Coercion and Involuntary Care: A Study of Involuntary and Voluntary Psychiatry Inpatients in Dublin

Abstract

Involuntary care is a feature of mental health services around the world. In addition to involuntary admission and treatment, specific coercive or restrictive practices including seclusion and physical restraint occur in inpatient mental health settings. This study aimed to determine the relationships, if any, between these formal coercive practices and perceived coercion on admission among psychiatry inpatients in Ireland, as well as any relationships between perceived coercion on admission and variables such as age, gender, and diagnosis. This study also aimed to determine the relationships between objective necessity for involuntary treatment as measured by the Compulsory Treatment Checklist (CTC), legal admission status (voluntary or involuntary) and various clinical parameters (e.g., symptoms, insight) in an Irish inpatient psychiatry setting.

I included 107 psychiatry inpatients aged 18 years or over who were admitted to the acute psychiatry admission units in Tallaght University Hospital and Connolly Hospital, Dublin, Ireland over a 30-month period between September 2017 and February 2020. Over a quarter (27.1%) of participating patients had involuntary status; nine (8.4%) had experienced at least one episode of seclusion, and ten (9.3%) had experienced at least one episode of restraint. When corrected for multiple testing, I found perceived coercion on admission to be significantly associated with involuntary status; perceived negative pressures on admission were significantly associated with involuntary status; and negative affective reactions to hospitalisation on admission were significantly associated with birth in Ireland. Total score across these four subscales was significantly associated with involuntary status. On multi-variable analyses, when corrected for multiple testing, seclusion and physical restraint did not have any significant associations separately but experience of seclusion or restraint when analysed together was associated with involuntary status. Each multi-variable model explained just over one third of the variance in the distribution of seclusion and restraint practices.

Higher Compulsory Treatment Checklist scores were significantly and independently associated with involuntary status (p<0.001), more positive symptoms of schizophrenia (p<0.001), and younger age (p=0.031). In this sample, the optimal cut-off score was 16.5, which detected compulsory treatment with a sensitivity of 82.8% and specificity of 69.2%. Although limited evidence is present to date on the use of this tool in other jurisdictions, I concluded that although useful, performance of this tool will likely vary across jurisdictions, resulting in different optimal cut-off scores in different countries.

Overall, I found perceived coercion on admission, assessed in retrospect by the patient, to be more closely associated with involuntary status and symptoms than it is with subsequent use of formal coercive practices, such as seclusion and restraint. This is an important finding in the context of proposed reforms to the Mental Health Act governing such practices. Use of seclusion and restraint is most strongly associated with involuntary admission status and, in the case of seclusion, younger age, rather than gender, diagnosis, symptoms, cognitive function, global functioning, therapeutic alliance, attitudes towards medication or insight. While I have explored the network of interactions between involuntary status and use of seclusion and restraint, this merits much closer attention, especially as use of seclusion and physical restraint appears to be associated with involuntary legal status independent of level of symptoms, therapeutic alliance or insight.