Abstract
SummaryBackgroundDisparities in involuntary psychiatric hospitalisation between population subgroups have been identified in adults, but little is known about the factors associated with involuntary hospitalisation in children or adolescents. We did a systematic review, meta-analysis, and narrative synthesis to investigate the social and clinical factors associated with involuntary psychiatric hospitalisation among children and adolescents.MethodsWe searched MEDLINE, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials for studies of any type up to July 22, 2020, that compared the characteristics of voluntary and involuntary psychiatric inpatients (mean age of sample ≤18 years). We synthesised results using random effects meta-analysis on unadjusted data and by narrative synthesis. Heterogeneity between studies was calculated using I2. This study is registered on PROSPERO, CRD42020099892.Findings23 studies from 11 countries were included in the systematic review and narrative synthesis, of which 19 studies (n=31 212) were included in the meta-analysis. On meta-analysis, involuntary rather than voluntary hospitalisation of minors was associated with a diagnosis of psychosis (eight studies; odds ratio 3·63, 95% CI 2·43–5·44, p<0·0001), substance misuse (five studies; 1·87, 1·05–3·30, p=0·032), or intellectual disability (four studies; 3·33, 1·33–8·34, p=0·010), as well as presenting with a perceived risk of harm to self (eight studies; 2·05, 1·15–3·64, p=0·015) or to others (five studies; 2·37, 1·39–4·03, p=0·0015). Involuntary hospitalisation was also found to be associated with being aged 12 years or older (three studies; 3·57, 1·46–8·73, p=0·0052) and being from a Black rather than a White ethnic group (three studies; 2·72, 1·88–3·95, p<0·0001). There was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 51·3% to 92·3%). Narrative synthesis found that more severe illness and poorer global functioning was associated with involuntary hospitalisation.InterpretationOver-representation of involuntary psychiatric hospitalisation in certain groups might begin in childhood, potentially establishing a cycle of inequality that continues into adulthood. Further research into the systemic factors underlying these health-care inequalities and the barriers to accessing less coercive psychiatric treatment is urgently required, with specific consideration of racial and ethnic factors.FundingUK National Institute for Health Research and Wellcome Trust.
Highlights
The 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 potentially “traumatic, frightening and confusing”,1 and represents a centuries-old debate about society’s need to balance paternalism with autonomy
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.[6,7,8]
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
Summary
The 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 potentially “traumatic, frightening and confusing”,1 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. 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.[2] Involuntary hospitalisation usually confers additional protections, such as the right to appeal and mandatory post-discharge care. 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.[6,7,8]
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