Attitudes of psychiatric patients towards hospitalization: a national multicenter study in Norway | BMC Psychiatry

We found that almost a third of IH patients and 96.5% of VH patients said they wanted to be hospitalized when asked after admission to hospital.

Two studies and a review of outcome studies reported similar results. In a US study of 260 consecutively admitted patients, they found that 52.6% of the IH group said they needed hospitalization and 85.9% of the VH group said the same. [22]. An English mixed-method follow-up study of 778 IH patients from 22 rural and urban hospitals reported patient attitudes toward IH during the first week of hospitalization [35]. One year after discharge, 96 patients were re-interviewed. Patients with a higher level of functioning at baseline were less likely to consider their IH justified compared to patients with a lower level of functioning. Patients who were less satisfied with treatment in the first week of IH reported IH index admission as less warranted. The rate of IH patients who wanted hospitalization was not described on admission. However, 40% of IH patients surveyed after 1 year felt that their admission was justified. A qualitative study with a subsample of 59 of these patients found that at admission, 25.4% of patients with IH felt that hospitalization was necessary [36].

Based on a review article of 18 HI outcome studies, three of the studies interviewed patients with HI within the first 25 days after admission [37]. Between 39 and 58% of IH patients said that hospitalization was necessary. However, these studies were rated as low to moderate quality, and they focused on changes in attitudes at follow-up rather than what characterizes patients at admission.

How can we understand this seemingly counter-intuitive finding? There are many dilemmas associated with this type of research. Voluntary inpatients (HV) would be expected to state that they want to be admitted and HI does not want to be admitted. However, studies have shown that patients do not always know if they are hospitalized voluntarily or involuntarily. In a Norwegian study, they found that 41% of IH patients thought they were in voluntary status, while 32% of VH patients thought they were in involuntary status. [38].

In primary health care, there may be a tradition of using HI when the physician is unsure whether the patient is psychotic or suicidal. In specialist care, there could be a shortage of beds resulting in an increased threshold for acute admissions. Lack of less restrictive alternative forms of care has been shown to be associated with increased use of HI [15].

In a Norwegian study of the attitudes towards IH of different stakeholders (ex-patients, parents of patients, members of monitoring committees, psychiatrists, other doctors and lawyers), psychiatrists and doctors were more favorable to the use of HI for patients unable to care for themselves, harm themselves or others, compared to other groups [39].

The reasons why doctors outside the psychiatric hospital want to admit patients involuntarily may be many, including that the doctor may have been uncertain as to whether the patient would voluntarily remain in the hospital, discharge on their own and would harm himself or others due to an unstable state of mental health. The doctor may be afraid of making a serious mistake. The use of HI could be an ultimate safeguard for the doctor. Doctors at a municipal emergency primary health care clinic have limited time to assess symptoms and list the pros and cons of IH, and may not have explored and listened carefully to the patient’s opinions about whether or not to be hospitalized. Doctors often don’t know the patients very well [40, 41]. Doctors may fear being criticized by health authorities for misassessing patients and therefore choose IH to be on the side of legal certainty [41]. Cultural or traditional aspects can also interfere. A study of informal coercion in 10 countries indicates that mental health professionals work with ambivalence and conflicting expectations [42].

In Norway, the Mental Health Care Act has a section 3-4 which prevents the transfer from voluntary admission to involuntary admission once the patient is admitted [43]. A voluntary hospitalized patient has the right to release himself at any time if he is not in danger to himself or to others. The VH patient cannot be converted to mandatory observation or mandatory mental health care. However, the prohibition of the first paragraph does not apply in cases where the discharge means that the patient poses an obvious and serious risk to his life and health and that of others. Very few cases in Norway are converted from VH to IH (201 in 2018) [44]. In some countries they do not have such a ban on converting VH to IH. In Denmark (2001), the proportion of HI adults out of the total number of psychiatric inpatients admitted that year was 7.1%. [45]. However, in Denmark in the same year, the proportion of patients forcibly detained inside the hospital (converted from VH to IH after a maximum of 7 days of hospital admission) was 8.1% . This shows that the Danish Mental Health Care Act has a more open possibility to accommodate the uncertainty GPs may have, without discharging the patient and then readmitting the patient with an IH status.

For the patient, there may be changes in attitude towards hospitalization during the admission phase. Some studies have focused on the IH admission process from the patient’s perspective. IH patients felt scared, overwhelmed, confused and lost control of the admissions process. There were also concerns about disrupted family relationships [46, 47]. IH patients wanted healthcare staff to focus more on patient contact, closeness and understanding. They wanted staff to wait instead of act. Doctors stressed the importance of human contact and mutual relationships in hospital settings to prevent coercion [47]. For caregivers, the most common reaction to admission was relief, worry and guilt, and frustration over delays in getting help in acute settings [48].

In our study, IH patients who said they wanted to be admitted had better mental health status with better overall functioning, consumed less medication, and were assessed with less suicidal danger before admission. However, they scored higher on depression. In the multivariate analysis, the depression factor was not given significance as a predictor (Table 3). These results are all descriptions of patients with IH with less severe psychiatric symptoms and – we might assume – with better understanding. However, these results are in contrast to the retrospective results of IH patients who justified their admission had a lower overall level of functioning at admission. [35].

The police are the only body empowered to use force against people outside the psychiatric hospital [49]. Police are only needed when patients are aggressive and need to be protected and prevented from harming themselves or others. This matches our findings that the predictors of IH patients wanting to be admitted were; less transported by the police, less aggressive and less agitated and less likely to use drugs. Overall, IH patients who wanted admission may not have needed police help because of their better behavior and were not affected by illegal drug use.

As expected, in our study almost all VH patients wanted to be admitted. The results seem to confirm that VH patients agreed that it was a correct decision by the GP to admit them. However, 3.5% of VHs said they did not want to be admitted. We did not have a follow-up question that could explain this finding. However, some VH patients have reported in several studies that admission to a psychiatric emergency unit in itself felt like coercion [50,51,52,53,54]. Our results could also mean that HIs are used too often in Norway since almost a third said they wanted to be hospitalized. Maybe GPs should use more time and investigate patient’s opinion on admission more deeply in dialogue during consultation and closer discussion with hospital if HI is the best solution for the patient.

In Norway, there has been a legal adjustment with the introduction of consent jurisdiction in the new Mental Health Care Act from autumn 2017. Nevertheless, admission to compulsory mental health care (IH ) has not been reduced in recent years. At the Norwegian national level, the number of references for HI seems very similar in 2016 (11,939) to 2018 (11,783). There are no calculations for the last 4 years [55].

Strengths and limitations

The main strength of this study was a large and representative sample of consecutively admitted patients. The inclusion of patients did not depend on the patients’ consent letter. Thus, all cases were included in the study. In Norway we have a national system of free psychiatric care and no acute private health care system. Inclusion of cases did not depend on patient consent.

The group of missing patients (287 cases) who did not answer whether they wanted or did not want to be admitted did not differ from the others on major characteristics such as sex, age, drug use and levels. of general symptoms (HoNOS).

The limitations were that we had multiple raters and locations with no ability to perform a reliability test across all raters. There could also be a delay until the evaluators asked the question of wanting admission or not during the admissions process, since we had not recorded when the question was asked, and what type of health professionals have asked the question.

Attitudes of psychiatric patients towards hospitalization: a national multicenter study in Norway | BMC Psychiatry

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