Voluntary and Involuntary Psychiatric Admissions in China

The legal framework for voluntary or involuntary admission is one of the most controversial issues in care at psychiatric hospitals all over the world (1–4). Involuntary admission is determined by a host of legal, social, and cultural factors (5). Rates of involuntary admission vary widely in Western settings, ranging from 3% to 67% of all psychiatric admissions (4,6–9).

In developed countries, the most frequently reported factors associated with involuntary admissions are aggressive behavior, lack of insight about illness management, male gender, and acute psychotic symptoms (6,10,11). Patients’ legal status is closely associated with treatment satisfaction (12); voluntary status is associated with better engagement with and adherence to treatment (13), whereas involuntary status may lead to poor satisfaction with treatment and inadequate medication adherence (14). Furthermore, some studies have shown that perception of coercion may be more important than other factors in the therapeutic relationship (15,16). Thus understanding the contributing factors underlying involuntary admission is important to prevent overly restrictive or unethical hospital treatment.

In relation to mental health, China has a different legal system and psychiatric services compared with the rest of the world. Individuals who are suspected of having mental disorders are often compulsorily (involuntarily) admitted to psychiatric hospitals, and the consent form is signed only by family members. Until recently, no national legal framework or guidelines on psychiatric involuntary admissions existed in China. Individuals with psychiatric symptoms often were compulsorily admitted to psychiatric hospitals on the basis of a presumed mental disorder with consent obtained from family members. To the best of our knowledge, data on involuntary psychiatric admissions in China are limited. In a study conducted in 2002, only 18.5% of 2,333 psychiatric inpatient admissions in 17 Chinese cities were voluntary (17). Thus it was widely believed that patients’ rights in psychiatric hospitals were not adequately protected (18).

On October 26, 2012, the new China Mental Health Law was passed, and it was implemented May 1, 2013 (19). The law underscores patients’ rights with respect to psychiatric admission, treatment, and discharge. Article 30 of the law emphasizes that psychiatric admissions and treatment should be determined solely by the patient, unless he or she is evaluated to have a severe mental disorder and has self-harmed or is at risk of self-harming behavior or has harmed others or is at risk of harming others. In the law, the “need for treatment criterion” has been replaced by the “risk criterion.” Provisions of the new law are expected to minimize abuses in regard compulsory treatment and to protect patients from inappropriate forced treatment or hospitalization. After the introduction of the new law, significant changes in the functions of mental health services were expected, especially with the increased awareness of the rights of people with mental illness and a likely reduction in the rate of involuntary admissions.

For mental health practitioners, administrators, legislators, and policy makers, introduction of the new mental health law presents a critical opportunity to understand the patterns of involuntary admissions and their contributing factors before and after implementation. This study aimed to examine the patterns of admissions in relation to sociodemographic and clinical variables in 16 psychiatric institutions across China before the implementation of the law.

Methods

Patients and Study Sites

This survey was part of an ongoing national project investigating mental health services in China before and after the implementation of the National Mental Health Law in May 2013. This longitudinal study was designed to collect key information to understand the impact of the law on the delivery of mental health services. The study was conducted at 16 psychiatric institutions in the representative regions of China (Table 1).

The study was undertaken from March 15, 2013, to April 14, 2013, and was approved by the Biomedical Ethics Board of the second Xiangya Hospital, Central South University in Hunan Province, as well as by the ethics committees of all participating institutions.

Patients were consecutively recruited if they were 18 years or older and were discharged from psychiatric inpatient facilities of the participating institutions during the study period. To be included, patients and their families or guardians had to understand the content of the interview and to sign their informed consent. Patients with dementia or other cognitive problems were excluded from consideration for the study.

Instruments and Evaluation

With consideration that patients in an acute illness phase could not complete the interview because they could not objectively report their admission status, the authority to provide informed consent was given to the family or guardian and to patients independently; if both parties agreed to participate in the study, face-to-face interviews were carried out with the family or guardian and with the patient, respectively, within one week after the psychiatrist discharged the patient from the hospital. Psychiatrists had over five years of experience in clinical practice and research studies. Every site had a local project coordinator. Data were collected, and personal information was deidentified and transferred to a central database.

A draft questionnaire for the interview was evaluated and revised by a core group of experts before distribution and was subsequently validated (3). Basic sociodemographic and clinical characteristics were collected by using a form designed for the study (3) that included patient’s age, gender, race-ethnicity, marital status, years of education, residence, employment, income, health insurance, history of drug or alcohol abuse or dependence, age of onset and length of psychiatric illness, prior psychiatric hospitalization, and history of violence or suicide attempt.

Psychiatric diagnoses were made according to ICD-10 criteria at discharge and collapsed into three groups: schizophrenia-related disorders (F20–29) (referred to hereinafter as schizophrenia), mood disorders (F30–39), and others (3,12). If patients had more than one diagnosis, the principal diagnosis given by the treating psychiatrist was recorded.

The Modified Overt Aggression Scale (MOAS) (20,21) was used to measure the level of aggression in the week before the index admission according to the information from the medical record and the patient’s family members. The MOAS comprises four subscales based on severity of aggressive behavior: verbal aggression, aggression toward property, self-aggression, and physical aggression toward other people. Each subscale is scored from 0 to 4. Possible subscale scores range from 0 to 16, with higher scores indicating more aggressive behavior. The MOAS total score was used as an overall measure of aggressive behavior.

The Insight and Treatment Attitudes Questionnaire (ITAQ) (22) was used to assess patients’ insight about their illness. Patients were interviewed by psychiatrists within one week after hospital discharge. The ITAQ consists of 11 items, with each rated on a 3-point scale: 0, no insight; 1, partial insight; and 2, good insight. Possible scores range from 0 to 22, with higher scores indicating better insight. The total score was entered in the statistical analysis.

There was no legal status for psychiatric admissions in most Chinese psychiatric hospitals prior to the introduction of the mental health law. Thus the patient self-reported the adminssion as involuntary or voluntary, according to the perceived level of coercion at the time of admission. Some patients were undecided whether their admission was clearly voluntary or involuntary, and we defined this as “partly voluntary admission.” In order to obtain patients’ perceptions about their admission, we asked them the following questions: “How did you perceive your recent admission? Did you go voluntarily to hospital, or were you forced to go? Can you give a decisive reply to these two questions?” The patients were divided into three groups according to their responses: voluntary, partly voluntary (undetermined involuntary admissions or voluntary admissions), and involuntary.

Statistical Analysis

Analyses were made with the SPSS 19.0 for Windows statistical package. The sample was divided into voluntary admission, involuntary admission, and partly voluntary admission groups. Descriptive statistics were used to calculate frequencies, means, and standard deviations, and the t test and chi square test were used for testing the significance of differences between the three admissions groups. Multinomial logistic regression was used to examine the factors independently contributing to involuntary or partly voluntary admissions. The level of significance was set at .05 (two tailed).

Results

Characteristics of the Study Sample

Of the 810 patients surveyed, 13 (2%) who had mental disorders resulting from general medical conditions did not fulfill the study entry criteria. Thus 797 (98%) patients completed the interview; 224 (28%) were voluntary admissions, 336 (42%) were involuntary admissions, and 237 (30%) were partly voluntary admissions (Table 2).

Demographic and Clinical Characteristics

The sociodemographic and clinical characteristics of the three groups are shown in Table 2. There were significant differences between the three groups in age, gender, years of education, marital status, residence, employment, prior psychiatric hospitalization, history of violence, psychiatric diagnosis, prior receipt of outpatient treatment, and MOAS and ITAQ total scores (p<.05).

Independent Contributors to Involuntary Admissions or Partly Voluntary Admissions

Multinomial logistic regression analysis revealed that male gender (odds ratio [OR]=1.6), past hospitalization (OR=2.0), diagnosis of schizophrenia (OR=4.2), and high MOAS score (OR=1.1) were the risk factors for involuntary admissions status, whereas more years of education (OR=.8), high ITAQ score (OR=.8), and outpatient treatment prior to the index admission (OR=.5) were its protective factors. Diagnosis of schizophrenia (OR=3.9) and high MOAS score (OR=1.1) were the risk factors for partly voluntary admissions status, whereas high education (OR=.9) and high ITAQ score (OR=.9) were its protective factors (Table 3).

Discussion

This national self-report survey found that before the introduction of China’s mental health law, the rate of involuntary psychiatric hospitalization in China was 42%, which is much higher than rates reported from Western settings, where it rarely exceeds 20% (4,9). Many parts of the world have enacted laws to order involuntary admissions and have transferred the authority from physicians to nonmedical professionals (1,23). However, in China (up until 2013), family members, rather than a third party, were responsible for seeking medical help and giving consent for hospitalization (24–26). Such practice facilitated access to treatment for patients, but it did not adequately protect their civil rights (27). Thus it is speculated that the relatively broad criteria for involuntary admissions may have led to higher rates of involuntary admissions in China compared with those in the developed countries.

In a 2002 study, only 18.5% of all hospital admissions were voluntary in a sample of 2,333 patients treated in 17 mental health centers across China (17). The rate of voluntary admissions was 28% in this study, suggesting that the rate of voluntary admissions might have modestly increased in the past ten years. Two factors may have contributed to this favorable change. First, the increased awareness of the imminent new mental health legislation may have influenced both psychiatric services and family members to pay greater attention to protecting patients’ civil rights. Second, before 2002 family members took responsibility for seeking medical help and paid for psychiatric treatment (24). In 2002, the Chinese government initiated sweeping health reforms (28,29), making mental health care an integral part of the national public health program (30). As a result, nearly 80% of the patients in this study had health insurance, compared with 30.1% in the 2002 study (17). However, previous studies also reported that health insurance also increased the likelihood of involuntary admissions (31). In this study, the proportion of involuntarily admitted patients with health insurance was higher than that of voluntarily admitted patients (83% versus 78%). Whether health insurance has a negative or positive effect on the admission pattern needs further study.

In our study male patients were more likely than female patients to be admitted involuntarily, which is consistent with results of studies done in other parts of the world (1,32,33). It is likely that male psychiatric patients showed potentially dangerous behavior more frequently than their female counterparts did. This finding suggests that perception of dangerousness and overtly dangerous behavior are important contributing factors to involuntary admissions.

Not surprisingly, diagnosis of schizophrenia or other psychoses and lack of insight were associated with involuntary admissions, whereas amount of education and past receipt of outpatient treatment were the protective factors of involuntary admissions. A prospective cohort study of acute psychiatric patients from Netherlands also showed that outpatient treatment could prevent involuntary admissions (11). It is suggested that improving access to community psychiatry services in China could be an effective way to reduce the rate of involuntary admissions (34). Identifying factors contributing to involuntary admissions could provide opportunities for policy reform, public education, and other preventive measures to minimize the need for coercive hospital practices.

Involuntary admission is associated with a range of negative feelings, including fear, embarrassment, anger, and helplessness (35). It also has a negative impact on treatment motivation, therapeutic relationships, and thus outcomes (14). Families of involuntarily admitted patients often have a complex and stressful experience when seeking hospitalization of their loved ones (36), and some authors have argued that involuntary admissions should be reduced (2,37,38). Although acute mental state and potential danger to self or others were the most important reasons for involuntary admissions in this study, it was expected that the rate of involuntary admission would be reduced in China after implementation of the new mental health law.

This study had several methodological limitations. First, assessment of admission status was subjective, being based on self-report. Because the legal framework for involuntary admissions had not been established in China before May 2013, the study lacked a standard definition of involuntary admissions. We defined involuntary admissions only by examining patients’ attitudes toward their hospital admission (agreement or disagreement with a statement concerning coercion). Second, the MOAS and ITAQ were administered to patients within the first week of discharge but not at the time of admission, which may have led to recall bias (38,39). Third, the effect of different treatment components on involuntary admissions could not be measured. Finally, some important variables affecting the type of admission, such as social support and functioning (40), were not recorded.

Conclusions

Before the introduction of China’s mental health law, no more than half of the hospitalized psychiatric patients were admitted voluntarily. Perception of dangerousness and poor insight were significant factors in involuntary psychiatric admissions in China. Factors contributing to the changes in patterns of psychiatric admissions after the implementation of the mental health law are important topics for further research.