking their consent, when the intensity of the symptomatology is severe enough to jeopardize personal or social interest 3 .
Data on the effectiveness of compulsory treatment are insufficient 4-5 while selfstigma in those involuntary hospitalized for compulsory mental health treatment has been well described in the international literature 6 . At the same time, compulsory hospitalization has been described as a severe stressor for family members of those involuntary admitted to psychiatric units for compulsory treatment, as well as for the healthcare professionals providing care to them 7 . Thus, documentation of data which may be applied in policy-making to prevent compulsory hospitalization in people facing mental health problems may be an important public health issue. epidemiological study in people who are involuntary admitted for compulsory treatment in the acute mental health services in Cyprus 15 − 17 , while relevant data from international contexts are also scare 18 − 19 . Therefore, it would be useful to report on the clinical characteristics and demographics of those involuntary hospitalized in acute mental health services in the cultural context of Cyprus; such data will form a national base on the one hand, but will also allow future comparisons with international data, on the other 9 . Also, such data may inform policy-making nationally and internationally.

Aim
The aim of the present study was the investigation of the socio-demographic and clinical characteristics of the adults who were involuntary hospitalized under compulsory mental health treatment order.

Material and method
Research design A descriptive correlational study with cross-sectional comparisons was applied.

Study environment
The study environment was the Athalassa Psychiatric Hospital (APH

Sample size
In total 761 admissions were recorded in the APH. 195 cases were rejected because they did not meet the age (n=9 were younger than 18 years and n=13 were older than 65) and diagnosis criteria. The later were mainly diagnosed with personality disorders (n=152). 21 individuals were diagnosed with mental retardation.
Moreover, 79 people were not included since informed consent was not achieved, either because the level of insight was not adequate at the time of discharge from the APH (n=43), or because the researcher was not present during the discharge, thus did not have the chance to have a meeting with the patient regarding informed consent process (n=34). Two individuals passed away during their hospitalization. 81 over the 487 total cases of individuals meeting the inclusion criteria were repeatedly evaluated. This was due to repeated relapses during the study period. Therefore, these patients were only once included in the present sample. Thus, the final sample consisted of 406 individuals as depicted in the flowchart (Diagram 1).

Data collection Process
The primary researcher who is an advanced psychiatric-mental health nurses along and independently with the psychiatrist on duty assessed all individuals admitted in the APH who met the criteria for entry in the study. Also, the demographic and clinical data were recorded. The process of obtaining written informed consent was taking place at the day of patients' discharge from the hospital. At first the degree of insight was assessed by the primary researcher in collaboration with the psychiatrist on duty according to the degree of patients' awareness on (a) the severity of their illness, (b) the occurrence of relapse, (c) the importance of adherence to therapy via a semi-structured interview guide. In cases that the degree of insight was assessed as adequate the primary researcher was explaining the aim and the objectives of the study, confidentiality issues as well as the fact the participation was voluntary and irrelevant to the clinical outcome or therapy issues of their ill health. The assessment interview time was about 15-20 minutes, while the informed consent process lasted for approximately 25 minutes. A translator was hired to support the assessment process in 4.3% of the participants, since their mother language was neither Greek nor English.

Data Collection Tool
A structured questionnaire encompassing clinical and demographic characteristics was used for data collection. The following variables were included: Gender, age, race, nationality, mother language, place of residence, marital status, nationality/nationality of spouse, educational level, occupational status, receiving allowance, BMI, family history of mental illness, admission diagnosis, symptom of admission and history of substance use (type and frequency). Data on substance use regarded both past and current use, with an emphasis on the period just before the onset of relapse symptoms. Regarding relapse symptoms, the most prominent according to the medical note was considered for data analysis. Following comprehensive description of the study aim and objectives the participants provided written informed consent to be included in the study. The voluntary nature of participation, the safety and anonymity of the participants as well as data confidentiality were assured. Also, the participants were informed orally and in writing through the consent form for their right to express complaints regarding the objectives and procedures of the study. All the researchers involved in the study were registered mental health professionals, and therefore legally obliged to respect data confidentiality and patient safety.

Data analysis
All variables were tested for normality and parametric/non-parametric tests were applied accordingly. Means and standard deviations (SD) were assessed for continuous variables and frequencies for categorical variable. Comparisons were assessed through the student's t or Mann Whitney U test and analysis of variance (ANOVA), as appropriate. Pearson's r (r) correlation coefficients were also explored.
To explore variables potentially mediating significant associations step-wise regression analysis was applied. A nominal significance level α=0.05 was used. Data were analyzed through the Statistical Package for Social Sciences (SPSS, Inc, Chicago, IL version 20.00).

Sample characteristics
The sample included 406 individuals (262 male, 144 female), while the majority were Greek-Cypriots (72.4%). Most of the admissions occurred in the winter (32%) and summer (29.3%) time, yet no statistically significant difference was noted. Most of the participants were Greek-speaking (82%). The most frequent city of participants' residence was the Nicosia district (38.4%). Approximately 86 % of the participants were single.
Nearly 25% of the respondents were holders of a bachelor's degree, while 39.9% had completed secondary education. Yet, most of the participants were unemployed (n=315) and only half of them were receiving state financial allowance (49.5%). The largest percentage of the participants (81.3%) declared "Christian Orthodox".
172 of the participants confirmed substance use (current or previous use), while 82 of them reported more than one substance used and almost half of them reported daily substance use (52.3%). Moreover, 117 of those who reported substance use fulfilled dual diagnosis criteria. In all cases, the most prominent substance used was cannabis (75.6%). ( Table 2).
The most common clinical diagnosis in the sample (n=406) was schizophrenia or a relevant psychotic disorder (86.4%).
The most frequent admission cause was non adherence to pharmacotherapy along with lack of insight (57.1%). In particular, 34.7% manifested disorganized behaviour and/or agitation, and/or self-care deficit along with non-adherence to pharmacotherapy and lack of insight; 19% reported aggressive behaviour towards others along with non-adherence to pharmacotherapy and lack of insight; and 3.4% expressed suicidal behaviour along with non-adherence to pharmacotherapy and lack of insight.
The second most prominent cause of involuntary admission (23.4%) was lack of insight along with disorganized behaviour, and/or agitation and/or self-care deficit although the participants reported adherence to pharmacotherapy in this subgroup. 9.6% were admitted due to aggressive behaviour against others and lack of insight, while 8.4% because of substance use and lack of insight. 1.5% were hospitalized because of self-harming bahaviour along with lack of insight.
Almost half of the participants (52%) were previously involuntary hospitalized in the APH, while 195 participants were compulsory admitted there for the first time.
Overall, 70.9% (n=288) had a positive history of mental health problems and 118 participants (29%) reported that the current episode was the first diagnosed mental health disturbance. Moreover, 171 participants reported a positive family history of mental health disorders. The most frequent diagnosis in these cases was schizophrenia/relevant psychotic disorder (18.0%) or a mood disorder (12.8%).

Differences between groups based on demographic characteristics
With regard to positive family history of mental health illness, female (p<0.0001) and white race participants (p=0.03) reported more frequently a positive family history of a severe mental disorder.

Substance use and demographics
A statistically significant association was observed between substance use and gender, since males reported more frequently substance use than females (x 2 , p<0.0001).
Also, a statistically significant association was observed between age and substance use (p<0.0001), since participants aged 25-34 years reported more frequently (current or previous) substance use compared to other age groups.
The participants with a negative history of substance use seemed to report more frequently a negative history of a serious mental disorder (p= 0.007). Therefore, it appeared that those involuntary admitted for compulsory therapy who did not use substances were less likely to report previous severe mental health problems. A statistically significant association was observed between substance use, on the one hand, and level of education and professional status, on the other. In particular, the graduates of secondary education (p=0.019) and unemployed (p=0.019) were more likely to have a positive history of current or previous substance use. Also, a statistically significant association was noted between frequency of use and number of substances used, since the participants who informed substance use daily reported more frequently more than one substance used (p< 0.0001). Furthermore, dual diagnosis was established more frequently in males (p<0.0001), in the age group of 25-34 years (p<0.0001), as well as in those reporting daily substance use (p= 0.01).
The subgroup of cannabis users. Cannabis was the most frequently substance used in the age group of 25-34 years, compared to other age groups (p< 0,0001). In addition, participants with a diagnosis of schizophrenia or other related psychotic disorders were reporting a positive history of cannabis use more frequently than participants diagnosed with other clinical conditions (p= 0.001). A statistically significant association was noted between district of residence and cannabis use, since the participants who resided in the Nicosia, the capital city of Cyprus, reported more often a positive history of cannabis use compared to the residents of the other urban or rural areas of Cyprus (p=0.04). The unmarried participants appeared to use more frequently cannabis than married ones (p=0.05). Overall, cannabis was used on a daily basis more frequently than other substances by the participants (p =0.001).
Symptoms during involuntary admission and demographics A statistically significant association was observed between admission symptoms and demographics. In particular it appeared that non-adherence to pharmacotherapy and lack of insight were more frequently manifested in the age Indeed, approximately one out of 2 participants herein reported a positive history of substance use, although most of them clarified that this regarded substance use in the past -not at present. Also, from those who reported a positive history of substance use approximately one out of two manifested daily use, while the main substance used was cannabis. Nevertheless, data show that substances use is an important clinical factor related to occurrence, as well as recurrence of mental disturbance symptoms 22 . In the present study almost one out of two participants reported substance use just before the onset of symptomatology that led to the involuntary hospitalization, while the main substance used was cannabis. Also, many of the participants although they did not report substance use directly before symptoms escalation or in a relatively short period prior to it, they reported a positive history of substance use in the past.
Regarding substance use occurrence in Cyprus, the study by Mitsis 23 held in 100 individuals with substance use-related disorders who asked for help in a nonsecurity, private clinic program in Cyprus, showed that cannabis was one of the most common substances used, while the majority of the participants had dual diagnosis 23  Marital status was also identified herein as a risk factor, since singles were more likely to be involuntary admitted at the APH. Indeed, international literature poses singles with no supportive family or social network in increased risk for compulsory treatment 3,9,[29][30]33,[35][36][41][42][43][46][47][52][53]56 . However, in one study in Bangladesh the majority of those under compulsory treatment (53.1%) were married 48 .
Most of the participants herein had completed secondary education. Also, one out of this basis, it could be considered that, compared to the past or other countries, the diagnosis of severe mental disorder in Cyprus is taking place at an early stage, and subsequently effective treatment is applied, thus restraining possible cognitive implications of severe mental disorders 47 − 48 . The relationship between education level and involuntary admission and/or readmission for compulsory treatment reported herein is also confirmed by other studies 27 . Previous data show an increased incidence of admissions in high security units for compulsory treatment in those with post-graduate education, and in particular holders of diplomas in vocational specializations 3,29,30,43,45,52,56 . This may suggest that in some countries the majority of mental health service users are integrated into professional specialization programmes, which enables them to acquire vocational skills and further prevent occupational exclusion, social isolation and self-stigmatisation 58 . In the present study most of the participants who had completed secondary education had no such training. Therefore, more extensive and inclusive vocational specialization/post-graduate education programmes are proposed, in terms of the number of trainees and type of specialization provided to individuals with severe mental health problems. Participation in these programmes needs to start during hospitalization and be further endured after discharged and during being in the community. Similarly, a cohort study in the general population in Iran suggests that most of the mental health service uses hold a Bachelor's degree 57 .
Nevertheless, there are contradictory data in studies conducted in South Asia (Bangladesh), Italy, Turkey, China, Germany, Norway and Greece according to which the largest percentage of those involuntary admitted for compulsory treatment had only primary education 41 − 42,47− 48,51,53 . Overall, education in professional skills and the necessity for effective vocational rehabilitation programmes needs to be a priority for healthcare systems, since there are data which show that unemployment is a severe stressor in people with mental health problems. Indeed, unemployed with financial problems seem to be more frequently involuntary admitted for compulsory treatment 3,9,27− 28,30,33,36,48,56 30,48 . This may indicate a late diagnosis of severe mental health problems which may lead to critical escalation of the severity of symptoms thus leading the young to be more frequently involuntary hospitalized. At the same time, these findings may highlight the effectiveness of community therapeutic programmes in the older and subsequently limited relapse rates and need for compulsory treatment in this group of patients. It is important to note that in the studies in which there was no age limit in the inclusion criteria the researchers reported older age groups as a risk factor for compulsory treatment 27,31,52,55,60 . This may explain to some degree relevant differences with other studies.
The place of residence and origin was found as a risk factor for compulsory treatment herein. Though, international data in general population regarding residence area as a risk factor for severe mental health problems seem to be contradictory. Specifically, Dreger et al. 59 , described an increased prevalence of severe mental disorders in people from urban areas in relation to those from rural areas 59 . On the contrary, based on the results of Amoran et al. 49 , the largest proportion of people with severe mental health problems come from rural areas.
Regarding the link between physical characteristics and mental health problems, Regarding educational programs on adherence to therapy, both pharmacotherapy and psycho-social interventions, special emphasis is proposed both during hospitalization and at community. A core element of these programs needs to be empowerment for participation in clinical decision-making regarding treatment options, as well as capacity building on self-management ill health skills. Relevant programs are really scare in Cyprus, mainly provided in private sector.
Moreover, acute short-term residential treatment programs for dual diagnosis are also proposed to be implemented in Cyprus, aiming to provide simultaneously treatment for mental disturbance symptoms and substance-use related problems 69 .
Also, the implementation of compulsory substance use treatment needs to be consider taking into account the cultural context of Cyprus and the data reported herein regarding target populations and duration of programmes.

Limitations
Data collection took place in a 14 months period which may have jeopardised the generalizability of the present findings. However, since approximately 17% of the participants were re-admitted in the APH this may suggest that a precise representation of those involuntary admitted for compulsory treatment has been achieved. In other studies, the time period for data collection is mainly 1 to 8 years.
More importantly, the cross-sectional design of the present study does not allow any inference in relation the direction of the observed associations. At least with regards to some factors, such as positive history of substance use or family history of mental disorders causality may be assumed. Overall, cross-national comparisons are difficult due to diverse healthcare systems and legislation norms regarding compulsory treatment for mental health problems, however there is a need for collaborative international studies to explore the prevalence of involuntary hospitalization and involuntary re-admissions across different settings and cultures employing common assessment tools and standard methodology. Nevertheless, the large sample in this study, the use of a structured clinical assessment procedure triangulated by two independent researchers permits a accurate data in this population.

Conclusions
The results of the present study confirm, to a certain degree, previous data The research team wishes to thank all participants who contributed.

Funding
Not applicable.

Availability of data and materials
The data will not be shared since they refer to sensitive population. Moreover, the participants have signed consent to solely participate in this research study. Also, in accordance to the ethical approval given by the Commissioner of Personal Data Collection, the data must be used only for the current study and access to those data have only the authors/researchers.    Figure 1 Flowchart of the final sample which consisted of 406 individuals.