This study evaluated clinical data from all acute inpatients from five psychiatric departments serving different catchment areas in Portugal in the years of 2002, 2007 and 2012, and identified several sociodemographic, clinical, and contextual factors associated with involuntary psychiatric hospitalizations in Portugal.
Male gender, having secondary and higher education, a psychiatric diagnosis of psychosis, and admission in 2007 and 2012 were associated with an increment of involuntary hospitalizations. Being married/cohabitating, having experienced a suicide attempt, and belonging to the catchment area of three of the psychiatric services evaluated (Hospital de Magalhães Lemos, EPE, Centro Hospitalar Psiquiátrico de Lisboa and Unidade Local de Saúde do Baixo Alentejo, EPE) were associated with a reduction of involuntary hospitalizations.
People with a psychotic disorder were found to be at high risk for involuntary hospitalization, one of the most consistent findings from studies worldwide [31, 32, 45−62]. It is reassuring that mental health legislation is being used most frequently for people with the most severe and disabling mental health conditions [4]. Since no definition of diagnosis is provided by legal frameworks, it is important to understand what specific pathways and mechanisms might increase the risk for involuntary admission in someone with psychosis. One study found that hostility and suspiciousness were significant compulsory admission determinants, and that diagnosis had no longer any independent influence on the risk of involuntary hospitalization after controlling for these specific symptoms [48]. A high level of suspiciousness and uncooperativeness might go hand in hand with reduced coping-strategies and insight, and lead to poor medication adherence and impaired capacity to establish a therapeutic alliance [51, 60, 62], explaining the higher risk of involuntary hospitalization in psychosis. Another study concluded that aggression and psychotic symptoms increased the odds of involuntary hospitalizations [63]. Increased stress-level and aggressive behaviors might be perceived as an imminent danger to self or others, reflecting the still widespread assumption that people with severe mental disorders are unpredictable and dangerous, and be a central factor in mental health professionals’ judgments regarding involuntary admission [38]. It is also likely that the shortage of community services for early recognition and assertive outreach is particularly serious for cases of psychosis, leading to a higher rate of acute psychiatric crisis and emergency admittances among this group [55].
Regarding sociodemographic factors, male gender was significantly associated with higher risk of involuntary hospitalizations. This finding is congruent with several previous studies [31, 32, 45−47, 52, 53, 55, 57, 58, 60, 64], while other studies have shown a higher risk in female gender [51, 65, 66]. Possible explanations might be related to societal attitudes and treatment culture that lead to different help-seeking behavior in males and females, or that mentally ill men are perceived as being more violent, suggesting that perception of dangerousness and overtly dangerous behavior are important contributing factors to involuntary hospitalizations [31, 32, 53, 60]. It is important to know that gender independently influences the risk of involuntary hospitalization. On the one hand, it provides evidence for the possible need to plan mental health services with differing pathways to care for women and men with severe mental disorders. On the other hand, it draws attention to issues relating to equality and human rights of mental health legislation, mental health services, or potentially discriminatory practices by other parties (e.g., police) [64].
Mixed results have been found regarding the association between educational level and involuntary hospitalization. The finding that a higher educational level is a risk factor for involuntary hospitalizations is in line with some studies [51, 62] but inconsistent with others [53, 58, 67]. Evidence is scarce and difficult to interpret. However, it has been hypothesized that schooling may be associated with greater awareness of individual’s rights, causing the patient to disagree with inpatient treatment [51].
Regarding marital status, most previous studies have shown that being married is associated with a reduced risk [46, 68] or being unmarried with a higher risk of involuntary hospitalizations [47, 51, 57, 61, 67]. However, one study showed married status to be associated with an increased risk of involuntary treatment [62]. Overall, the finding of a greater likelihood of involuntary care among unmarried people may reflect the associations between poorer social capability, loneliness, scant social support, and severe mental health difficulties [4, 51, 61]. It might also reflect the role that friends and family may have in encouraging and facilitating help-seeking by voluntary means [4].
In line with some studies [47, 48, 56, 62] but in contradiction with other [54], we found that a history of suicidal attempt within the previous 12 months was a negative predictor of involuntary treatment. A possible explanation could be that after non-fatal suicidal attempt the individual may receive more social support from family and friends that, in turn, may increase his/her compliance with treatment and hospitalization [47]. Moreover, these patients could gain good insight into the severity of their clinical condition and develop a therapeutic collaboration, learning to ask for help and voluntary hospitalization when in need [48]. Alternatively, individuals with severe physical damage resulting from attempted suicide are voluntarily hospitalized for treatment in general hospitals with consequent referral to psychiatric departments [47].
Previous research on the system-related factors associated with involuntary hospitalizations is somehow scarce and inconclusive. Factors such as previous mental health service utilization [53, 69, 70], availability of inpatient beds [34, 52, 71], availability of alternative less restrictive forms of care, such as temporary housing or residential crisis stabilization [72− 74], adequacy of community services [4], availability of home visits [75, 76], lower levels of service integration [62, 77], referral procedures such as contact with police, referral by physicians who did not know the patient or the professional that requires a compulsory admission [63, 65, 67], and longer waiting times for obtaining appropriate mental health care [62, 75] may be associated with involuntary hospitalization. This study found variation across psychiatric services, suggesting that services organization plays a role in predicting involuntary hospitalizations. However, service-level variables were not included in the analysis and it is not possible to ascertain which are the aspects of mental health care organization specifically involved.
Another relevant finding was the increase in involuntary hospitalizations in 2007 and 2012 in comparison to 2002. This may correspond to a time trend, following the increasing rates over time in some European countries [4]. The increment in 2012 may also reflect an association between the Great Recession and involuntary hospitalizations in Portugal. During periods of economic recession, it is plausible that factors such as family stress, dearth of social associations, social stigma associated with mental health problems, reduced tolerance for persons with mental illness, declining social capital and increased desire for security in society will lower the threshold and shape the decision for an involuntary admission [60, 78−80], that involves a complex interaction between clinical judgement, patients’ psychopathology, social variables, fulfilment of legal requirements, and local availability of resources.
The results of this study should be interpreted in the light of several limitations. First, the analysis was based on a retrospective observational study based on clinical records and we did not have access to information on several factors that might be helpful in explaining the likelihood of involuntary hospitalization, such as symptom severity, level of psychosocial functioning, insight, perceived social support or poor adherence to outpatient treatment. Second, the use of routinely collected clinical data may lead to data quality issues (e.g. risk of misclassification). Third, the dataset did not include system or area-related variables that might describe the organizational, environmental or situational factors influencing involuntary hospitalization. Evidence for an association between availability of inpatient beds and involuntary hospitalization is sparse and inconclusive [4]. Mixed results have been found about the adequacy of community services and the rate of involuntary hospitalization. Reduced rates of involuntary care were found to be associated with more home visits [76], with availability of home visits after 22H [75], and with the availability of alternative less restrictive forms of care [72, 73]. However, community services rated more highly by service users were associated with greater numbers of patients admitted involuntarily [33]. In this study, it was not possible to conduct a retrospective analysis of the different typologies of service organization that could help to clarify the impact of factors such referral procedures, use of crisis intervention practices, total number of psychiatric beds, availability of adequate housing, social care, and other support services. Fourth, patients from Unidade Local de Saúde do Baixo Alentejo, EPE were admitted to Centro Hospitalar Psiquiátrico de Lisboa, which makes interpretation of results more complex. Finally, the findings from this study may allow limited comparisons given the marked differences between mental health systems across different countries.
Despite these limitations, this study provided a detailed analysis of all psychiatric admissions under the Mental Health Act over the course of three years in different psychiatric departments covering catchment areas with distinct geographical and socioeconomic characteristics. This study did not restrict potential risk factors to patient characteristics alone, although a future more in-depth analysis of service and area aspects is needed to lead to better predictions and to provide data for services and policies improvement.