Unfreiwillige psychiatrische Hospitalisierungen im Kanton Zürich 1995 bis 2001: Wieviel? Wer? Wie? Mit welchem Ergebnis?

Abstract

Background: There is a long-term discussion on legitimation and ethical foundation of coercive treatment in psychiatry. Mental health professionals as well as society tolerate coercive measures in a position of double paternalism. Medical paternalism favours the hope of fullilling the assumed real will of a patient by treating the malady that darkens the patient's will. Social paternalism seeks to protect members of society from perceived though not epidemiologically proven risks stemming from mentally ill persons. Epidemiological data on involuntary hospitalisation has not been available for Switzerland at methodologically sufficient standards. Aims: This paper aims at describing the frequency of involuntary hospitalisation, referral patterns for inpatient treatment, therapeutic measures undertaken and outcome of involuntary patients as compared to voluntary patients. Methods: Involuntary hospitalisation was operationalised as physicians' ratings of the presumed will of the patient, documented in the database PSYREC of the Swiss canton of Zurich. This database covered all admissions between January 1, 1995 and December 31, 2001 (n = 50 055). It was used to estimate the proportion of involuntary hospitalisations among all psychiatric admissions. A population-based age and sex standardised rate of involuntary hospitalisations per 1000 inhabitants was calculated for the years between 1996 and 2001. Indepth analysis of referral patterns, therapeutic measures and outcome was performed in a subsample of n = 24607 treatment episodes from January 1, 1998 until December 31, 2000. Results: About 33% of all hospitalisations between 1995 and 1997 were rated as involuntary. For the period between 1998 and 2001 the rate of involuntary hospitalisations had decreased to a lower level of about 28%. The rate of involuntary hospitalisations per 1000 inhabitants rose from 1.57 in 1995 to 1.99 in 2001. The 6-year increase of 27% in the rate of involuntary hospitalisations was considerably smaller than the simultaneous increase of more than 50% for the total hospitalisation rate in the same period. Male and female patients had very similar risks of involuntary hospitalisation. The age profile of voluntary and involuntary patients was similar. Involuntary admissions were more prevalent among patients with diagnoses at admission of mania (F30), delusional disorders (F22) and schizotypal disorders (F21). The great majority of involuntary intakes were initiated by the health care system (general practitioners and psychiatric specialists both >25%, somatic hospitals 17%). Legal authorities were responsible for only 5% of involuntary admissions. The risk of being coercively medicated during the hospital stay was 6-fold for involuntarily admitted patients. Their risk of fixation or isolation was 5.6 times higher. Psychopharmacological medical ion (either forced or voluntary) is the most prominent therapeutic measure during the hospital stay (for both voluntary and involuntary patients in about 75%). Involuntary patients receive more crisis intervention, but less other therapeutic measures during their stay as compared to voluntary patients. Physicians' ratings of the outcome of involuntary stays displayed no difference to the outcome of voluntary stays. Discussion: The rate of involuntary treatment is high for the canton of Zurich compared to other European countries. However, hospitalisation rates have increased faster for voluntary patients than involuntary patients, probably due to changing treatment habits in the mental health care system.