By Domenico Giacco and Stefan Priebe

Abstract

Background

Psychiatric patients showing risk to themselves or others can be involuntarily hospitalised. No data is available on whether following hospitalisation there is a reduction in psychopathological indicators of risk such as suicidality and hostility. This study aimed to assess changes in suicidality and hostility levels following involuntary admission and their patient-level predictors.

Methods

A pooled analysis of studies on involuntary treatment, including 11 countries and 2790 patients was carried out. Suicidality and hostility were measured by the Brief Psychiatric Rating Scale.

Results

2790 patients were included; 2129 followed-up after one month and 1864 after three months. 387 (13.9%) patients showed at least moderate suicidality when involuntarily admitted, 107 (5.0%) after one month and 97 (5.2%) after three months. Moderate or higher hostility was found in 1287 (46.1%) patients after admission, 307 (14.5%) after one month, and 172 (9.2%) after three months. Twenty-three (1.2%) patients showed suicidality, and 53 (2.8%) patients hostility at all time-points. Predictors of suicidality three months after admission were: suicidality at baseline, not having a diagnosis of psychotic disorder and being unemployed. Predictors of hostility were: hostility at baseline, not having a psychotic disorder, living alone, and having been hospitalized previously.

Conclusions

After involuntary hospital admission, the number of patients with significant levels of suicidality and hostility decreases substantially over time, and very few patients show consistently moderate or higher levels of these symptoms. In patients with psychotic disorders these symptoms are more likely to improve. Social factors such as unemployment and isolation could hamper suicidality and hostility reduction and may be targeted in interventions to reduce risk in involuntarily admitted patients.

Main results

More than 50% of the involuntarily admitted patients showed at least moderate levels of either suicidality or hostility when they were admitted; 14% of suicidality, 46% of hostility, and 6% of both. For most patients suicidality and hostility reduced over time. Only a small percentage of patients were consistently rated as suicidal or hostile (0.8% and 5.2% respectively).

The general trend of substantial suicidality and hostility reduction was found across countries, despite very different legislations, health care systems and practices of coercive treatment [3,12]. The precise extent of improvement showed some variation among countries, but these differences should be interpreted with much caution as the absolute numbers of patients with suicidality or hostility at follow-ups were rather small in most countries.

Very few patients consistently showed moderate or higher levels of suicidality and hostility throughout the study period. Yet, for some other patients symptoms fluctuated over time. Suicidality and hostility tend to decrease in those patients who have them initially and can occur in others who did not show them when they were admitted.

The prediction of suicidality and hostility after three months showed that–in addition to the baseline levels of the given symptom–being diagnosed with a psychotic disorder and better social support, in form of employment and social contacts, predicted more favorable outcomes. These variables predicted differences that were not only statistically significant but also clinically relevant.

Comparison with literature and interpretation of findings

Involuntary hospitalisation and reduction in suicidality and hostility.

The reduction of suicidality and hostility after involuntary admission is more evident than the improvement of general symptoms and global functioning of patients. Existing observational studies have suggested only limited improvements of general symptoms and minimal, if any, social gains following involuntary admissions [2,5,7].

There are several possible explanations for these differences:

  1. Patients with more or less chronic disorders and a consistently poor social situation may be involuntarily admitted because of fluctuating psychopathological risk indicators rather than because of generally high symptom levels. A mere regression to the mean will then show a reduction of risk levels, but not necessarily a substantial improvement of general symptoms or the social situation.
  2. Suicidality and hostility may be particularly alarming for clinicians so that they focus treatment on them and, hence, achieve more substantial improvements on these symptoms than on other outcomes.
  3. Hospital wards can provide a regulated and protective environment with supervision through staff and contacts with other patients. This setting might have an especially positive effect on suicidality and hostility [17,18].

  4. Predictors of sustained risk.

    Patients diagnosed with a psychotic disorder were less likely to show suicidality and hostility three months after involuntary admission. This finding held true when the influence of baseline suicidality and hostility levels and other patient characteristics were also considered in the analysis.

    The high likelihood of the reduction of suicidality in patients with psychotic disorders (four times higher than for other patients) seem to be inconsistent with other studies which have shown a high risk of suicide in these patients, especially after discharge from hospital [19,20]. In many services, patients with psychotic disorders represent the largest single diagnostic group among involuntary admitted patients. Clinicians are likely to be familiar with treating these patients, and experienced in using the appropriate treatment methods. This might result in a greater suicidality and hostility reduction in patients with psychoses [21,22] than in patients with non-psychotic disorders for whom it can be more difficult to find effective treatment methods in in-patient settings.
    Having both suicidality and hostility at the time of involuntary admission did not predict a higher probability of having either suicidality or hostility after three months. This is inconsistent with some previous studies in which hostility was predictive of suicidal behavior. Yet, the previous studies were not conducted in involuntary patients [23,24].In addition to baseline risk levels and the clinical diagnosis of a non-psychotic disorder, social factors were identified as predictors of suicidality and hostility after three months.The association between unemployment and suicide risk is well documented in the general population [25,26]. The higher levels of suicidality and hostility following discharge in patients who were unemployed confirms this association and suggest that it may also apply to involuntary patients. Further research may explore whether effective vocational rehabilitation, initiated during or after hospital treatment, can reduce suicidality, in addition to potentially improving other health and social outcomes.Hostility after three months was more frequent among patients with previous hospitalisations, which may reflect a more persistent course of the illness, and among those living alone. Associations between social isolation and levels of hostility have been shown before [27]. Hostility might both lead to social isolation and be influenced by it. Programs to increase social networks of patients with severe mental illness can aim to break this cycle and may be evaluated as to whether they indeed reduce hostility levels.

    In the absence of evidence from randomised controlled trials, the findings of this study provide the best available support to date that involuntary admissions are indeed followed by a reduction of suicidality and hostility. Even if these symptoms fluctuate over time and the identified improvements may be influenced by a regression to the mean, involuntary hospital admission is followed by a substantial and clinically relevant reduction in suicidality and hostility, in particular in patients with psychotic disorders.

    The findings may inform ethical debates about the justification of involuntary admissions. One major aspect for ethical decision making in clinical practice is beneficence [28]. The substantial improvement of suicidality and hostility can be seen as an important benefit for patients and suggest the beneficence of involuntary admissions.

    Future research should explore the exact mechanisms leading to improvements of suicidality and hostility, and identify which treatments are especially effective in facilitating these improvements. Interventions may aim to foster patients’ social inclusion. Getting patients into regular employment and overcoming their social isolation might have the specific benefit of risk reduction. This may require innovative strategies, e.g. using peer support, befriending schemes, and specific social interventions.

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Giacco D, Priebe S (2016) Suicidality and Hostility following Involuntary Hospital Treatment. PLoS ONE 11(5): e0154458. doi:10.1371/journal.pone.0154458