Perceived Trauma During Hospitalization and Treatment Participation Among Individuals With Psychotic Disorders

There is growing evidence that experiences related to psychiatric treatment, especially those related to coercion and patient safety, are perceived as traumatic by treatment recipients (1,2). Not surprisingly, evidence suggests that traumatic and coercive experiences during hospitalization are negatively associated with patient satisfaction with treatment. In addition, there is limited evidence that these experiences are related to willingness to engage in future treatment (3–5). We aimed to address these questions by focusing on perceptions of trauma due to psychiatric hospitalization, distressing or coercive experiences that occurred during hospitalization, and the association of these experiences with treatment participation.

The aims of this study were to examine the prevalence of perceived trauma and specific distressing experiences during hospitalization, explore whether patient characteristics and specific experiences were related to perceived trauma, and assess whether perceived trauma and specific experiences were associated with treatment participation among a representative cohort of patients who were followed for ten years after their first admission for a psychotic disorder. We hypothesized that perceived trauma and endorsement of specific distressing experiences would be associated with lower treatment participation. Sensitivity analyses were included to assess whether the associations were influenced by paranoid ideation.

Methods

The sample was drawn from the ten-year follow-up of the Suffolk County Mental Health Project, a prospective-cohort study of 628 patients who were hospitalized for psychosis for the first time between 1989 and 1995 in Suffolk County, New York (6). The study was approved by the Committee on Research Involving Human Subjects of the State University of New York at Stony Brook and the institutional review boards of participating hospitals. Written informed consent, or parental consent for those under age 18, was obtained from all participants. Face-to-face interviews took place at index admission and at six-month, 24-month, 48-month, and ten-year follow-ups. This study analyzed data from 395 participants who completed the survey module on psychiatric hospitalization–related trauma at the ten-year assessment (67% of the 586 original cohort members who were alive at year 10).

Diagnoses were determined based on the consensus of the researchers at the 24-month follow-up (7). Diagnoses were categorized according to DSM-IV into schizophrenia spectrum disorders, bipolar disorder with psychotic features, and other psychotic disorders.

Perceived trauma associated with psychiatric hospitalization was assessed by an interviewer-administered questionnaire. Perceived trauma was indicated by a positive response to the question, “Was [were any of] your hospitalization[s] traumatic or extremely distressing to you?” If the answer was yes, participants were asked to describe distressing experiences that happened in the hospital. They were also asked whether they experienced involuntary admission, being put in restraints, being put in seclusion, physical abuse by hospital staff, physical abuse by another patient, being threatened or endangered, receiving forced medication, and overcrowding. These are referred to as “specific experiences.”

Treatment participation was assessed in two ways. First, respondents were asked, “Sometimes people think they might need mental health services but don’t go. Was there ever a time in the past six years that you thought you might need the services of a mental health professional but didn’t go?” Positive responses indicated having forgone needed treatment during the past six years (the interval from the last face-to-face contact). Second, we examined time spent in treatment across the ten years of follow-up. This was coded by the interviewer from extensive information on treatment history obtained at each follow-up. Information sources included the participant interview, medical records, and interviews with a significant other. Time in treatment represented the percentage of time that the participant received any form of treatment. Based on the distribution of this variable, it was categorized as <75% versus 75% or more.

Other measures included age at baseline, sex, race-ethnicity (non-Hispanic white, non-Hispanic black, or other), social class of origin (low, medium, high), education at ten-year follow-up (high school or less versus more than high school), work or school status during the month before first hospitalization (full-time, part-time, none, or homemaker only), marital status at ten-year follow-up (married versus not married), whether the participant was living independently prior to first hospitalization, baseline insurance type (none, public, or private), whether the first hospitalization was involuntary according to hospital records, rate of rehospitalization during follow-up (per ten years), state hospital admission during follow-up (yes or no), illness course (full remission versus partial or no remission), and severity of psychopathology at the ten-year follow-up (Brief Psychiatric Rating Scale [BPRS] total score) (8).

The sample included 226 (57%) males and 169 (43%) females. A total of 290 (73%) were non-Hispanic white, 65 (17%) were non-Hispanic black, and 40 (10%) were Hispanic, Asian, or American Indian. [A table summarizing other characteristics of the population is available online as a data supplement to this article.]

Logistic regression was used to assess the associations of patient characteristics with perceived trauma, adjusted for rehospitalization history and BPRS score at ten-year follow-up. We also examined the association of perceived trauma and specific experiences with treatment participation (failure to seek treatment and time in treatment), adjusted for age, sex, race, and BPRS score at ten-year follow-up. Analyses were conducted by using Stata 11 (9). Missing data were accounted for by listwise deletion. Sensitivity analyses assessed whether the associations detected may have been influenced by paranoid ideation at the time of the ten-year follow-up, indicated by the BPRS item for “suspiciousness.”

Results

Overall, 268 participants (69%) reported that at least one of their hospitalizations was traumatic or extremely distressing. The most commonly reported specific experiences were involuntary hospitalization (N=217, 62%), being put in restraints (N=142, 40%), and being forced to take medication (N=130, 37%). The least commonly reported specific experiences were physical abuse by staff (N=22, 6%) or other patients (N=30, 9%). Compared with participants who did not report perceived trauma, participants who reported perceived trauma were more likely to report each specific experience. [A table comparing specific experiences among patients who did or did not report perceived trauma is available in the online data supplement.]

Perceived trauma was more commonly reported by females than males (adjusted odds ratio [AOR]=1.97, 95% confidence interval [CI]=1.19–3.27, p=.009) and by homemakers versus those who were fully employed (AOR=6.05, CI=1.33–27.43, p=.020). Because no male participants were homemakers, we reestimated this association among females only, and it remained significant (AOR=5.94, CI=1.22–28.98, p=.028). Other characteristics were not associated with perceived trauma. [A table comparing the likelihood of perceived trauma by participant characteristic is available in the online data supplement.]

Ninety-one participants (23%) reported foregoing needed treatment at least once during the past six years. This rate did not differ between those who did and did not report perceived trauma and was not associated with any of the specific experiences (data not shown).

Time in treatment was observed for 298 participants. Of these, 173 participants (58%) were in treatment at least 75% of the time during the follow-up period. Associations of perceived trauma and specific experiences with time in treatment are presented in Table 1. The point estimates for all associations except overcrowding were less than 1.00, indicating that those who endorsed these items were less likely to spend at least 75% of time in treatment. In the full sample, forced medication was significantly associated with reduced time in treatment (p=.001). Among those with a schizophrenia spectrum diagnosis, forced medication was also associated with spending less time in treatment, and the association was stronger than in the full sample (p=.01). No associations among those with bipolar disorder with psychosis and those with other psychotic disorders were significant at the p<.05 level. When a Bonferroni-corrected alpha of .0056 was used, the association between forced medication and time in treatment for the whole sample was the only association in Table 1 that was statistically significant. None of these associations were affected by inclusion of the BPRS item measuring suspiciousness at ten-year follow-up.

Reduced time in treatment may result from symptom improvement as well as from disengagement with treatment. Therefore, we assessed three indicators of improvement among those who did and did not report forced medication: ten-year BPRS score, change in BPRS score from baseline to ten-year follow-up, and remission status at ten-year follow-up. No significant differences were observed.

Discussion

More than two-thirds of participants with psychotic disorders had at least one hospitalization that they found to be traumatic or extremely distressing. This perception was associated with participant sex and employment status but not with other characteristics analyzed in this study. We did not find associations between perceived trauma and two measures of treatment participation. However, self-reported forced medication was significantly associated with spending less time in treatment over the ten-year period.

Perceived trauma during psychiatric hospitalization was reported more commonly by females than males. Although this finding is novel, it is consistent with sex differences in the risk of posttraumatic stress disorder (PTSD) after a traumatic event (10) and with gender differences in trauma and PTSD exposures in this cohort (11). Trauma perception also differed by employment status. This may be related to the role of social support in trauma response and is consistent with evidence that social support is associated with both employment status and traumatic stress among women (12).

Perceived trauma was not associated with foregoing needed treatment or with time in treatment. It may be that although a majority of patients had experienced trauma during psychiatric hospitalization, these experiences did not outweigh the benefits of treatment.

Although our study design did not allow for temporal ordering between specific experiences and treatment participation, the association between forced medication and time in treatment may indicate that coercive experiences are associated with reduced treatment participation. Our findings mirror the mixed results of previous studies, in that forced medication was the only coercive event significantly associated with treatment participation in the full sample (4,5,13,14). This association appeared to differ by diagnostic group, given that it was strongest among those with schizophrenia and weaker among those with bipolar disorder with psychosis and other psychotic disorders. We did not find evidence that those who reported forced medication experienced greater symptom improvement than those who did not, which reduces the plausibility of symptom improvement as an explanation for the association between forced medication and time in treatment. However, we cannot rule out that poor insight into need for care affects both treatment participation and the probability of being forced to take medication (15).

Although this study was based on a relatively large and representative sample of first-admission patients recruited from a variety of facilities, the study’s limitations should be considered when interpreting the results. As mentioned above, the temporal ordering of specific experiences and perceived trauma and treatment participation could not be established, preventing us from being able to infer causal relationships. Second, assessment of perceived trauma and specific experiences relied on self-report, which may have been subject to recall bias or influenced by the participant’s mental state. We were able to consider the latter in sensitivity analyses and by adjustment for BPRS score at ten-year follow-up. Although we could not measure recall bias, our findings are in line with other reports (2). Third, there was attrition over the ten-year follow-up, and 16% of those who participated in the ten-year follow-up did not complete the hospital trauma module. Fourth, although we controlled for illness severity and stratified the sample by diagnosis type, the reasons for foregoing or spending less time in treatment were unknown. Fifth, the trauma questionnaire and measures of treatment participation were developed for this study. Finally, because our sample was from one catchment area, the results may not generalize to other populations.

Conclusions

In the context of these limitations, this study extends findings from previous studies suggesting that a large percentage of patients with psychotic disorders perceive their hospitalizations as traumatic. Although trauma perception was not associated with treatment participation in our study, reporting forced medication was associated with reduced time in treatment. This association varied by diagnostic group. Future studies would benefit from including larger samples of participants with specific diagnoses in order to explore these differences further.