Characteristics associated with involuntary versus

Authors: Jason Craw Michael T Compton

Publish Date: 2006/10/11

Volume: 41, Issue: 12, Pages: 981-988

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Abstract

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 dischargeData 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 ratiosIn 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 medicationsA 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 researchIn the United States criteria for involuntary psychiatric hospitalization generally require imminent dangerousness to oneself or others or complete inability to care for oneself 1 2 though specific criteria vary between states 3 An important rationale for involuntary psychiatric hospitalization is that patients admitted for evaluation often have severe deficits in their capacities to make treatment decisions 4 5 Patients often revise their beliefs about the need for treatment during or after hospitalization A study conducted by Gardner et al 6 found that slightly more than half of patients who initially stated upon admission that they did not need hospitalization later admitted they indeed had needed treatment when reinterviewed several weeks after dischargeIt has been suggested that involuntary treatment may reduce the likelihood that patients will voluntarily seek care in the future 7 8 Subsequent aversion to psychiatric services may be due to a distrust of clinicians arising from coercive tactics or a lack of procedural justice eg the patient is treated unfairly disrespected ignored or excluded from the decisionmaking process encountered during hospitalization 1 8 9 On the other hand involuntary hospitalization may provide patients with needed treatment even if involuntarily that results in improved outcomes and treatment adherence 10 Some research indicates that the presence or absence of coercion is accurately reflected by the patient’s legal status but other studies demonstrate that coercive pressures and perceived coercion do not necessarily correlate well with legal status in all settings 8 11Evidence associating legal status with sociodemographic and clinical variables is sparse and inconsistent One study found that higher readmission rates and more unstable discharge living arrangements were associated with involuntary legal status on hospital admission 12 A metaanalytic review conducted using studies from the 1950s through the early 1980s found that the only significant outcome measure correlated with admission legal status was length of stay 13 Studies have reached opposing conclusions regarding whether or not male gender is significantly associated with involuntary legal status especially when controlling for severity of illness 7 12 14 With regard to clinical characteristics psychotic disorder diagnoses greater illness severity and more frequent preadmission assaultive behaviors may be associated with involuntary admission 13 Even fewer studies have examined factors associated with converting from involuntary to voluntary legal status during hospitalization 14 15 16 Cuffel 14 identified greater clinical improvement less severe diagnoses and nonminority ethnicity as factors predictive of converting to voluntary status early in the hospitalization Later during hospitalization the only factor associated with legal status conversion was having discharge living arrangements involving family and friendsStudies that find significant associations between legal status and outcomes may influence policies relating to resource allocation during hospitalization discharge planning and outpatient followup 12 15 For instance research characterizing those at risk for very short involuntary hospitalization ie discharge upon expiration of shortterm commitment addresses the need for more thorough and engaged evaluation and treatment while hospitalized One may be able to enhance treatment adherence with a more focused treatment and evaluation plan in conjunction with closer followup after discharge 12 Though legal status is often overlooked in studies in which it would be particularly relevant it is clearly an important variable for further research

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