Taking an Evidence-Based Approach to Involuntary Psychiatric Hospitalization

Civil commitment statutes typically authorize involuntary hospitalization when someone poses a danger to self or others, or cannot adequately provide self-care, because of mental illness. Every U.S. state authorizes emergency psychiatric holds, whereby people are temporarily held and assessed in a health care facility (1). States often have different policies regarding extending these holds for further hospitalization, for example, after a court hearing (1). Despite reductions in the number of patients in state and other long-term psychiatric facilities over recent decades, short-term psychiatric holds, which may lead to further hospitalization, remain common; one study estimated that >590,000 emergency psychiatric holds occurred across 24 states in 2014 (2). Involuntary psychiatric hospitalization can be distressing for individuals and is controversial but also potentially lifesaving. To what degree is this practice evidence based?

Randomized Controlled Trials

Dozens of observational studies have investigated involuntary psychiatric hospitalization, including the characteristics of patients receiving these services, factors that shape clinician decision making, and predictors of outcomes of civil commitment hearings (3, 4). Moreover, a small number of randomized controlled trials (RCTs) have examined outpatient commitment (i.e., court-ordered, community-based treatment for individuals with severe mental illness) with mixed findings (5). By comparison, involuntary psychiatric hospitalization continues in every U.S. state, largely without RCTs supporting its use.

Ethical and practical concerns are key reasons for the lack of RCTs comparing involuntary psychiatric hospitalization with outpatient care. Randomly assigning individuals who meet emergency or inpatient commitment criteria to outpatient follow-up care instead of usual care (e.g., involuntary hospitalization) carries substantial risks, including that study participants might harm themselves or others. Such a trial would be unlikely to satisfy the equipoise between study arms needed for randomization. Even if robust outpatient models that would result in equipoise for a subset of patients were offered, research oversight organizations may hesitate to authorize random treatment assignment of certain patients in crisis, such as acutely suicidal or homicidal individuals. Furthermore, many researchers and clinicians might not agree to participate in these trials without protections from malpractice liability or other legal claims.

Some RCTs have examined aspects of involuntary psychiatric hospitalization, such as strategies to prevent use of seclusion and restraint; however, RCTs seeking to evaluate more fundamental purposes of involuntary psychiatric hospitalization (e.g., preventing self-harm or violence due to mental illness) have been rarer. In one example, a 2008 trial randomly assigned 393 patients in California who met involuntary hospitalization criteria for danger to self or grave disability (i.e., inability to care for self) due to mental illness to usual locked inpatient care or an unlocked crisis residential facility (6). The authors reported that patients who had been randomly assigned to the unlocked setting had greater satisfaction with services and short-term improvement in several psychiatric symptoms compared with those assigned to locked inpatient care (6). Although its findings were intriguing, the trial also had considerable limitations because most randomly assigned participants did not complete all follow-up interviews and the study did not address several key outcome measures, such as incidents of absconding or self-harm (6).

Observational Studies

Because of these challenges surrounding RCTs, observational studies have been the mainstay of research into involuntary psychiatric hospitalization (3). Comparing treatment outcomes among groups by controlling for covariates has been one method for studying these practices, sometimes with surprising findings. For instance, a 15-year study using propensity score matching on >145,000 cases of inpatient admissions in Germany found that treatment on unlocked psychiatric units was associated with decreased probabilities of suicide attempts and absconding compared with treatment on locked units (7). These types of studies are thought provoking but also have methodological concerns, including the potential for confounding factors (e.g., clinician impression, availability of social supports, and past attempts at community treatment) that might not be fully addressed and likely shape clinical decision making around involuntary care (4).

Additional naturalistic studies with quasi-experimental designs have been conducted. For instance, one study examined Virginia’s use of temporary detention orders (TDOs) that lasted up to 48 hours before commitment hearings; however, hearings could be held earlier or delayed (e.g., because of weekends or holidays), allowing comparisons along a spectrum ranging from approximately 24 to 96 hours of detention before hearings (8). By examining 500 Medicaid recipients placed under TDOs between 2008 and 2009, the authors found that increased TDO length was associated with reduced risk for subsequent hospitalization after commitment hearings, suggesting that longer psychiatric holds may facilitate stabilization (8). Yet, in some circumstances, longer TDOs might also lead to longer total time in the hospital (i.e., TDO stays combined with post-TDO hospitalization) compared with shorter TDOs (8).

Future Directions

Research-based methods alone cannot resolve all the questions surrounding involuntary psychiatric hospitalization. Besides limitations arising from study methodologies, translating study outcomes into policy requires balancing clinical outcomes, such as incidents of self-harm or violence, with notions of personal liberty and autonomy, which are harder to measure. As noted by Appelbaum (4), “Difficult choices must be made about the relative weights our society places on freedom, autonomy, and paternalistic beneficence. These are questions of values, not numbers.” Still, more systematic data collection and research can shape the use of these policies, including their effects on patients, families, clinicians, and the broader public, as well as systems (e.g., hospitals, courts, and police) tasked with providing these services (4).

Collecting Basic Data

Estimates suggest that hundreds of thousands of involuntary psychiatric holds take place annually in the United States; however, many states do not publicly track these figures, and it is unknown how many emergency and inpatient commitments occur each year (2, 9). Regardless of the feasibility of RCTs and observational studies surrounding involuntary psychiatric hospitalization, basic data collection is needed to better track the use of these interventions across the country (2, 9). States should develop systems for collecting and reporting standardized data regarding involuntary psychiatric hospitalizations, including emergency and inpatient commitments, ideally with national coordination of these efforts (2, 9).

Of note, a patient’s legal status may not always reflect the degree of voluntariness associated with hospitalization (i.e., some “voluntary” patients may feel coerced into hospitalization, whereas some “involuntary” patients may not necessarily oppose hospitalization). Nonetheless, clinicians and other first responders must rely on legal statutes for involuntary psychiatric hospitalization, typically requiring legal documentation and attestation that patients meet specific legal criteria. Because public policies govern the use of involuntary psychiatric hospitalization, better tracking is necessary to characterize the frequency and circumstances in which these laws are applied.

Measuring Outcomes

Beyond collecting basic data surrounding involuntary psychiatric hospitalization, such as the frequency of use, researchers and policy makers should also measure short- and long-term outcomes associated with these policies (4). Because legal statutes usually include specific criteria (e.g., danger to self or others) for authorizing these interventions, it is essential to study whether emergency and inpatient commitments truly decrease the incidence of these types of outcomes (e.g., self-harm, violence, or inability to care for self) over time (4). Additional associated outcomes worth investigating include those at the systems level (e.g., emergency department utilization, frequency of homelessness, and incarceration rates) and at the individual level (e.g., severity of psychiatric symptoms, medication use, and general well-being) after involuntary psychiatric hospitalization.

It is important to note that involuntary psychiatric hospitalization can be highly distressing to patients and their families. As with investigation of any clinical intervention, research on involuntary psychiatric hospitalization must weigh potential benefits, such as alleviating psychiatric illness and preventing suicide or violence, with potential harms, such as worsening of psychiatric distress, perceptions of coercion, separation from social supports, loss of housing or employment, and financial consequences of hospital-level care (10). Research surrounding involuntary psychiatric hospitalization is often conducted by people in positions of authority, such as clinicians, researchers, and policy makers, but the perspectives of patients, families, and others with lived experience must be incorporated into these efforts.

Reducing Unnecessary Use

Broader policy reforms are needed to address social determinants of health, such as homelessness, poverty, criminal legal involvement, and access to firearms, that shape the need for involuntary psychiatric hospitalization. Additional research, including RCTs and observational studies, can help guide these efforts, for instance, by identifying policies that might prevent unnecessary use of involuntary psychiatric hospitalization. As an example, research suggests that psychiatric advance directives (PADs) may be one way to help address patients’ mental health needs without involuntary hospitalization (5, 11). A 2016 meta-analysis of RCTs found that these types of advance directives—but not community treatment orders, compliance enhancement measures, or integrated treatment services—were associated with reductions in compulsory psychiatric admissions (5). Nonetheless, PADs have variable legal recognition across the United States, and many patients and mental health professionals do not understand how or why to use PADs; therefore, they rarely do so (11).

Intensive home treatment (i.e., high-intensity outpatient psychiatric care with home visits) is another alternative intervention worth further investigation in U.S. contexts. RCTs in international settings suggest that intensive home treatment may be associated with decreased days in the hospital over 1–2 years of follow-up, with comparable patient satisfaction and clinical outcomes such as suicide attempts or suicide (12, 13). These RCTs have typically studied patients in acute psychiatric crisis who may generally require hospitalization, not just those requiring involuntary hospitalization (12, 13). Moreover, some patients with chronic mental health needs in U.S. settings already receive high-intensity outpatient services, such as assertive community treatment. Nonetheless, home-based treatment remains understudied as a potential and acute stabilizing option to reduce the need for involuntary psychiatric hospitalization in the United States.

Conclusions

Policy makers across the United States are seeking to expand use of involuntary hospitalization, including broadening civil commitment criteria for people with mental disorders, as well as people with substance use disorders (14, 15). Accordingly, the importance of systematically monitoring, studying, and improving involuntary hospitalization practices has become even more relevant (9). Despite the controversies surrounding involuntary psychiatric hospitalization, many would likely agree that its use should be limited as a last resort when all other options have run out. Whether or not research-based methods can ultimately answer every question about involuntary psychiatric hospitalization, it remains clear that far too many questions remain unexplored.