- Email: [email protected]
Involuntary psychiatric hospitalization and its relationship to psychopathology and aggression
Accepted Manuscript
Involuntary psychiatric hospitalization and its relationship to psychopathology and aggression Pedro Henrique Canova Mosele , Guillierme Chervenski Figueir , Amadeu Antonio Bertuol Filho , ˆ Jose´ Antonio Reis Ferreira de Lima , Vitor Crestani Calegaro ˆ PII: DOI: Reference:
S0165-1781(17)32040-1 10.1016/j.psychres.2018.04.031 PSY 11354
To appear in:
Psychiatry Research
Received date: Revised date: Accepted date:
13 November 2017 15 March 2018 11 April 2018
Please cite this article as: Pedro Henrique Canova Mosele , Guillierme Chervenski Figueir , Amadeu Antonio Bertuol Filho , Jose´ Antonio Reis Ferreira de Lima , Vitor Crestani Calegaro , Involˆ ˆ untary psychiatric hospitalization and its relationship to psychopathology and aggression, Psychiatry Research (2018), doi: 10.1016/j.psychres.2018.04.031
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ACCEPTED MANUSCRIPT Highlights
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Having personal income was associated with voluntary admission. Suicide risk at admission was associated with voluntariness. Activation, resistance and positive symptoms were associated with involuntariness. Aggression in the first 24 hours of admission was associated with involuntariness. Data support involuntary hospitalization for patients with severe mental illness.
ACCEPTED MANUSCRIPT Involuntary psychiatric hospitalization and its relationship to psychopathology and aggression Pedro Henrique Canova Moselea*, Guillierme Chervenski Figueira, Amadeu Antônio Bertuol Filhob, José Antônio Reis Ferreira de Limac, Vitor Crestani Calegarod a
Psychiatry Residence, University Hospital of Santa Maria, , Santa Maria, RS, Brazil b
c
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Internal Medicine Residence, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil Medicine Course, Federal University of Santa Maria, , Santa Maria, RS, Brazil
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* Corresponding author:
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Pedro Henrique Canova Mosele
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Department of Neuropsychiatry, Federal University of Santa Maria, Santa Maria, RS, Brazil
Departamento de Neuropsiquiatria
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Universidade Federal de Santa Maria
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Av. Roraima, 1000 Santa Maria, RS
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Zip-code: 97105-900
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Phone number: +55 55 3213-1864 Fax: +55 55 30257596 Email: [email protected]
ACCEPTED MANUSCRIPT
Abstract The
current
study
investigates
the
relationship
between
involuntary
hospitalization, severity of psychopathology, and aggression. Adult psychiatric inpatients hospitalized from August, 2012 to January, 2013 were evaluated via
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the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Scale (OAS). Individuals were compared regarding voluntariness of hospitalization. Of the 137 hospitalizations in the period, 71 were involuntary (INV). The variables
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associated with involuntariness were being brought to hospital by ambulance or police, and aggression in the first 24 hours of admission. Risk of suicide at admission, and having personal income were associated with voluntariness. The dimensions of the BPRS associated with involuntary hospitalization were resistance,
and
positive
symptoms.
Involuntary
psychiatric
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activation,
hospitalization was associated with agitation, psychosis and aggression. The
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data support the indication of involuntary hospitalization for treatment of patients
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with severe mental illness.
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Keywords: Commitment of Mentally Ill, Psychiatry, Involuntary admission.
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1. Introduction The involuntary status of psychiatric hospitalizations is a widely-discussed theme and encompasses clinical, ethical, and juridical dimensions. The principle
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criteria used for employing this mode of hospitalization are the severity of the disorder, the presence of danger to oneself or to others, and the urgent necessity for treatment (Riecher and Rossler, 1993). However, there are important variations in the literature concerning indications and prevalence. This
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seems to reflect important legal, cultural, and structural differences between the mental health care systems throughout the world (Riecher and Rossler, 1993); (Salize and Dressing, 2004).
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In the 1970s in Brazil, a process of altering the basics of psychiatric care began. Embedded in the international, political, and ideological context of the
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time, it questioned the relevance and the implications of hospital treatment of
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the mentally ill (Del-Ben et al., 1999); (Jorge and França, 2001); (Hirdes, 2009). Since then, a great shift in the direction of prioritization of social rehabilitation
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and outpatient treatment in the model of mental health care in the country has taken place, mainly with the creation of Federal Law 10.216/2001. This law
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defines, in the only paragraph of article 6, types of hospitalization as “I – voluntary hospitalization: that which is done with the consent of the patient; II – involuntary hospitalization: that which is done without the consent of the patient and at the request of a third party; and III – compulsory hospitalization: that imposed by the courts” (Lei 10.216, 2001). In all these contexts, it is up to the
ACCEPTED MANUSCRIPT physician together with the responsible family members to evaluate and authorize psychiatric hospitalization as well as to define its end.
Various clinical and epidemiological data are associated with involuntary hospitalization in international studies. There is evidence of association with
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schizophrenia and other psychotic illnesses (Ng and Kelly, 2012); (Riecher et al., 1991), severity of symptoms (Hustoft et al., 2013), male gender (Riecher et al., 1991); (Wheeler et al., 2005) and low socioeconomic status (Webber and Huxley, 2004). At the same time, divergent opinions arising from the
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particularities of methodology, legislation, and context of the location of each study are common in the literature (Jaime et al., 2011); (Kelly et al., 2004).
Disagreements in the academic, clinical, and legal fields concerning
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involuntary psychiatric hospitalization have ensured that it continues to be polemical. In Brazil, studies on this topic, which permeates the daily work of
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psychiatric wards, are still scarce. Therefore, it is necessary to discuss and deepen the knowledge related to its implications and possible associated
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factors in the light of current scientific evidence. Our hypothesis was that
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involuntary psychiatric hospitalization is related principally to the severity of psychopathology and aggression. The objective was to study clinical and
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demographic factors associated with the involuntariness of psychiatric hospitalization in the context of a reference psychiatric emergency room for the central region of the state of Rio Grande do Sul in Brazil.
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2. Methods
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2.1 Subjects
A naturalistic study with patients hospitalized in the Psychiatry Service of the Hospital Universitário de Santa Maria (HUSM, University Hospital of Santa Maria) was performed. HUSM is a general hospital of high complexity and a
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reference for the Sistema Único de Saúde (SUS, Brazil’s Universal Health Service) for 42 municipalities in central Rio Grande do Sul (RS) serving a population of approximately 500,000. At the time of the study, the service
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consisted of a psychiatric emergency room and a mixed, closed hospitalization
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unit with 25 beds intended for short-term hospitalization.
The research subjects were patients admitted from August, 2012 to
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January, 2013 and made up part of a larger study that proposed to monitor
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episodes of aggression occurring during hospitalization, the partial results of which are published in separate article (Calegaro et al., 2014).
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The inclusion criteria were: (1) being from 18 to 65 years of age and (2)
being admitted to the Psychiatry Service of HUSM. Patients with acute psychiatric symptoms due to a general medical condition (e.g., delirium) were excluded.
ACCEPTED MANUSCRIPT 2.2 Measures and analytical methods
A research form was used to evaluate the sociodemographic, clinical, and prior relevant history of the patients. It was completed via psychiatric interview and review of medical records. Admissions were considered involuntary when
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determined by the on-duty psychiatrist or by judicial order (compulsory). The risk of suicide and heteroaggression were assessed by the on-duty psychiatrist at the emergency room. The diagnoses were coded according to the tenth edition of the International Classification of Diseases (ICD-10) and recorded on
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the discharge note.
The research team, which included residents in psychiatry, medicine undergraduates and a coordinator, were trained to use the study instruments
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before data collection. Inter-rater reliability was not tested objectively. A 40-days
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pilot phase was carried out to correct flaws in data collection.
The Brief Psychiatric Rating Scale (BPRS) evaluated the presence and
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severity of psychopathological symptoms grouped by the dimensions of Affect, Negative Symptoms, Positive Symptoms, Resistance, and Activation and was
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scored at admission by the residents in psychiatry (Shafer, 2005). The
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structured interview guide of the BPRS (SIG-BPRS) was used, increasing the reliability of the scale (Crippa et al., 2001)
The Overt Aggression Scale (OAS) was scored daily over the
hospitalization period by the medicine undergraduates to evaluate the presence of episodes of verbal aggression, physical aggression against objects, physical
ACCEPTED MANUSCRIPT aggression against self, and physical aggression against other people (Hellings et al., 2005).
The statistical analysis was done using SPSS v23. The sample was divided into two groups, voluntary hospitalizations (VOL) and involuntary (INV).
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The normality of the variables was tested and none were found to be normally distributed. Thus, the groups were compared using non-parametric tests: The Mann-Whitney U test, χ2 test, and Fisher’s exact test, on a case-by-case basis. A significance level of 5% was used for all tests. After the univariate analysis,
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multivariate analysis using forward stepwise logistic regression was done. Variables with p < 0.010 were selected and evaluated as to their relevance for inclusion in the model.
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2.3 Ethics of the study
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The study was approved by the Research Ethics Committee of Universidade Federal de Santa Maria (UFSM, Federal University of Santa
PT
Maria). Informed consent was obtained from all the patients, signed by
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themselves, their family members, or legal guardians.
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3. Results
A flow-chart of the sample composition is presented in Figure 1. It
demonstrates that 127 patients were selected among the 1,625 consultations performed during the study period. The general description of the sample, including demographic and admission data of the 137 participants of the study, can be found in Table 1. It demonstrates that the risk of hetero-aggression at admission, male gender, being single, separated or widowed, having no paying
ACCEPTED MANUSCRIPT job and being brought to hospital by ambulance or police were variables associated with involuntary admission. The risk of suicide at admission was associated with voluntary admission.
The analysis revealed no statistical significance in the median duration of
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hospitalization (VOL 8,5 days, Q1=2 days, Q3=21 days vs. INV 15 days, Q1=1 day, Q3=33 days), the absence of connection with any psychiatry service (VOL 27.7% vs INV 39.1%), the mean number of previous hospitalizations (4 for both groups), and it being the first hospitalization (VOL 27.3% vs INV 19.7%) or
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psychiatric consultation (VOL 19.7% vs. INV 22.5%).
There was a predominance of patients with a prior history of selfaggression in the VOL group (VOL 57.6% vs. INV 40.8%) and suicide attempt in
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the 24 hours prior to hospitalization (VOL 27.3% vs. INV 14.1%). More than half of the patients hospitalized presented a history of physical aggression (VOL
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65.2% vs. INV 73.2%). There was no statistical difference between the groups.
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The relationship between the diagnostic hypothesis on the discharge note and the voluntariness of the hospitalization is described in Table 2. Only the
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diagnosis of a major or recurrent depressive, or a borderline personality
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disorder were associated with the voluntariness of the admission.
A past history of compulsive marijuana use, related by patients and/or
family members (VOL 15.4% vs. INV 33.3%; p = 0.017) and current tobacco use (VOL 36.9% vs. INV 56.3%; p = 0.002) was significantly higher among individuals hospitalized involuntarily. When asked about adherence to the use of psychopharmaceuticals, only 28% of the total sample stated using them
ACCEPTED MANUSCRIPT regularly. There was no statistical relationship of this variable with the groups. Among the psychopharmaceuticals used at the time of hospitalization, there was a difference in the use of anticonvulsants (VOL 34.8% vs. INV 19.7%; p = 0.036), low-potency antipsychotics (VOL = 28.8% vs. INV = 11.3%; p = 0.009), and antidepressants (VOL 27.3% vs. INV 11.3%; p = 0.028). The
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use of lithium was greater among voluntary patients, however not statistically significantly so (VOL 33.3% vs. INV 18.3%; p = 0.051).
Figure 2 relates the voluntariness of psychiatric hospitalization to the
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presence of aggression in the week prior and the first 24 hours of admission. It presents that being verbally aggressive, or aggressive against objects in the week before and in the first 24 hours of hospitalization was statistically associated with the involuntariness of the admission. The same applies to the
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presence of physical aggression in the week before and in the first 24 hours of
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hospitalization.
Over the course of hospitalization, the INV group presented a greater
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mean on the OAS (17.30 ± 32.72) compared to the VOL group (5.91 ± 10.466)
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and this difference was statistically significant (p =0.007).
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Figure 3 presents the relationship between hospitalization voluntariness
and BPRS score. The VOL group was statistically associated with a higher score on the Affect dimension, while the Activation, Resistance and Positive symptoms dimensions were associated with de INV group.
Hereafter, the variables with p <0.010 were evaluated as to their relevance for inclusion in the logistic regression model. As a function of the necessary
ACCEPTED MANUSCRIPT sample size for the analysis of all the variables, only those of greatest relevance with respect to the underlying construct were selected. For example, inclusion of the variable “suicide risk” was preferred as opposed to “suicide attempt at admission”, “history of suicide attempt in the week before”, and “prior history of self-aggression”. The model was statistically significant (
= 68.803; p < 0.001)
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and represented a variance of 40.9% to 54.5% of the data.
The final model is presented in Table 3. It demonstrates that being brought to the hospital by ambulance or police was the major risk factor for the
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involuntariness of hospitalization. Also, the presence of aggression in the first 24 hours of admission were statistically associated with the INV group. Having personal income, and risk of suicide at admission were associated with the VOL
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group.
The variables not in the equation (not significant) were history of
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aggression in the week before, tobacco use, major or recurrent depression,
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borderline personality disorder, gender, and marital status.
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4. Discussion
Patients admitted involuntarily were in the majority male, with a
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psychopathological profile related to aggression, psychomotor agitation, positive symptoms, and resistance, while those hospitalized voluntarily presented higher scores of depression and anxiety, beyond being at greater risk of selfaggression.
The primary predictor of involuntary hospitalization was transport by ambulance or police, which could be explained by the fact that the INV group
ACCEPTED MANUSCRIPT presented more aggression in the week before. For these patients, the risk of aggression toward others was considered the primary motive for hospitalization. The INV group also presented greater aggression at admission and during psychiatric
hospitalization,
reinforcing
the
importance
of
involuntary
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hospitalization for containment of this behavior.
Various studies have found an association between aggression and involuntary hospitalization. Biancosino et al., (2009) studied 1,324 patients and found evidence that those involuntarily hospitalized were 4.75 times more likely
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to present violence during admission. Violent behavior was a predictor for a high BPRS score. A Swiss study with 2,017 participants, found that involuntarily hospitalized patients presented 2.16 times more episodes of severe aggression (Abderhalden et al., 2007). In Germany, Ketelsen, Zechert, Driessen, and
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Schulz (2007) found evidence that critical behavior leading to involuntary
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admission was one of the greatest risk factors for the presence of aggression.
Patients hospitalized involuntarily presented more severe illness reflected
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by the resistance dimension (hostility, uncooperativeness, suspiciousness),
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activation (excitement, tension, mannerisms-posturing), and positive symptoms (thought
content,
conceptual
disorganization,
hallucinatory
behavior,
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grandiosity), as measured by the BPRS. This tendency is directly related to the presented aggressive behavior, and possibly to the absence of insight, necessitating coercion in bringing such patients to the hospital. Hustoft et al., (2013) came to similar conclusions after interviewing 3,326 patients in 20 admission units, finding an association between involuntariness and being
ACCEPTED MANUSCRIPT brought to the hospital by police, beyond finding high scores when assessing the presence of aggression, agitation, delirium, and hallucinations.
A few Brazilian studies that analyzed factors associated with involuntary hospitalization present divergent findings. One study undertaken in the city of
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São Paulo by Chang, Ferreira, Ferreira, and Hirata (2013) evaluated the scores of 2,289 patients and found that 13.3% of hospitalizations were involuntary, associated significantly with female gender, psychosis, diagnosis of anorexia nervosa, schizophrenia, personality disorder, alcohol and substance related
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disorders. In another Brazilian study, Oliveira, Pinto, Aguiar, Sampaio, and Medeiros (2011) revealed, in a sample of 393 participants, that involuntary hospitalization was associated with male gender and presented a greater
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prevalence of aggression.
In our study, the patients hospitalized voluntarily were, in the majority,
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brought to the hospital by family members. The presence of suicide risk at admission was a predictor for the voluntariness of hospitalization. Factors as
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suicide ideation, planning and attempt were taken into account by the
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psychiatrist on-duty at the emergency room to determine the presence of
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suicide risk.
There was a greater prevalence of depressive disorders and of borderline
personality disorder in this group. Beyond this, they presented greater severity of symptoms related to the Affect dimension (anxiety, depression, guilt, and somatic) as evaluated by the BPRS.
ACCEPTED MANUSCRIPT The voluntariness of hospitalization was significantly related to prior use of anticonvulsants,
low-potency
antipsychotics,
and
antidepressants.
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demonstrates the concordance between the psychopathological context of these patients and the therapeutics used. There are similarities between these data and those found by Hustoft et al. (2013), who found higher scores for
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depression and a greater incidence of suicide ideation among patients hospitalized voluntarily.
Regarding the demographic variables, involuntariness of hospitalization
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was related to being single, divorced or widowed, and not having remunerative employment. Obverse to this, having personal income was a predictive factor of voluntariness of hospitalization. This seems to represent the impact of mental illness on productivity and on the capacity for relationships in the patients, as
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well as to corroborate the lack of socioeconomic support as a determining factor
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associated with involuntary hospitalizations. By the same token, Chang et al. (2013) found a significantly greater proportion of unmarried and unemployed
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people among those hospitalized involuntarily. Webber and Huxley (2004), in a study that evaluated 300 psychiatric assessments in two London districts, found
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an association between involuntary hospitalization and inefficiency in one’s
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social support network.
Attention must be paid to the differences between the general
psychopathological profile of the HUSM Psychiatry Service’s patients and those of other national and international studies. Bipolar disorder was present in almost half of the patients, while schizophrenia was diagnosed in only a small portion of the sample. As an example, these finding diverge from the reference
ACCEPTED MANUSCRIPT data for involuntary hospitalizations occurring from 1990 to 2000 in European Union member states, which diagnosed schizophrenia and other psychotic disorders in 30 to 50% of these patients (Salize and Dressing, 2004). In this sense, the low rate of regular use of prescribed psychopharmaceuticals prior to hospitalization and the elevated proportion of patients without a relationship with
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some psychiatry service in the studied sample is clear. The data reveal obstacles to satisfactory maintenance of outpatient treatment and could be taken as factors influencing the necessity of psychiatric hospitalization, be it
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voluntary or involuntary.
The primary limitation of the study was that it was confined to a single hospital,
whose
sample
may
have
social
and/or
psychopathological
characteristics differing from those encountered in other places. This could
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present difficulties in extrapolating the collected data to other national or
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international psychiatry services. Also, variables that presented with substantial numerical differences in VOL and INV groups, but did not reach statistical
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differences, could be understood as statistical type 2 errors, due to the sample size (e.g. “suicide attempt in the 24 hours prior to hospitalization”). Finally, no
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scales were used to determine the risk of suicide of heteroaggression as main
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reason to hospitalization (it were evaluated only by the clinical judgement of the psychiatrist on-duty at the emergency room).
In conclusion, this study confirmed the initial hypothesis that involuntary
psychiatric hospitalization is associated with the severity of psychopathology and aggression. It demonstrated that patients hospitalized involuntarily were more aggressive in the week before and during hospitalization, were more
ACCEPTED MANUSCRIPT frequently brought to the hospital by the police and/or by ambulance, and presented more symptoms of agitation, psychosis, and paranoia than voluntarily hospitalized patients.
There is evidence that involuntary hospitalization, when correctly
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recommended, constitutes an important aspect of a therapy intended for patients whose mental illness is not only severe, but are still capable of endangering themselves and those around them.
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Acknowledgements
The authors gratefully acknowledge the collaboration of the professor Ângelo Batista Miralha da Cunha, chief of the department of Neuropsychiatry of the
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Federal University of Santa Maria.
This work was supported by the Program for Scientific Initiation at University of
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none declared.
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the University Hospital of Santa Maria (PROIC-HUSM). Conflict of interest:
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Table 1 – General description of the sample (n = 137) and differences between the VOL and INV groups. VOL (n = 66) Gender (p = 0.009)
n 30
Male
Age (mean; SD)
37
12
INV (n = 71) n
% 48 67.6% 37
12
18-25
9
13.6%
14 19.7%
26-35
27
40.9%
25 35.2%
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Age ranges
% 45.5%
36-45 46-55 56-65
8
12.1%
11 15.5%
17
25.8%
15 21.1%
5
7.6%
44
66.7%
47 66.2%
33
50.0%
35 49.3%
6
8.5%
White
Has children
Yes
Marital status (p = 0.030)
Single, separated, or widowed
42
63.6%
57 80.3%
Married or stable partnership
24
36.4%
14 19.7%
7
10.8%
10 14.1%
With family/partner
58
89.2%
61 85.9%
Primary school, incomplete
28
43.8%
41 57.7%
Primary school, completed
10
15.6%
10 14.1%
Secondary school, completed
20
31.3%
15 21.1%
6
9.4%
No paying job
24
36.4%
45 63.4%
Paying job
18
27.3%
13 18.3%
Receiving sick pay/disability
11
16.7%
Retired
13
19.7%
10 14.1%
Arrived alone, with family, or others
61
92.4%
26 40.0%
5
7.6%
39 60.0%
Living situation
Alone
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Schooling
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Ethnicity
Post-secondary school, completed
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Occupation (p = 0.007)
Mode of arrival at hospital
5
3
7.0%
4.2%
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(p < 0.001)
Brought by ambulance or police
Risk of suicide (p < 0.001)
Yes
28
42.4%
10 14.1%
Risk of hetero-aggression
Yes
26
39.4%
49 69.0%
Yes
24
36.9%
40 56.3%
(p = 0.001) Tobacco use (p = 0.026)
VOL: voluntary hospitalizations; INV: involuntary hospitalizations. SD: standard deviation Absence of p-value indicates no statistical difference between groups
ACCEPTED MANUSCRIPT Table 2 – Diagnostic hypotheses according to the ICD-10 classification and differences between the VOL and INV groups.
VOL ( n = 66 ) n
INV ( n = 71 )
%
n
%
11
16.7%
16
22.5%
Alcohol
2
3.0%
3
4.2%
Cocaine / crack
1
1.5%
0
0.0%
8
12.1%
13
18.3%
10
15.2%
17
23.9%
2
3.0%
6
8.5%
4
6.1%
5
7.0%
4
6.1%
6
8.5%
40
60.6%
39
54.9%
30
45.5%
35
49.3%
22
33.3%
33
46.5%
5
7.6%
2
2.8%
11
16.7%
2
2.8%
28
42.4%
25
35.2%
19
28.8%
4
5.6%
1
1.5%
5
7.0%
8
12.1%
16
22.5%
8
12.1%
7
9.9%
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Substance abuse disorder (F10-F19)
Multiple substances Psychotic disorders (F20-F29) Schizophrenia Schizoaffective disorder
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Unspecified psychosis Mood disorder (F30-F39) Bipolar disorder Manic or mixed episode
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Depressive episode
Major or recurrent depressive disorder (p = 0.007)
Borderline (p < 0.001) Antisocial
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Personality disorder (F60-F69)
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Unspecified personality disorder Mental retardation (F70-F79)
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VOL: voluntary hospitalization group; INV: involuntary hospitalization group. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th revision
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Absence of p-value indicates no statistical difference between groups
ACCEPTED MANUSCRIPT Table 3 – Predictors of involuntary admission determined by logistic regression modeling. 95% CI B Brought to hospital by ambulance or
E.P.
Wald
gl
p
ExpB
Inferior
Superior
3.153 0.614
26.368 1
0<.001
23.411
7.026
78.004
-1.451 0.622
5.448 1
0.020
0.234
0.069
0.792
st
1.077 0.484
4.958 1
0.026
2.936
1.138
7.575
Personal income
-1.118 0.488
5.256 1
0.022
0.327
0.126
0.850
Constant
-1.195 0.761
2.469 1
0.116
0.303
Risk of suicide at admission Aggression in 1 24 hr of admission
= 0.409 (Cox & Snell);
= 0.545 (Nagelkerke);. CI = confidence interval.
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Note:
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police
ACCEPTED MANUSCRIPT
Figure legends
1,625 consultations
259 patients on observation in the emergency room
152 eligeble
4 > 65 years old 4 < 18 years old 98 were not admitted 1 did not sign informed consent
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107 did not meet inclusion criteria
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1366
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13 not evaluated during hospitalization
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139 included
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n = 137
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Figure 1 – Sample composition
2 excluded due to delirium
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Voluntary %
Involuntary %
96.9% 88.9%
84.9%
94.9%
66.2% 47.2% 35.8% 25.6% 16.9%
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17.9%
5.6%
Verbal\against Self-aggression Physical (p=0.010) objects (p=0.004) (ns)
11.1%
Verbal\against Self-aggression Physical (p=0.032) objects (p=0.001) (ns) Agression in the first 24h of hospitalization
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Aggresion in the week before hospitalization
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NS: Not significant.
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Figure 2 – Comparison of frequency of aggression and voluntary or involuntary hospitalization
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Voluntary
Involuntary
Affect (p < 0.001) 12 10 8 6 Positive symptoms (p = 0.014)
4
Activation (p < 0.001)
2
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0
Negative symptoms (ns)
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Resistance (p < 0.001)
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NS: Not significant.
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Figure 3: Schematic comparison of the means of scores between the BPRS dimensions.
Involuntary psychiatric hospitalization and its relationship to psychopathology and aggression Pedro Henrique Canova Mosele , Guillierme Chervenski Figueir , Amadeu Antonio Bertuol Filho , ˆ Jose´ Antonio Reis Ferreira de Lima , Vitor Crestani Calegaro ˆ PII: DOI: Reference:
S0165-1781(17)32040-1 10.1016/j.psychres.2018.04.031 PSY 11354
To appear in:
Psychiatry Research
Received date: Revised date: Accepted date:
13 November 2017 15 March 2018 11 April 2018
Please cite this article as: Pedro Henrique Canova Mosele , Guillierme Chervenski Figueir , Amadeu Antonio Bertuol Filho , Jose´ Antonio Reis Ferreira de Lima , Vitor Crestani Calegaro , Involˆ ˆ untary psychiatric hospitalization and its relationship to psychopathology and aggression, Psychiatry Research (2018), doi: 10.1016/j.psychres.2018.04.031
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Highlights
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Having personal income was associated with voluntary admission. Suicide risk at admission was associated with voluntariness. Activation, resistance and positive symptoms were associated with involuntariness. Aggression in the first 24 hours of admission was associated with involuntariness. Data support involuntary hospitalization for patients with severe mental illness.
ACCEPTED MANUSCRIPT Involuntary psychiatric hospitalization and its relationship to psychopathology and aggression Pedro Henrique Canova Moselea*, Guillierme Chervenski Figueira, Amadeu Antônio Bertuol Filhob, José Antônio Reis Ferreira de Limac, Vitor Crestani Calegarod a
Psychiatry Residence, University Hospital of Santa Maria, , Santa Maria, RS, Brazil b
c
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Internal Medicine Residence, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil Medicine Course, Federal University of Santa Maria, , Santa Maria, RS, Brazil
d
* Corresponding author:
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Pedro Henrique Canova Mosele
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Department of Neuropsychiatry, Federal University of Santa Maria, Santa Maria, RS, Brazil
Departamento de Neuropsiquiatria
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Universidade Federal de Santa Maria
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Av. Roraima, 1000 Santa Maria, RS
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Zip-code: 97105-900
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Phone number: +55 55 3213-1864 Fax: +55 55 30257596 Email: [email protected]
ACCEPTED MANUSCRIPT
Abstract The
current
study
investigates
the
relationship
between
involuntary
hospitalization, severity of psychopathology, and aggression. Adult psychiatric inpatients hospitalized from August, 2012 to January, 2013 were evaluated via
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the Brief Psychiatric Rating Scale (BPRS) and the Overt Aggression Scale (OAS). Individuals were compared regarding voluntariness of hospitalization. Of the 137 hospitalizations in the period, 71 were involuntary (INV). The variables
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associated with involuntariness were being brought to hospital by ambulance or police, and aggression in the first 24 hours of admission. Risk of suicide at admission, and having personal income were associated with voluntariness. The dimensions of the BPRS associated with involuntary hospitalization were resistance,
and
positive
symptoms.
Involuntary
psychiatric
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activation,
hospitalization was associated with agitation, psychosis and aggression. The
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data support the indication of involuntary hospitalization for treatment of patients
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with severe mental illness.
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Keywords: Commitment of Mentally Ill, Psychiatry, Involuntary admission.
ACCEPTED MANUSCRIPT
1. Introduction The involuntary status of psychiatric hospitalizations is a widely-discussed theme and encompasses clinical, ethical, and juridical dimensions. The principle
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criteria used for employing this mode of hospitalization are the severity of the disorder, the presence of danger to oneself or to others, and the urgent necessity for treatment (Riecher and Rossler, 1993). However, there are important variations in the literature concerning indications and prevalence. This
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seems to reflect important legal, cultural, and structural differences between the mental health care systems throughout the world (Riecher and Rossler, 1993); (Salize and Dressing, 2004).
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In the 1970s in Brazil, a process of altering the basics of psychiatric care began. Embedded in the international, political, and ideological context of the
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time, it questioned the relevance and the implications of hospital treatment of
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the mentally ill (Del-Ben et al., 1999); (Jorge and França, 2001); (Hirdes, 2009). Since then, a great shift in the direction of prioritization of social rehabilitation
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and outpatient treatment in the model of mental health care in the country has taken place, mainly with the creation of Federal Law 10.216/2001. This law
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defines, in the only paragraph of article 6, types of hospitalization as “I – voluntary hospitalization: that which is done with the consent of the patient; II – involuntary hospitalization: that which is done without the consent of the patient and at the request of a third party; and III – compulsory hospitalization: that imposed by the courts” (Lei 10.216, 2001). In all these contexts, it is up to the
ACCEPTED MANUSCRIPT physician together with the responsible family members to evaluate and authorize psychiatric hospitalization as well as to define its end.
Various clinical and epidemiological data are associated with involuntary hospitalization in international studies. There is evidence of association with
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schizophrenia and other psychotic illnesses (Ng and Kelly, 2012); (Riecher et al., 1991), severity of symptoms (Hustoft et al., 2013), male gender (Riecher et al., 1991); (Wheeler et al., 2005) and low socioeconomic status (Webber and Huxley, 2004). At the same time, divergent opinions arising from the
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particularities of methodology, legislation, and context of the location of each study are common in the literature (Jaime et al., 2011); (Kelly et al., 2004).
Disagreements in the academic, clinical, and legal fields concerning
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involuntary psychiatric hospitalization have ensured that it continues to be polemical. In Brazil, studies on this topic, which permeates the daily work of
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psychiatric wards, are still scarce. Therefore, it is necessary to discuss and deepen the knowledge related to its implications and possible associated
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factors in the light of current scientific evidence. Our hypothesis was that
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involuntary psychiatric hospitalization is related principally to the severity of psychopathology and aggression. The objective was to study clinical and
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demographic factors associated with the involuntariness of psychiatric hospitalization in the context of a reference psychiatric emergency room for the central region of the state of Rio Grande do Sul in Brazil.
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2. Methods
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2.1 Subjects
A naturalistic study with patients hospitalized in the Psychiatry Service of the Hospital Universitário de Santa Maria (HUSM, University Hospital of Santa Maria) was performed. HUSM is a general hospital of high complexity and a
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reference for the Sistema Único de Saúde (SUS, Brazil’s Universal Health Service) for 42 municipalities in central Rio Grande do Sul (RS) serving a population of approximately 500,000. At the time of the study, the service
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consisted of a psychiatric emergency room and a mixed, closed hospitalization
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unit with 25 beds intended for short-term hospitalization.
The research subjects were patients admitted from August, 2012 to
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January, 2013 and made up part of a larger study that proposed to monitor
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episodes of aggression occurring during hospitalization, the partial results of which are published in separate article (Calegaro et al., 2014).
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The inclusion criteria were: (1) being from 18 to 65 years of age and (2)
being admitted to the Psychiatry Service of HUSM. Patients with acute psychiatric symptoms due to a general medical condition (e.g., delirium) were excluded.
ACCEPTED MANUSCRIPT 2.2 Measures and analytical methods
A research form was used to evaluate the sociodemographic, clinical, and prior relevant history of the patients. It was completed via psychiatric interview and review of medical records. Admissions were considered involuntary when
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determined by the on-duty psychiatrist or by judicial order (compulsory). The risk of suicide and heteroaggression were assessed by the on-duty psychiatrist at the emergency room. The diagnoses were coded according to the tenth edition of the International Classification of Diseases (ICD-10) and recorded on
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the discharge note.
The research team, which included residents in psychiatry, medicine undergraduates and a coordinator, were trained to use the study instruments
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before data collection. Inter-rater reliability was not tested objectively. A 40-days
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pilot phase was carried out to correct flaws in data collection.
The Brief Psychiatric Rating Scale (BPRS) evaluated the presence and
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severity of psychopathological symptoms grouped by the dimensions of Affect, Negative Symptoms, Positive Symptoms, Resistance, and Activation and was
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scored at admission by the residents in psychiatry (Shafer, 2005). The
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structured interview guide of the BPRS (SIG-BPRS) was used, increasing the reliability of the scale (Crippa et al., 2001)
The Overt Aggression Scale (OAS) was scored daily over the
hospitalization period by the medicine undergraduates to evaluate the presence of episodes of verbal aggression, physical aggression against objects, physical
ACCEPTED MANUSCRIPT aggression against self, and physical aggression against other people (Hellings et al., 2005).
The statistical analysis was done using SPSS v23. The sample was divided into two groups, voluntary hospitalizations (VOL) and involuntary (INV).
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The normality of the variables was tested and none were found to be normally distributed. Thus, the groups were compared using non-parametric tests: The Mann-Whitney U test, χ2 test, and Fisher’s exact test, on a case-by-case basis. A significance level of 5% was used for all tests. After the univariate analysis,
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multivariate analysis using forward stepwise logistic regression was done. Variables with p < 0.010 were selected and evaluated as to their relevance for inclusion in the model.
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2.3 Ethics of the study
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The study was approved by the Research Ethics Committee of Universidade Federal de Santa Maria (UFSM, Federal University of Santa
PT
Maria). Informed consent was obtained from all the patients, signed by
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themselves, their family members, or legal guardians.
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3. Results
A flow-chart of the sample composition is presented in Figure 1. It
demonstrates that 127 patients were selected among the 1,625 consultations performed during the study period. The general description of the sample, including demographic and admission data of the 137 participants of the study, can be found in Table 1. It demonstrates that the risk of hetero-aggression at admission, male gender, being single, separated or widowed, having no paying
ACCEPTED MANUSCRIPT job and being brought to hospital by ambulance or police were variables associated with involuntary admission. The risk of suicide at admission was associated with voluntary admission.
The analysis revealed no statistical significance in the median duration of
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hospitalization (VOL 8,5 days, Q1=2 days, Q3=21 days vs. INV 15 days, Q1=1 day, Q3=33 days), the absence of connection with any psychiatry service (VOL 27.7% vs INV 39.1%), the mean number of previous hospitalizations (4 for both groups), and it being the first hospitalization (VOL 27.3% vs INV 19.7%) or
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psychiatric consultation (VOL 19.7% vs. INV 22.5%).
There was a predominance of patients with a prior history of selfaggression in the VOL group (VOL 57.6% vs. INV 40.8%) and suicide attempt in
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the 24 hours prior to hospitalization (VOL 27.3% vs. INV 14.1%). More than half of the patients hospitalized presented a history of physical aggression (VOL
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65.2% vs. INV 73.2%). There was no statistical difference between the groups.
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The relationship between the diagnostic hypothesis on the discharge note and the voluntariness of the hospitalization is described in Table 2. Only the
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diagnosis of a major or recurrent depressive, or a borderline personality
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disorder were associated with the voluntariness of the admission.
A past history of compulsive marijuana use, related by patients and/or
family members (VOL 15.4% vs. INV 33.3%; p = 0.017) and current tobacco use (VOL 36.9% vs. INV 56.3%; p = 0.002) was significantly higher among individuals hospitalized involuntarily. When asked about adherence to the use of psychopharmaceuticals, only 28% of the total sample stated using them
ACCEPTED MANUSCRIPT regularly. There was no statistical relationship of this variable with the groups. Among the psychopharmaceuticals used at the time of hospitalization, there was a difference in the use of anticonvulsants (VOL 34.8% vs. INV 19.7%; p = 0.036), low-potency antipsychotics (VOL = 28.8% vs. INV = 11.3%; p = 0.009), and antidepressants (VOL 27.3% vs. INV 11.3%; p = 0.028). The
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use of lithium was greater among voluntary patients, however not statistically significantly so (VOL 33.3% vs. INV 18.3%; p = 0.051).
Figure 2 relates the voluntariness of psychiatric hospitalization to the
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presence of aggression in the week prior and the first 24 hours of admission. It presents that being verbally aggressive, or aggressive against objects in the week before and in the first 24 hours of hospitalization was statistically associated with the involuntariness of the admission. The same applies to the
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presence of physical aggression in the week before and in the first 24 hours of
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hospitalization.
Over the course of hospitalization, the INV group presented a greater
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mean on the OAS (17.30 ± 32.72) compared to the VOL group (5.91 ± 10.466)
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and this difference was statistically significant (p =0.007).
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Figure 3 presents the relationship between hospitalization voluntariness
and BPRS score. The VOL group was statistically associated with a higher score on the Affect dimension, while the Activation, Resistance and Positive symptoms dimensions were associated with de INV group.
Hereafter, the variables with p <0.010 were evaluated as to their relevance for inclusion in the logistic regression model. As a function of the necessary
ACCEPTED MANUSCRIPT sample size for the analysis of all the variables, only those of greatest relevance with respect to the underlying construct were selected. For example, inclusion of the variable “suicide risk” was preferred as opposed to “suicide attempt at admission”, “history of suicide attempt in the week before”, and “prior history of self-aggression”. The model was statistically significant (
= 68.803; p < 0.001)
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and represented a variance of 40.9% to 54.5% of the data.
The final model is presented in Table 3. It demonstrates that being brought to the hospital by ambulance or police was the major risk factor for the
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involuntariness of hospitalization. Also, the presence of aggression in the first 24 hours of admission were statistically associated with the INV group. Having personal income, and risk of suicide at admission were associated with the VOL
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group.
The variables not in the equation (not significant) were history of
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aggression in the week before, tobacco use, major or recurrent depression,
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borderline personality disorder, gender, and marital status.
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4. Discussion
Patients admitted involuntarily were in the majority male, with a
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psychopathological profile related to aggression, psychomotor agitation, positive symptoms, and resistance, while those hospitalized voluntarily presented higher scores of depression and anxiety, beyond being at greater risk of selfaggression.
The primary predictor of involuntary hospitalization was transport by ambulance or police, which could be explained by the fact that the INV group
ACCEPTED MANUSCRIPT presented more aggression in the week before. For these patients, the risk of aggression toward others was considered the primary motive for hospitalization. The INV group also presented greater aggression at admission and during psychiatric
hospitalization,
reinforcing
the
importance
of
involuntary
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hospitalization for containment of this behavior.
Various studies have found an association between aggression and involuntary hospitalization. Biancosino et al., (2009) studied 1,324 patients and found evidence that those involuntarily hospitalized were 4.75 times more likely
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to present violence during admission. Violent behavior was a predictor for a high BPRS score. A Swiss study with 2,017 participants, found that involuntarily hospitalized patients presented 2.16 times more episodes of severe aggression (Abderhalden et al., 2007). In Germany, Ketelsen, Zechert, Driessen, and
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Schulz (2007) found evidence that critical behavior leading to involuntary
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admission was one of the greatest risk factors for the presence of aggression.
Patients hospitalized involuntarily presented more severe illness reflected
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by the resistance dimension (hostility, uncooperativeness, suspiciousness),
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activation (excitement, tension, mannerisms-posturing), and positive symptoms (thought
content,
conceptual
disorganization,
hallucinatory
behavior,
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grandiosity), as measured by the BPRS. This tendency is directly related to the presented aggressive behavior, and possibly to the absence of insight, necessitating coercion in bringing such patients to the hospital. Hustoft et al., (2013) came to similar conclusions after interviewing 3,326 patients in 20 admission units, finding an association between involuntariness and being
ACCEPTED MANUSCRIPT brought to the hospital by police, beyond finding high scores when assessing the presence of aggression, agitation, delirium, and hallucinations.
A few Brazilian studies that analyzed factors associated with involuntary hospitalization present divergent findings. One study undertaken in the city of
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São Paulo by Chang, Ferreira, Ferreira, and Hirata (2013) evaluated the scores of 2,289 patients and found that 13.3% of hospitalizations were involuntary, associated significantly with female gender, psychosis, diagnosis of anorexia nervosa, schizophrenia, personality disorder, alcohol and substance related
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disorders. In another Brazilian study, Oliveira, Pinto, Aguiar, Sampaio, and Medeiros (2011) revealed, in a sample of 393 participants, that involuntary hospitalization was associated with male gender and presented a greater
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prevalence of aggression.
In our study, the patients hospitalized voluntarily were, in the majority,
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brought to the hospital by family members. The presence of suicide risk at admission was a predictor for the voluntariness of hospitalization. Factors as
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suicide ideation, planning and attempt were taken into account by the
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psychiatrist on-duty at the emergency room to determine the presence of
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suicide risk.
There was a greater prevalence of depressive disorders and of borderline
personality disorder in this group. Beyond this, they presented greater severity of symptoms related to the Affect dimension (anxiety, depression, guilt, and somatic) as evaluated by the BPRS.
ACCEPTED MANUSCRIPT The voluntariness of hospitalization was significantly related to prior use of anticonvulsants,
low-potency
antipsychotics,
and
antidepressants.
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demonstrates the concordance between the psychopathological context of these patients and the therapeutics used. There are similarities between these data and those found by Hustoft et al. (2013), who found higher scores for
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depression and a greater incidence of suicide ideation among patients hospitalized voluntarily.
Regarding the demographic variables, involuntariness of hospitalization
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was related to being single, divorced or widowed, and not having remunerative employment. Obverse to this, having personal income was a predictive factor of voluntariness of hospitalization. This seems to represent the impact of mental illness on productivity and on the capacity for relationships in the patients, as
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well as to corroborate the lack of socioeconomic support as a determining factor
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associated with involuntary hospitalizations. By the same token, Chang et al. (2013) found a significantly greater proportion of unmarried and unemployed
PT
people among those hospitalized involuntarily. Webber and Huxley (2004), in a study that evaluated 300 psychiatric assessments in two London districts, found
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an association between involuntary hospitalization and inefficiency in one’s
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social support network.
Attention must be paid to the differences between the general
psychopathological profile of the HUSM Psychiatry Service’s patients and those of other national and international studies. Bipolar disorder was present in almost half of the patients, while schizophrenia was diagnosed in only a small portion of the sample. As an example, these finding diverge from the reference
ACCEPTED MANUSCRIPT data for involuntary hospitalizations occurring from 1990 to 2000 in European Union member states, which diagnosed schizophrenia and other psychotic disorders in 30 to 50% of these patients (Salize and Dressing, 2004). In this sense, the low rate of regular use of prescribed psychopharmaceuticals prior to hospitalization and the elevated proportion of patients without a relationship with
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some psychiatry service in the studied sample is clear. The data reveal obstacles to satisfactory maintenance of outpatient treatment and could be taken as factors influencing the necessity of psychiatric hospitalization, be it
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voluntary or involuntary.
The primary limitation of the study was that it was confined to a single hospital,
whose
sample
may
have
social
and/or
psychopathological
characteristics differing from those encountered in other places. This could
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present difficulties in extrapolating the collected data to other national or
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international psychiatry services. Also, variables that presented with substantial numerical differences in VOL and INV groups, but did not reach statistical
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differences, could be understood as statistical type 2 errors, due to the sample size (e.g. “suicide attempt in the 24 hours prior to hospitalization”). Finally, no
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scales were used to determine the risk of suicide of heteroaggression as main
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reason to hospitalization (it were evaluated only by the clinical judgement of the psychiatrist on-duty at the emergency room).
In conclusion, this study confirmed the initial hypothesis that involuntary
psychiatric hospitalization is associated with the severity of psychopathology and aggression. It demonstrated that patients hospitalized involuntarily were more aggressive in the week before and during hospitalization, were more
ACCEPTED MANUSCRIPT frequently brought to the hospital by the police and/or by ambulance, and presented more symptoms of agitation, psychosis, and paranoia than voluntarily hospitalized patients.
There is evidence that involuntary hospitalization, when correctly
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recommended, constitutes an important aspect of a therapy intended for patients whose mental illness is not only severe, but are still capable of endangering themselves and those around them.
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Acknowledgements
The authors gratefully acknowledge the collaboration of the professor Ângelo Batista Miralha da Cunha, chief of the department of Neuropsychiatry of the
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Federal University of Santa Maria.
This work was supported by the Program for Scientific Initiation at University of
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none declared.
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the University Hospital of Santa Maria (PROIC-HUSM). Conflict of interest:
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Table 1 – General description of the sample (n = 137) and differences between the VOL and INV groups. VOL (n = 66) Gender (p = 0.009)
n 30
Male
Age (mean; SD)
37
12
INV (n = 71) n
% 48 67.6% 37
12
18-25
9
13.6%
14 19.7%
26-35
27
40.9%
25 35.2%
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Age ranges
% 45.5%
36-45 46-55 56-65
8
12.1%
11 15.5%
17
25.8%
15 21.1%
5
7.6%
44
66.7%
47 66.2%
33
50.0%
35 49.3%
6
8.5%
White
Has children
Yes
Marital status (p = 0.030)
Single, separated, or widowed
42
63.6%
57 80.3%
Married or stable partnership
24
36.4%
14 19.7%
7
10.8%
10 14.1%
With family/partner
58
89.2%
61 85.9%
Primary school, incomplete
28
43.8%
41 57.7%
Primary school, completed
10
15.6%
10 14.1%
Secondary school, completed
20
31.3%
15 21.1%
6
9.4%
No paying job
24
36.4%
45 63.4%
Paying job
18
27.3%
13 18.3%
Receiving sick pay/disability
11
16.7%
Retired
13
19.7%
10 14.1%
Arrived alone, with family, or others
61
92.4%
26 40.0%
5
7.6%
39 60.0%
Living situation
Alone
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Schooling
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Ethnicity
Post-secondary school, completed
CE
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Occupation (p = 0.007)
Mode of arrival at hospital
5
3
7.0%
4.2%
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(p < 0.001)
Brought by ambulance or police
Risk of suicide (p < 0.001)
Yes
28
42.4%
10 14.1%
Risk of hetero-aggression
Yes
26
39.4%
49 69.0%
Yes
24
36.9%
40 56.3%
(p = 0.001) Tobacco use (p = 0.026)
VOL: voluntary hospitalizations; INV: involuntary hospitalizations. SD: standard deviation Absence of p-value indicates no statistical difference between groups
ACCEPTED MANUSCRIPT Table 2 – Diagnostic hypotheses according to the ICD-10 classification and differences between the VOL and INV groups.
VOL ( n = 66 ) n
INV ( n = 71 )
%
n
%
11
16.7%
16
22.5%
Alcohol
2
3.0%
3
4.2%
Cocaine / crack
1
1.5%
0
0.0%
8
12.1%
13
18.3%
10
15.2%
17
23.9%
2
3.0%
6
8.5%
4
6.1%
5
7.0%
4
6.1%
6
8.5%
40
60.6%
39
54.9%
30
45.5%
35
49.3%
22
33.3%
33
46.5%
5
7.6%
2
2.8%
11
16.7%
2
2.8%
28
42.4%
25
35.2%
19
28.8%
4
5.6%
1
1.5%
5
7.0%
8
12.1%
16
22.5%
8
12.1%
7
9.9%
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Substance abuse disorder (F10-F19)
Multiple substances Psychotic disorders (F20-F29) Schizophrenia Schizoaffective disorder
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Unspecified psychosis Mood disorder (F30-F39) Bipolar disorder Manic or mixed episode
M
Depressive episode
Major or recurrent depressive disorder (p = 0.007)
Borderline (p < 0.001) Antisocial
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Personality disorder (F60-F69)
PT
Unspecified personality disorder Mental retardation (F70-F79)
CE
VOL: voluntary hospitalization group; INV: involuntary hospitalization group. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th revision
AC
Absence of p-value indicates no statistical difference between groups
ACCEPTED MANUSCRIPT Table 3 – Predictors of involuntary admission determined by logistic regression modeling. 95% CI B Brought to hospital by ambulance or
E.P.
Wald
gl
p
ExpB
Inferior
Superior
3.153 0.614
26.368 1
0<.001
23.411
7.026
78.004
-1.451 0.622
5.448 1
0.020
0.234
0.069
0.792
st
1.077 0.484
4.958 1
0.026
2.936
1.138
7.575
Personal income
-1.118 0.488
5.256 1
0.022
0.327
0.126
0.850
Constant
-1.195 0.761
2.469 1
0.116
0.303
Risk of suicide at admission Aggression in 1 24 hr of admission
= 0.409 (Cox & Snell);
= 0.545 (Nagelkerke);. CI = confidence interval.
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CE
PT
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Note:
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police
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Figure legends
1,625 consultations
259 patients on observation in the emergency room
152 eligeble
4 > 65 years old 4 < 18 years old 98 were not admitted 1 did not sign informed consent
AN US
107 did not meet inclusion criteria
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1366
M
13 not evaluated during hospitalization
ED
139 included
CE
PT
n = 137
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Figure 1 – Sample composition
2 excluded due to delirium
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Voluntary %
Involuntary %
96.9% 88.9%
84.9%
94.9%
66.2% 47.2% 35.8% 25.6% 16.9%
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17.9%
5.6%
Verbal\against Self-aggression Physical (p=0.010) objects (p=0.004) (ns)
11.1%
Verbal\against Self-aggression Physical (p=0.032) objects (p=0.001) (ns) Agression in the first 24h of hospitalization
M
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Aggresion in the week before hospitalization
AC
CE
PT
NS: Not significant.
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Figure 2 – Comparison of frequency of aggression and voluntary or involuntary hospitalization
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Voluntary
Involuntary
Affect (p < 0.001) 12 10 8 6 Positive symptoms (p = 0.014)
4
Activation (p < 0.001)
2
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0
Negative symptoms (ns)
AN US
Resistance (p < 0.001)
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NS: Not significant.
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Figure 3: Schematic comparison of the means of scores between the BPRS dimensions.