[Articles] Clinical and social factors associated with involuntary psychiatric hospitalisation in children and adolescents: a systematic review, meta-analysis, and narrative synthesis

IntroductionThe 2018 UK independent review of the Mental Health Act 1983 recognises that the use of involuntary psychiatric hospitalisation can “help restore health, and even be life-saving”, but is also potentially “traumatic, frightening and confusing”,UK Department of Health and Social Care
Modernising the Mental Health Act: increasing choice, reducing compulsion. and represents a centuries-old debate about society's need to balance paternalism with autonomy. Involuntary hospitalisation is generally used as a last resort and is designed to offer protection to those who are temporarily unable to protect themselves or those around them due to the presence of a mental disorder. Although mental health legislation differs internationally and even intranationally, an involuntary hospitalisation is authorised only when specific legal criteria are met. In most European countries, these criteria include presenting with a broadly defined mental disorder and risk to oneself or others.European Commission
Compulsory admission and involuntary treatment of mentally ill patients—legislation and practice in EU-member states. Involuntary hospitalisation also usually confers additional protections, such as the right to appeal and mandatory post-discharge care. However, involuntary treatment is sometimes experienced as traumatic,Akther SF Molyneaux E Stuart R Johnson S Simpson A Oram S Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis. can lead to future reluctance to engage with mental health care,Weich S McBride O Twigg L et al.Variation in compulsory psychiatric inpatient admission in England: a cross-classified, multilevel analysis. and can be associated with other restrictive interventions such as seclusion and restraint.Sashidharan SP Mezzina R Puras D Reducing coercion in mental healthcare. In addition, growing evidence indicates that factors outside of those specified in mental health legislation can affect and potentially systematically bias decisions around who needs involuntary treatment.Walker S Mackay E Barnett P et al.Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesis.Barnett P Mackay E Matthews H et al.Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data.Sheridan Rains L Weich S Maddock C et al.Understanding increasing rates of psychiatric hospital detentions in England: development and preliminary testing of an explanatory model.In adults, people from Black and minority ethnic groups are more likely to be hospitalised against their will than people from White and non-minority groups.Barnett P Mackay E Matthews H et al.Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. Other sociodemographic factors associated with involuntary care of adults are male gender, unemployment, receiving welfare benefits, and living in areas of increased deprivation.Walker S Mackay E Barnett P et al.Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesis. Additionally, people with a diagnosis of psychosis, those brought into hospital by police, and those who have been hospitalised involuntarily before are more likely to have an involuntary than a voluntary admission.Walker S Mackay E Barnett P et al.Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesis. However, little is known about the social and clinical factors that could increase the likelihood of an involuntary psychiatric hospitalisation among children and adolescents. Given that a previous involuntary hospitalisation is associated with future involuntary hospitalisation, an involuntary hospitalisation in childhood or adolescence might increase the risk of further coercive care in adulthood, potentially establishing a cycle of health-care inequalities and increased use of coercive treatment among certain groups.Research in context

Evidence before this study

We did preliminary searches of MEDLINE, PsycINFO, and Embase between January, 1983, and May, 2018, with no restriction by language, as a scoping review. Our search terms included “mental health” OR “involuntary treatment” OR “psychiatric hospitalisation” AND “risk factor”, and we limited the search to studies of individuals younger than 18 years. We identified few studies on children and adolescents and involuntary hospitalisation and no systematic reviews or meta-analyses on this topic.

Added value of this study

Previous research into the factors associated with involuntary psychiatric hospitalisation has focused on adult populations. Some adults, such as those from Black and minority ethnic groups and those who have been detained before, are more likely to have an involuntary than a voluntary psychiatric admission, but the reasons for these differences remain unclear. Based on a small number of studies, we identified that involuntary rather than voluntary psychiatric hospitalisation among children and adolescents was associated with older age (12 years or older), a diagnosis of psychosis, substance misuse, intellectual disability, and presenting as a risk to oneself or others. We also found that young people from crudely defined Black ethnic groups were more likely to be hospitalised involuntarily than were young people from White ethnic groups.

Implications of all the available evidence

The over-representation of certain groups in involuntary care might begin in childhood and establish cycles of health inequality that persist into adulthood. Understanding the social and clinical factors associated with involuntary hospitalisation among individuals younger than 18 years has received little academic, clinical, or political attention to date, but is essential in order to address causes and pathways of detention; identify targets for interventions to reduce the use of coercive practice; and prevent the establishment of potentially lifelong negative mental health treatment trajectories.

The small amount of research on the involuntary hospitalisation of children and adolescents to date could be because mental health legislation is used less often to detain them against their will than adults.UK Department of Health and Social Care
Modernising the Mental Health Act: increasing choice, reducing compulsion. However, the involuntary hospitalisation of children and adolescents is increasing in the UK, and has also been increasing in other countries, although up-to-date data are scarce.NHS Digital
Mental health services monthly statistics.Increase in involuntary psychiatric admissions of minors. A register study.Siponen U Välimäki M Kaivosoja M Marttunen M Kaltiala-Heino R Increase in involuntary psychiatric treatment and child welfare placements in Finland 1996–2003. A nationwide register study.Mertens C Campforts E Bal S Van Berlaer G Hubloue I Lampo S Risk factors of compulsory admission of minors. A case-control study. For example, in Finland, involuntary admissions of people younger than 18 years was 2·4 per 10 000 in 1995, and increased to 7·2 per 10 000 in 2000.Increase in involuntary psychiatric admissions of minors. A register study. In addition, although in most countries the essential legal criteria for the involuntary hospitalisation of children and adolescents are the same as for adults,Compulsory admission of mentally ill patients in European Union member states. the hospitalisation of children and adolescents is complicated by the role of parents and guardians. In the UK, for example, a person aged 15 years or younger with a mental disorder who does not want to be admitted can, according to the law, be admitted to hospital under parental consent, and would legally be defined as a voluntary patient.UK Department of Health
Mental Health Act 1983: code of practice. If this same young person's parents did not consent to the admission (or potentially one parent did and the other did not), they could be admitted to hospital involuntarily, under the Mental Health Act. The difference between these two scenarios is the views of the parents and not necessarily the needs of the young person. Equally, a 16-year-old in the UK who agrees to be admitted might be thought not to have capacity to consent to this because of their developmental level and can be admitted to hospital involuntarily under the Mental Health Act. Therefore, a binary distinction between voluntary and involuntary hospitalisation of young people might be overly simplistic. However, understanding more about the clinical and sociodemographic factors that are associated with legally defined involuntary and voluntary admissions of young people is important in order to design early interventions to reduce coercion; to ensure equity of care; and to potentially prevent negative service trajectories being established.

To our knowledge, no previous systematic reviews or meta-analyses of the factors associated with involuntary psychiatric hospitalisation among children and adolescents have been done. We aimed to assess international evidence on the associations between social and clinical factors and the involuntary hospitalisation of children and adolescents.

ResultsOur initial search identified 3358 potentially eligible studies, of which 555 were identified as duplicates, resulting in 2803 studies to be screened. After screening of titles and abstracts, 101 potentially relevant full-text articles were identified, of which 22 met inclusion criteria. The updated search on July 22, 2020, identified one additional study meeting inclusion criteria (figure). No further studies were identified on the forward or backward searches.Figure thumbnail gr1The key characteristics of the 23 included studies are shown in table 1. The studies were all from high-income countries, with 17 from seven European countries (Finland, Germany, UK, Netherlands, Switzerland, Belgium and Sweden), two each from the USA and Canada and one each from New Zealand and Israel. In all except one study, the maximum age of the participants was 18 years.Lindsey MA Joe S Muroff J Ford BE Social and clinical factors associated with psychiatric emergency service use and civil commitment among African-American youth. In total, 41 271 young inpatients were represented in the studies, of whom 9753 (23·6%) were hospitalised involuntarily. 19 of 23 studies were retrospective cohort studies, which relied on routinely collected data from hospital or national databases, and samples in all studies were representative of the population of patients admitted.

Table 1Key characteristics of included studies

11 studies were rated as moderate quality, seven were rated high quality, and five were rated low quality. There was considerable variability between the studies but one of the main areas of weakness was in the data analysis, with only seven studies controlling for potential confounders.

All studies were included in the narrative synthesis, and all except four studiesSiponen U Välimäki M Kaivosoja M Marttunen M Kaltiala-Heino R Increase in involuntary psychiatric treatment and child welfare placements in Finland 1996–2003. A nationwide register study.Involuntary psychiatric hospitalization of minors.Khenissi C Erkolahti R llonen T Saarijärvi S Adolescents' involuntary psychiatric treatment.Ottisova L Smith P Oram S Psychological consequences of human trafficking: complex posttraumatic stress disorder in trafficked children. were included in the meta-analysis (included participants n=31 212). These four studies were excluded from the meta-analysis because the exact number of voluntary or involuntary patients (or both) was not clearly stated. The full meta-analysis results are presented in table 2, and forest plots are provided in the appendix (pp 4–10).

Table 2Risk factors for involuntary psychiatric hospitalisation based on meta-analysis of unadjusted data

Our meta-analysis found that a diagnosis of intellectual disability was associated with involuntary rather than voluntary hospitalisation (four studies, OR 3·33, 95% CI 1·33–8·34, p=0·010). Intellectual disability was only clearly defined in one study, as an intelligence quotient of less than 80,Pros and cons of using the Mental Health Act for severe eating disorders in adolescents. and was given in addition to the primary diagnosis in all except one study.Jendreyschak J Illes F Hoffmann K et al.Voluntary versus involuntary hospital admission in child and adolescent psychiatry: a German sample.

The odds of an involuntary rather than voluntary hospitalisation were higher for young people with a diagnosis of psychosis than for those without psychosis (eight studies; OR 3·63, 95% CI 2·43–5·44, p<0·0001). Young people with a primary (not comorbid) diagnosis of substance misuse were more likely to be hospitalised involuntarily than voluntarily (five studies; 1·87, 1·05–3·30, p=0·032). A diagnosis of behavioural problems (which included diagnoses such as attention-deficit hyperactivity disorder and conduct disorder) was associated with decreased odds of an involuntary rather than voluntary hospitalisation (six studies; 0·71, 0·50–0·84, p=0·0012), as was a diagnosis of anxiety disorder (two studies; 0·19, 0·05–0·81, p=0·025).

Young people who were perceived to be at risk of harm to themselves (including self-harm, suicidal ideation, or suicide attempts) had increased odds of an involuntary hospitalisation compared with those not at risk (eight studies; OR 2·05, 95% CI 1·15–3·64, p=0·015), as did those who were perceived to be at risk of harm to others (including aggression, violent acts, or danger to others; five studies; 2·37, 1·39–4·03, p=0·0015). Having had a previous psychiatric hospital admission was not associated with involuntary hospitalisation among children and adolescents.

With the exception of anxiety and developmental disorders, there was substantial heterogeneity identified for all of the clinical factors included in the meta-analysis (I2 from 66·7% to 92·3%). Because there are no clear outliers in terms of data, it is likely that this heterogeneity is due to the variety of methods used to make clinical decisions about diagnosis and risk, as well as characteristics of different health and legal systems. In addition, the analysis of most of these variables was based on a small number of studies.

In terms of sociodemographic factors, we did not identify any association between gender and involuntary hospitalisation, although heterogeneity was very high (I2=80·4%). Few studies considered ethnicity, and categorisation was often crude when it was included, with a lack of clarity as to whether it was self-reported. However, the data recorded showed that the odds of an involuntary rather than a voluntary hospitalisation among children and adolescents from Black ethnic groups (including Black British, Black Caribbean, Black African, African American, and Black Other) was higher than those for young people from White ethnic groups (White British, White Irish, or White Other; three studies; 2·72, 1·88–3·95, p<0·0001). Among young people from Asian ethnic groups (Indian, Pakistani, Bangladeshi, Asian, or Other) and other ethnic groups (an ethnic group not listed or mixed ethnic origin), there was no significant difference in the risk of involuntary versus voluntary hospitalisation compared with young people from White groups, although this analysis was based on only two studies. For the analyses of ethnicity statistical heterogeneity was low.

Four studies (three from the UK and one from the USA) examined the association between ethnicity and involuntary hospitalisation further. In a UK-based historical cohort study, Corrigall and BhugraThe role of ethnicity and diagnosis in rates of adolescent psychiatric admission and compulsory detention: a longitudinal case-note study. found that differences in the use of the Mental Health Act according to ethnicity only occurred in those with psychosis. Young people from Black and Other ethnic groups with psychosis were more likely to be detained under the Mental Health Act at any point in their admission than those with psychosis in the White group (OR 3·0, 95% CI 1·3–6·7 for Black participants and 3·1, 1·1–8·8 for participants of Other ethnicities). In the non-psychosis group, there were no significant differences in use of the Mental Health Act.The role of ethnicity and diagnosis in rates of adolescent psychiatric admission and compulsory detention: a longitudinal case-note study. Kilgus and colleaguesKilgus MD Pumariega AJ Cuffe SP Influence of race on diagnosis in adolescent psychiatric inpatients. found that during a 1-year period in a state hospital facility in South Carolina, African American adolescents were twice as likely to be involuntarily hospitalised at the time of admission than White American adolescents (OR 2·051, p=0·043), controlling for both gender and diagnosis.Kilgus MD Pumariega AJ Cuffe SP Influence of race on diagnosis in adolescent psychiatric inpatients. In a UK cross-sectional study, Tolmac and HodesEthnic variation among adolescent psychiatric in-patients with psychotic disorders. found that young Black people were significantly more likely to be detained under the Mental Health Act than young White people on admission. However, when looking at the use of the Mental Health Act at any point during the hospitalisation, there was no significant difference between the ethnic groups.Ethnic variation among adolescent psychiatric in-patients with psychotic disorders.

Older adolescents (16–17 years old) were more likely to be involuntarily hospitalised than those aged 12–15 years (two studies, OR 2·82, 95% CI 1·04–7·63, p=0·042). In addition, adolescents aged 12 years or older were more likely to have an involuntarily rather than voluntary admission compared with those younger than 12 years (three studies; 3·57, 1·46–8·73, p=0·0052).

We found no evidence of an association between involuntary hospitalisation and whether a young person was living with their parents or family at the time of admission, although none of the four relevant studies clearly specified the living arrangements of those not living with family, so these participants could have included those living with friends, in an institution, or in foster care. Having a previous history of experiencing any type of abuse, physical abuse, or sexual abuse was not associated with involuntary hospitalisation. Although the data were not suitable for meta-analysis, Ottisova and colleaguesOttisova L Smith P Oram S Psychological consequences of human trafficking: complex posttraumatic stress disorder in trafficked children. found, contrary to their hypothesis, that young victims of trafficking (74% of whom had been subjected to physical or sexual violence) were no more likely to be involuntarily rather than voluntarily admitted for psychiatric inpatient care than those who had not been trafficked, despite the high rate of self-harm (33%) and suicide attempts (27%) identified in the trafficked group.Among included studies, there was no evidence of publication bias through visual examination of the funnel plots (appendix pp 16–24). We were able to do one meta-regression on publication year (before 2010 vs 2010 or later), but further post-hoc analysis was not possible due to the small number of studies. Restricting the analysis to high-quality studies was not feasible for the same reason. The meta-regression on publication year identified that in studies published in 2010 or later, young people with personality disorder were more likely to be admitted voluntarily than involuntarily (appendix p 15). There was no evidence that publication date was associated with the legal status of admission for any of the other variables.The narrative synthesis included all 23 studies. Most studies measured differences in gender between the voluntary and involuntary patients, but only four studies stratified the legal and diagnostic groups by gender. Jendreyschak and colleaguesJendreyschak J Illes F Hoffmann K et al.Voluntary versus involuntary hospital admission in child and adolescent psychiatry: a German sample. found that in those younger than 12 years, having a diagnosis of psychosis or intellectual disability and being male was significantly associated with an involuntary rather than voluntary admission. In patients aged 12 years or older, both male and female patients with a diagnosis of substance misuse disorders, psychosis, neurotic disorders, or intellectual disability were significantly more likely to be admitted involuntarily than voluntarily (the study was rated as high quality).Jendreyschak J Illes F Hoffmann K et al.Voluntary versus involuntary hospital admission in child and adolescent psychiatry: a German sample. Mears and colleaguesMears A White R O'Herlihy A et al.Characteristics of the detained and informal child and adolescent psychiatric in-patient populations. found that most of the involuntary patients with mood disorder diagnoses were female and most of those admitted involuntarily with a diagnosis of schizophrenia were male (the study was rated as low quality). In a high-quality Finnish register study, Kaltiala-HeinoIncrease in involuntary psychiatric admissions of minors. A register study. found that affective and neurotic disorders were the most common diagnoses among the female patients who were admitted involuntarily, whereas conduct disorders, psychotic disorders, and substance misuse were the most common diagnoses in the male patients who were admitted involuntarily. In a later, smaller, but also high-quality study (n=187), Kaltiala-HeinoInvoluntary commitment and detainment in adolescent psychiatric inpatient care. found that hostility, “temper tantrums”, or breaking property were significantly associated with being referred to hospital involuntarily, but only in girls.A range of measures was used to record the young people's psychiatric symptoms and level of functioning. These included the Children's Global Assessment Scale, Health of the Nation Outcome Scales for Children and Adolescents, Beck Depression Inventory-II, Brief Psychiatric Rating Scale, Global Assessment of Functioning, State-Trait Anxiety Inventory, and the Child Behaviour Checklist. In the seven studies in which these rating scales were used, five studies (three rated high quality, one moderate quality, and one low quality) found that young people admitted involuntarily had scores indicative of substantially more severe clinical presentation or poorer levels of functioning than those hospitalised voluntarily.Pros and cons of using the Mental Health Act for severe eating disorders in adolescents.Ellila HT Sourander A Välimäki M Warne T Kaivosoja M The involuntary treatment of adolescent psychiatric inpatients—a nation-wide survey from Finland.Laget J Chanez J-M Dubos P-F et al.Psychiatric hospitalisation of adolescents in Lausanne (Vaud): admissions, paths of care, role and subjective experience.Lindsey MA Joe S Muroff J Ford BE Social and clinical factors associated with psychiatric emergency service use and civil commitment among African-American youth.So P Wierdsma AI Kasius MC et al.Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth. These findings could not be included in the meta-analysis due to variation in how results were reported.Mears and colleaguesMears A White R O'Herlihy A et al.Characteristics of the detained and informal child and adolescent psychiatric in-patient populations. used the Health of the Nation Outcome Scales for Children and Adolescents, but instead of giving overall scores, they detailed the results of the individual sections. They found that those admitted involuntarily to 71 inpatient units in England and Wales had significantly more hallucinations and delusions, peer relationship problems, and family problems than those admitted voluntarily. However, those with physical illnesses, somatic symptoms, and emotional difficulties were significantly more likely to be admitted voluntarily than involuntarily.Mears A White R O'Herlihy A et al.Characteristics of the detained and informal child and adolescent psychiatric in-patient populations. A moderate-quality Canadian study by Persi and colleaguesPersi J Bird BM DeRoche C A comparison of voluntary and involuntary child and adolescent inpatient psychiatry admissions. found that there was no difference in clinical presentation or global level of functioning between the voluntary and involuntary patients, with no significant differences between the Children's Global Assessment Scale or the Child Behaviour Checklist scores between the two groups. However, although 80% of the patients were admitted involuntarily, only 11% of the patients remained involuntarily detained after psychiatric review, leading the authors to suggest that involuntary admissions might be overused.Only two studies reported whether any previous psychiatric hospital admissions were involuntary.Khenissi C Erkolahti R llonen T Saarijärvi S Adolescents' involuntary psychiatric treatment.So P Wierdsma AI Kasius MC et al.Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth. Khenissi and colleaguesKhenissi C Erkolahti R llonen T Saarijärvi S Adolescents' involuntary psychiatric treatment. found that more of the involuntary than voluntary patients had previously been sent for involuntary treatment (51·3% vs 14·9%, pSo P Wierdsma AI Kasius MC et al.Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth. also identified that a previous involuntary admission was significantly associated with involuntary versus voluntary admission (pContact with community psychiatric services before admission was reported in two high-quality studies.Involuntary commitment and detainment in adolescent psychiatric inpatient care.So P Wierdsma AI Kasius MC et al.Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth. So and colleaguesSo P Wierdsma AI Kasius MC et al.Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth. found that a lack of medical compliance and a lack of motivation for treatment, measured on the Severity of Psychiatric Illness Scale, were both significantly associated with involuntary hospitalisation on multivariate analysis, although it is unclea

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