- Email: [email protected]
Psychiatrists' perception of psychiatric commitment
International Journal of Law and Psychiatry 25 (2002) 109 – 117
Psychiatrists’ perception of psychiatric commitment ˚ berg-Wistedtc Birgitta Alexiusa,*, Kerstin Bergb, Anna A a
Karolinska Institute, Institution for Clinical Neuroscience, Section of Psychiatry, St. Go¨ran’s Hospital, Stockholm, Sweden b Karolinska Institute, Institution for Clinical Neuroscience, Section of Psychiatry, St. Go¨ran’s Hospital, Stockholm, Sweden c Karolinska Institute, Institution for Clinical Neuroscience, Section of Psychiatry, St. Go¨ran’s Hospital, Stockholm, Sweden
1. Introduction Psychiatric commitment versus voluntary admission is, in emergency psychiatry, a crucial evaluation. In a study of Marson, Mc Govern, and Pomp (1988) of psychiatric decisionmaking in the emergency room, psychosis, incapacitating symptoms, prior hospitalization, and homicidal or suicidal features were important factors relevant to hospitalization. Inexperienced clinicians hospitalized more patients than experienced. Hiday (1992) has described formal and informal methods in the USA for coercive hospitalization. Assorted pressures can be employed to get a patient to agree to voluntary admission. Monahan et al. (1995) have, in cases of psychiatric hospitalization, dealt with coercion as a dependent variable. For situations that they judged to be coercive, they proposed criteria for approval or rejection of the proposal to commit. As to practices and attitudes of Swedish psychiatrists vis-a`-vis compulsory treatment, Kullgren, Jacobsson, Lyno¨e, Kohn, and Levev (1996) used a questionnaire composed of clinical vignettes. Agreement was high re commitment of patients who belonged to welldefined diagnostic groups; but low re patients with disruptive behavior apparently associated with social problems. Differences between male and female responders were uncommon. Voluntarily hospitalized patients who had filed a notice of intent to leave the hospital were studied in Boston by Appelbaum and Hamm (1982) and in New York by Schwartz,
* Corresponding author. Department of Psychiatry, St. Go¨ran’s Hospital, SE-11281 Stockholm, Sweden. Tel.: +46-8-672-1000; fax: +46-8-672-4940. E-mail address: [email protected] (B. Alexius). 0160-2527/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 1 6 0 - 2 5 2 7 ( 0 1 ) 0 0 11 4 - 5
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Appelbaum, and Kaplan (1984) as to the attendant psychiatrist’s decision for either their commitment or release. The decisions by these psychiatrists correlated well with legal criteria and clinical features. The decision-making process in North Carolina re emergency commitment was investigated by Miller and Fiddleman (1988). Criteria used by law enforcement officers for emergency, involuntary hospitalization—namely mental disorder, dangerousness to self or others, and violent behavior—were not well articulated in most of their petitions. Compulsory psychiatric care in Sweden re ethical justification, medical status, and social paternalism, was studied by Kjellin and coworkers (Kjellin, Andersson, Candefjord, Palmstierna, & Wallsten, 1997; Kjellin & Nilstun, 1993; Kjelling & Westrin, 1998; Kjellin et al., 1993). Investigation of the outcome and of the ethical justification for such psychiatric care showed that 30% of the patients did not fulfill the established criteria for involuntary treatment. Sjo¨stro¨m (1997) explored the practical application of the Swedish Compulsory Psychiatric Care Act, especially identification of the need for compulsory care. Most important in a physician’s psychiatric interview was assessment of the patient’s insight as to the illness and his/her ability to make a considered, stable decision about hospital care and psychotropic medication. Psychiatric patients’ capacity to consent to voluntary hospitalization has been clinically assessed by Billick, Naylor, Majeske, Burgert, and Davis (1996) and Polythress, Cascardi, and Ritterband (1996). Such competency was, in the majority of both voluntarily admitted and committed patients, severely impaired. The Swedish Compulsory Psychiatric Care Act (1991) permits retention at a psychiatric facility if the patient (a) suffers from a severe psychiatric disorder or categorically requires full-time psychiatric care and (b) either opposes such care or, because of the disorder, lacks the ability to arrive at or express a considered decision as to hospitalization. A patient’s therapeutic needs should determine whether or not coercive management is to be instituted. Also relevant, is the risk for injury to others. The provisions of the Compulsory Psychiatric Care Act are difficult to define and the decision-making process in conjunction with the execution of a certificate for compulsory psychiatric care is complicated. Involuntary hospitalization due to mental illness involves judgments about ethical principles. The National Commision for the Protection of Human Subjects of Biomedical and Behavioral Research (1978) advocated principles such as beneficence, nonmaleficence, autonomy, and justice. Beneficence is the duty to benefit others; nonmaleficence, not to harm others. Autonomy refers to respect for the wishes of those involved, for their dignity and integrity. Justice concerns only distributive justice that, irrespective of sex, age, race, and politics, all have the same right to treatment. Physicians’ varying implementations of these ethical components reflect their biases and their capability to relate to patients, evaluate psychopathology, and appraise latent violence, as well as their awareness of ancillary resources outside the psychiatric facility. This study examined involuntary admissions at an urban psychiatric emergency unit with a catchment area of 1.4 million inhabitants. About 20% of patients hospitalized from this unit were involuntary admissions.
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2. Objective The aim of the study was to analyze
the determinants of the decision to commit and the physician’s assessment of fulfillment/violation of relevant ethical principles concerning interested groups.
3. Methods and material The study was conducted from March to June 1998 at a psychiatric emergency unit where approximately 700 patients appeared monthly and of them about 70 were committed. Every committed case was included until the sample totaled 200. The unit’s physicians evaluate symptomatology by BPRS constructed by Overall and Gorham (1962), global functioning by GAF from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994), suicidal intent, when relevant, by SIS constructed by Beck, Schuyler, and Herman (1994), and diagnose in accord with DSM-IV (American Psychiatric Association, 1994). Committed patients were assessed as follows: (1) risk for violence by HCR-20 by Webster, Douglas, Eaves, and Hart (1997), (2) primary reason for commitment, (3) their attitudes towards hospitalization, and (4) ethical ‘‘benefits/costs’’. (A special form was compiled.) Ethical evaluation followed Tore Nilstun’s two-dimensional model (1990) (Table 1). One dimension of this model concerns ethical principles. The other reflects those affected by the coercion, namely: patients, families, psychiatric staff/welfare personnel, and community. Ethical benefits attained by implementation of these principles are: enhanced well-being, increased range for life’s decisions, and equitable distribution of benefits and burdens of a social nature. Ethical costs arising from violation of theses principles include suffering, deprivation of self-determination, and deleterious care, which usually correlates with low socioeconomical status. Ethical conflicts involved in each commitment were analyzed and specified by the examining physician. ‘‘Beneficence’’ is an item that exclusively provided ethical benefits
Table 1 Model for description and analysis of ethical conflicts in psychiatric care Ethical principles Groups Patients Families Personnel Community
Beneficence
Nonmaleficence
Autonomy
Justice
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(+); ‘‘nonmaleficence,’’ solely ethical costs ( ). ‘‘Autonomy’’ and ‘‘justice,’’ however, generally entailed benefits as well as costs. When physicians concluded that neither ethical benefits nor costs arose from the commitment, their entry in the table was ‘‘ ± ’’. Each physician’s age, gender, and status either as resident or accredited psychiatrist were noted in the patient’s special form. There were no nonresponders among the physicians. All 200 cases consecutively collected during a 3-month period in 1998 corresponded to 25% of the commitments at the emergency department during that year and, therefore, are believed to be representative for this psychiatric facility. BPRS, GAF, SIS, and DSM-IV were routinely used on the psychiatric department. The data for this study were not collected by researchers who had their interrater reliability assessed but and as a group the physicians were trained to use these evaluative instruments. The present study was carried out in an emergency unit where patients often are very violent and/or noncommunicative. Sometimes it is difficult to complete interviews. In such groups, BPRS scores for psychiatric symptoms may be too low. HCR-20 was not used routinely because this scale was developed to rate institutionalized, forensic patients about whom physicians have adequate information as to their prior status and present situation. The HCR-20 assessments in this study were probably low due to lack of sufficient, relevant information. Nonetheless, it seemed important for physicians who consider commitment to have access to a scale that rates risk for violence. Assessments of ethical principles depend on personal reference frames and we found it impossible to attain consensus in a group of physicians though the principles are thoroughly described in the general recommendations for the implementation of the Compulsory Psychiatric Care Act by National Board of Health and Welfare. A majority of the physicians maintained that commitment always violated patients’ autonomy. Their opponents believed that commitment could benefit autonomy because patients with severe mental illnesses and gross defects in their reasoning process may have diminished capacity to make autonomous decisions. It is the illness, which violates autonomy. Treatment can improve patients’ status and thereby increase their options to make autonomous choices and thus restore their autonomy. In the present study, we wanted to elucidate this ethical conflict that has been discussed during seminars led, among others, by the moral philosopher Tore Nilstun. The local ethics committee approved the study. For the statistical analysis, Student’s t test was used for differences in means and chi-square test for differences in proportions.
4. Results 4.1. Demographic data and psychiatric diagnosis Fifty-seven percent of the patients was men and 43% women. The mean age was 41 ± 15 years (range 18 to 87). Six percent of the patients were afflicted by organic mental syndrome, 44% schizophrenia or other psychotic disorders, 28% mood disorders, 16%
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substance-related disorders, and 6% anxiety disorder. Nineteen percent of the patients received the dual diagnosis of ‘‘substance abuse’’ plus other psychiatric disorder. 4.2. Psychiatric function and symptoms The mean GAF, a measure of function, was 29.9 ± 12.0 (100 = healthy). Patients with substance-related disorders had the lowest GAF; their mean score was 27.0. The mean BPRS, a measure of symptoms, was 33.4 ± 11.0 (96 = extremely severe symptoms). Forty-one percent had suicidal ideas and 15% had made a suicide attempt. The mean score for these patients on SIS was 13 ± 6 (30 = very high risk for suicide). Thirty percent was assessed as potentially dangerous. Of these, 73% were men. The mean HCR-20 was 18 ± 7 (40 = very high risk for violence); for men, it was 19 ± 7; for women, 16 ± 5. Patients with anxiety disorder had the highest HCR-20, with mean score 20 ± 5. 4.3. Days of commitment The mean duration of commitment was 31.7 ± 88.0 days (range 1–680). Thirty percent of the patients were released within 24 hours; 50% of these had a substance-related disorder or a dual diagnosis of psychotic disorder and drug abuse. Fifty percent of the remaining patients were discharged from their involuntary hospitalization within 28 days. Psychotic patient, detained for longer periods than other diagnostic groups, had a mean stay of 49.3 days ( P < .05) (Fig. 1). Duration of involuntary care showed no differences as to gender or age.
Fig. 1. Days of commitment (mean and one standard deviation) related to diagnosis in 200 committed patients from a psychiatric emergency unit.
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Table 2 Ethical benefits/costs regarding beneficence and autonomy for patients in percent assessed by physicians in a psychiatric emergency unit (N = 200) Patients Patients
Fulfilled autonomy
Violate autonomy
Neither fulfilled nor violate autonomy
Fulfilled beneficence Not fulfilled beneficence
29 1
50 6
14 0
4.4. The physicians Fifty-five physicians, 34 women and 21 men, participated in the study. Sixteen women and two men were accredited psychiatrists. Female residents wrote 36% of the certificates; female specialists wrote 16%. The mean age of the female physicians was 41 ± 8 years. Forty-four percent of the certificates were issued by male residents; 4% by male specialists. The mean age of the male physicians was 37 ± 6 years. 4.5. The ethical conflict between principles of beneficence and patients’ autonomy In 93% of the commitments, the physicians assessed that the compulsory care did benefit patients whereas 56% deemed that patients’ autonomy had been violated (Table 2). In 29% of the cases, the only assessments of ethical benefits were for these two principles; in 6%, the only assessment related to ethical costs. 4.6. The ethical benefits/costs regarding family, community, and patient The analysis of ethical benefits/costs for the family/community showed almost the same proportion of ethical benefits 29% and 25%, respectively. Forty-four percent assessed that patients’ autonomy had been violated. In 12% of the cases, there were only ethical costs (Table 3).
Table 3 Ethical benefits/costs regarding beneficence for families/community and autonomy for patients in percent assessed by physicians in a psychiatric emergency unit (N = 200) Patient Families/community
Fulfilled autonomy
Violate autonomy
Neither fulfilled nor violate autonomy
Fulfilled beneficence Not fulfilled beneficence
29 (25) 1 (5)
44 (44) 12 (12)
12 (11) 2 (3)
Data for community are shown in parenthesis.
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4.7. The ethical benefits/costs regarding physicians’ gender, accreditation, and age A greater proportion of male physicians judged the commitment to benefit the community ( P < .05). Residents more often than specialists believed the involuntary admission would benefit the community ( P < .01). Assessment of the ethical benefits/costs related to patients’ autonomy showed that older physicians more often concluded that the compulsory care would violate the patients’ autonomy ( P < .05). No statistically significant differences were found between male and female physicians or specialists and residents in evaluation of this variable. 4.8. Decision-making in compliance with the Compulsory Psychiatric Care Act All patients were assessed as having a severe psychiatric disorder. Suicidal thoughts were judged to have a major impact on the commitment decision in 30% of cases; whereas potentially dangerous ideas or impulses in 7%. Analysis of to what extent the patients fulfilled the criterion ‘‘opposes such care’’ or ‘‘due to his/her psychiatric condition, obviously lacks ability to express a considered decision on the issue’’ showed that 53% were assessed as negative to hospital care, 24% were ambivalent to hospitalization, and 23% were not able to effect or to communicate their decision as to hospitalization.
5. Discussion The clinical ratings showed that the committed patients were severely disturbed. The patients in this study had a mean GAF of 29.9 ± 12.0, somewhat lower than a mean GAF of 32.3 ± 11.5 in Kjellin and Westrin’s study (1998) of a group of committed patients from two Swedish counties. The present patient group’s mean BPRS of 33.4 ± 11.0 was higher than the 24.6 ± 11.9 in Kjellin et al.’s (1997) report. This reflects a larger incidence of symptoms. Schwartz et al. (1984) who investigated correlations between clinical variables and the decision to commit psychiatric patients, found that the most determinative factors were inability to care for oneself, mental illness, need of treatment, and psychosis. In the same study of 21 clinical features related to coercion, danger to self and/or others were ranked as 12 and 9, respectively. These findings are congruent with our results, where suicidal ideas and dangerousness were ranked as having a major impact on the decisionmaking process in, respectively, 30% and 7% of cases compared to 63% for severe psychiatric disorders. Analysis of the legal criteria pertinent to the patient’s consent to psychiatric hospitalization showed that nearly 50% of the patients were ambivalent or could not communicate their decision. A competency questionnaire exploring this issue could be of value to physicians. Physicians’ evaluation of the ethical costs regarding patients’ autonomy showed that more than half of the physicians considered that it had been violated and one third that it had been fulfilled. The physicians were instructed to mark ‘‘benefits’’ for increased
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possibilities for patients to decide about their lives, and ‘‘costs’’ for deprivation of the right for self-determination. When physicians assessed a patient’s autonomy higher than benefits of his/her care, commitment probably did not occur. Differences between physicians influence the commitment decision. This aspect will be analyzed in a project, which will investigate the type of care given to patients brought to the emergency unit by the police.
6. Conclusions
The most important determinant when a physician issued a certificate for compulsory care was severity of the patient’s psychiatric symptoms. Suicidal impulse was a relatively strong determinant of the decision to commit, whereas dangerousness to others was assessed as not especially important. Analysis of the legal criteria regarding consent to psychiatric hospitalization showed that nearly 50% of the patients were ambivalent or were unable to communicate their decision. A competency questionnaire exploring this issue could be valuable for physicians. Physicians assessed compulsory care on the one hand to benefit patients, on the other to violate their autonomy. Review of the conflict ‘‘benefits’’ of commitment versus ‘‘costs’’ showed that the benefits were valued higher by physicians who opted for commitment. Contemplated analysis of the decision-making process regarding a patient group consisting of both voluntary and committed patients might increase our knowledge about this aspect of coercion. Male physicians more often than female and residents more often than specialists judged that involuntary admission would benefit the community. Physicians who assessed that the care would violate the autonomy of the patient had a higher mean age.
Acknowledgments The study was supported by a grant from the Swedish Society of Medicine.
References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Appelbaum, P. S., & Hamm, R. M. (1982). Decision to seek commitment; psychiatric decision making in a legal context. Archives of General Psychiatry, 39, 447 – 451. Beck, A. T., Schuyler, D., & Herman, I. (1974). Development of suicidal intent scales. In A. T. Beck, H. L. P. Resnik, & D. J. Letteri (Eds.), The prediction of suicide (pp. 45-56). Bowie, MD: Charles Press. Billick, S. B., Naylor, P. W., Majeske, M. F., Burgert, W., & Davis, G. P. (1996). A clinical study of competency in psychiatric inpatients. Bulletin of the American Academy of Psychiatry and Law, 24, 505 – 511.
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Hiday, V. A. (1992). Coercion in civil commitment: process, preferences and outcome. International Journal of Law and Psychiatry, 15, 359 – 377. Kjellin, L., Andersson, K., Candefjord, I.-L., Palmstierna, T., & Wallsten, T. (1997). Ethical benefits and costs of coercion in short-term inpatient psychiatric care. Psychiatric Services, 48, 1567 – 1570. Kjellin, L., & Nilstun, T. (1993). Medical and social paternalism. Regulation of and attitudes towards compulsory psychiatric care. Acta Psychiatrica Scandinavica, 88, 415 – 419. Kjellin, L., & Westrin, C.-G. (1998). Involuntary admission and coercive measures in psychiatric care. Registered and reported. International Journal of Law and Psychiatry, 21, 31 – 42. ¨ stman, M., Candefjord, I.-L., Ekblom, B., Machl, M., A ¨ ngKjellin, L., Westrin, C.-G., Eriksson, K., Axelsson-O ¨ fors, G., & Ostman, O. (1993). Coercion in psychiatric care: problems of medical ethics in a comprehensive empirical study. Behavioral Science and the Law, 11, 323 – 334. Kullgren, G., Jacobsson, L., Lyno¨e, N., Kohn, R., & Levav, I. (1996). Practices and attitudes among Swedish psychiatrists regarding the ethics of compulsory treatment. Acta Psychiatrica Scandinavica, 93, 389 – 396. Marson, D. C., Mc Govern, M. P., & Pomp, H. C. (1988). Psychiatric decision making in the emergency room: a research overview. American Journal of Psychiatry, 145, 918 – 925. Miller, R. D., & Fiddleman, P. F. (1988). Emergency involuntary commitment: a look at the decision making process. Hospital and Community Psychiatry, 39, 1049 – 1054. Monahan, J., Hoge, S. K., Lidz, C., Roth, L. H., Bennett, N., Gardner, W., & Mulvey, E. (1995). Coercion and commitment: understanding involuntary mental hospital admission. International Journal of Law and Psychiatry, 18, 249 – 263. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report: ethical principles and guidelines for the protection of human subjects of research. Washington, DC: U.S. Government Printing Office. Nilstun, T. (1990). Public health measures with HIV infection. A model for identification and analysis of ethical conflicts. In P. Allebeck, & B. Jansson (Eds.), Ethics in medicine: individual integrity versus demands of society ( pp. 202 – 213). New York: Raven Press. Overall, J. E., & Gorham, D. R. (1962). The Brief Psychiatric Rating Scale. Psychological Reports, 10, 799 – 812. Polythress, N. G., Cascardi, M., & Ritterband, L. (1996). Capacity to consent to voluntary hospitalization: searching for a satisfactory Zinermon screen. Bulletin of the American Academy of Psychiatry and Law, 24, 439 – 452. Schwartz, H. I., Appelbaum, P. S., & Kaplan, R. D. (1984). Clinical judgements in the decision to commit: psychiatric discretion and the law. Archives of General Psychiatry, 41, 811 – 815. Sjo¨stro¨m, S. (1997). Party or patient? Discursive practices relating to coercion in psychiatric and legal settings. Dissertation, Borea Bokfo¨rlag, Umea˚. Tilla¨mpning av lagen om psykiatrisk tva˚ngsva˚rd [The Compulsory Psychiatric Care Act and the implementation of its provisions]. (1991). Socialstyrelsen. Allma¨nna ra˚d fra˚n socialstyrelsen: 9. Stockholm (in Swedish: LPT). Webster, C. D., Douglas, K. S., Eaves, D., & Hart, S. D. (1997). HCR-20. Assessing risk for violence. Version 2. Vancouver: Simon Fraser University and Forensic Psychiatric Services Commission of British Columbia.
Psychiatrists’ perception of psychiatric commitment ˚ berg-Wistedtc Birgitta Alexiusa,*, Kerstin Bergb, Anna A a
Karolinska Institute, Institution for Clinical Neuroscience, Section of Psychiatry, St. Go¨ran’s Hospital, Stockholm, Sweden b Karolinska Institute, Institution for Clinical Neuroscience, Section of Psychiatry, St. Go¨ran’s Hospital, Stockholm, Sweden c Karolinska Institute, Institution for Clinical Neuroscience, Section of Psychiatry, St. Go¨ran’s Hospital, Stockholm, Sweden
1. Introduction Psychiatric commitment versus voluntary admission is, in emergency psychiatry, a crucial evaluation. In a study of Marson, Mc Govern, and Pomp (1988) of psychiatric decisionmaking in the emergency room, psychosis, incapacitating symptoms, prior hospitalization, and homicidal or suicidal features were important factors relevant to hospitalization. Inexperienced clinicians hospitalized more patients than experienced. Hiday (1992) has described formal and informal methods in the USA for coercive hospitalization. Assorted pressures can be employed to get a patient to agree to voluntary admission. Monahan et al. (1995) have, in cases of psychiatric hospitalization, dealt with coercion as a dependent variable. For situations that they judged to be coercive, they proposed criteria for approval or rejection of the proposal to commit. As to practices and attitudes of Swedish psychiatrists vis-a`-vis compulsory treatment, Kullgren, Jacobsson, Lyno¨e, Kohn, and Levev (1996) used a questionnaire composed of clinical vignettes. Agreement was high re commitment of patients who belonged to welldefined diagnostic groups; but low re patients with disruptive behavior apparently associated with social problems. Differences between male and female responders were uncommon. Voluntarily hospitalized patients who had filed a notice of intent to leave the hospital were studied in Boston by Appelbaum and Hamm (1982) and in New York by Schwartz,
* Corresponding author. Department of Psychiatry, St. Go¨ran’s Hospital, SE-11281 Stockholm, Sweden. Tel.: +46-8-672-1000; fax: +46-8-672-4940. E-mail address: [email protected] (B. Alexius). 0160-2527/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 1 6 0 - 2 5 2 7 ( 0 1 ) 0 0 11 4 - 5
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Appelbaum, and Kaplan (1984) as to the attendant psychiatrist’s decision for either their commitment or release. The decisions by these psychiatrists correlated well with legal criteria and clinical features. The decision-making process in North Carolina re emergency commitment was investigated by Miller and Fiddleman (1988). Criteria used by law enforcement officers for emergency, involuntary hospitalization—namely mental disorder, dangerousness to self or others, and violent behavior—were not well articulated in most of their petitions. Compulsory psychiatric care in Sweden re ethical justification, medical status, and social paternalism, was studied by Kjellin and coworkers (Kjellin, Andersson, Candefjord, Palmstierna, & Wallsten, 1997; Kjellin & Nilstun, 1993; Kjelling & Westrin, 1998; Kjellin et al., 1993). Investigation of the outcome and of the ethical justification for such psychiatric care showed that 30% of the patients did not fulfill the established criteria for involuntary treatment. Sjo¨stro¨m (1997) explored the practical application of the Swedish Compulsory Psychiatric Care Act, especially identification of the need for compulsory care. Most important in a physician’s psychiatric interview was assessment of the patient’s insight as to the illness and his/her ability to make a considered, stable decision about hospital care and psychotropic medication. Psychiatric patients’ capacity to consent to voluntary hospitalization has been clinically assessed by Billick, Naylor, Majeske, Burgert, and Davis (1996) and Polythress, Cascardi, and Ritterband (1996). Such competency was, in the majority of both voluntarily admitted and committed patients, severely impaired. The Swedish Compulsory Psychiatric Care Act (1991) permits retention at a psychiatric facility if the patient (a) suffers from a severe psychiatric disorder or categorically requires full-time psychiatric care and (b) either opposes such care or, because of the disorder, lacks the ability to arrive at or express a considered decision as to hospitalization. A patient’s therapeutic needs should determine whether or not coercive management is to be instituted. Also relevant, is the risk for injury to others. The provisions of the Compulsory Psychiatric Care Act are difficult to define and the decision-making process in conjunction with the execution of a certificate for compulsory psychiatric care is complicated. Involuntary hospitalization due to mental illness involves judgments about ethical principles. The National Commision for the Protection of Human Subjects of Biomedical and Behavioral Research (1978) advocated principles such as beneficence, nonmaleficence, autonomy, and justice. Beneficence is the duty to benefit others; nonmaleficence, not to harm others. Autonomy refers to respect for the wishes of those involved, for their dignity and integrity. Justice concerns only distributive justice that, irrespective of sex, age, race, and politics, all have the same right to treatment. Physicians’ varying implementations of these ethical components reflect their biases and their capability to relate to patients, evaluate psychopathology, and appraise latent violence, as well as their awareness of ancillary resources outside the psychiatric facility. This study examined involuntary admissions at an urban psychiatric emergency unit with a catchment area of 1.4 million inhabitants. About 20% of patients hospitalized from this unit were involuntary admissions.
B. Alexius et al. / International Journal of Law and Psychiatry 25 (2002) 109–117
111
2. Objective The aim of the study was to analyze
the determinants of the decision to commit and the physician’s assessment of fulfillment/violation of relevant ethical principles concerning interested groups.
3. Methods and material The study was conducted from March to June 1998 at a psychiatric emergency unit where approximately 700 patients appeared monthly and of them about 70 were committed. Every committed case was included until the sample totaled 200. The unit’s physicians evaluate symptomatology by BPRS constructed by Overall and Gorham (1962), global functioning by GAF from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994), suicidal intent, when relevant, by SIS constructed by Beck, Schuyler, and Herman (1994), and diagnose in accord with DSM-IV (American Psychiatric Association, 1994). Committed patients were assessed as follows: (1) risk for violence by HCR-20 by Webster, Douglas, Eaves, and Hart (1997), (2) primary reason for commitment, (3) their attitudes towards hospitalization, and (4) ethical ‘‘benefits/costs’’. (A special form was compiled.) Ethical evaluation followed Tore Nilstun’s two-dimensional model (1990) (Table 1). One dimension of this model concerns ethical principles. The other reflects those affected by the coercion, namely: patients, families, psychiatric staff/welfare personnel, and community. Ethical benefits attained by implementation of these principles are: enhanced well-being, increased range for life’s decisions, and equitable distribution of benefits and burdens of a social nature. Ethical costs arising from violation of theses principles include suffering, deprivation of self-determination, and deleterious care, which usually correlates with low socioeconomical status. Ethical conflicts involved in each commitment were analyzed and specified by the examining physician. ‘‘Beneficence’’ is an item that exclusively provided ethical benefits
Table 1 Model for description and analysis of ethical conflicts in psychiatric care Ethical principles Groups Patients Families Personnel Community
Beneficence
Nonmaleficence
Autonomy
Justice
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(+); ‘‘nonmaleficence,’’ solely ethical costs ( ). ‘‘Autonomy’’ and ‘‘justice,’’ however, generally entailed benefits as well as costs. When physicians concluded that neither ethical benefits nor costs arose from the commitment, their entry in the table was ‘‘ ± ’’. Each physician’s age, gender, and status either as resident or accredited psychiatrist were noted in the patient’s special form. There were no nonresponders among the physicians. All 200 cases consecutively collected during a 3-month period in 1998 corresponded to 25% of the commitments at the emergency department during that year and, therefore, are believed to be representative for this psychiatric facility. BPRS, GAF, SIS, and DSM-IV were routinely used on the psychiatric department. The data for this study were not collected by researchers who had their interrater reliability assessed but and as a group the physicians were trained to use these evaluative instruments. The present study was carried out in an emergency unit where patients often are very violent and/or noncommunicative. Sometimes it is difficult to complete interviews. In such groups, BPRS scores for psychiatric symptoms may be too low. HCR-20 was not used routinely because this scale was developed to rate institutionalized, forensic patients about whom physicians have adequate information as to their prior status and present situation. The HCR-20 assessments in this study were probably low due to lack of sufficient, relevant information. Nonetheless, it seemed important for physicians who consider commitment to have access to a scale that rates risk for violence. Assessments of ethical principles depend on personal reference frames and we found it impossible to attain consensus in a group of physicians though the principles are thoroughly described in the general recommendations for the implementation of the Compulsory Psychiatric Care Act by National Board of Health and Welfare. A majority of the physicians maintained that commitment always violated patients’ autonomy. Their opponents believed that commitment could benefit autonomy because patients with severe mental illnesses and gross defects in their reasoning process may have diminished capacity to make autonomous decisions. It is the illness, which violates autonomy. Treatment can improve patients’ status and thereby increase their options to make autonomous choices and thus restore their autonomy. In the present study, we wanted to elucidate this ethical conflict that has been discussed during seminars led, among others, by the moral philosopher Tore Nilstun. The local ethics committee approved the study. For the statistical analysis, Student’s t test was used for differences in means and chi-square test for differences in proportions.
4. Results 4.1. Demographic data and psychiatric diagnosis Fifty-seven percent of the patients was men and 43% women. The mean age was 41 ± 15 years (range 18 to 87). Six percent of the patients were afflicted by organic mental syndrome, 44% schizophrenia or other psychotic disorders, 28% mood disorders, 16%
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substance-related disorders, and 6% anxiety disorder. Nineteen percent of the patients received the dual diagnosis of ‘‘substance abuse’’ plus other psychiatric disorder. 4.2. Psychiatric function and symptoms The mean GAF, a measure of function, was 29.9 ± 12.0 (100 = healthy). Patients with substance-related disorders had the lowest GAF; their mean score was 27.0. The mean BPRS, a measure of symptoms, was 33.4 ± 11.0 (96 = extremely severe symptoms). Forty-one percent had suicidal ideas and 15% had made a suicide attempt. The mean score for these patients on SIS was 13 ± 6 (30 = very high risk for suicide). Thirty percent was assessed as potentially dangerous. Of these, 73% were men. The mean HCR-20 was 18 ± 7 (40 = very high risk for violence); for men, it was 19 ± 7; for women, 16 ± 5. Patients with anxiety disorder had the highest HCR-20, with mean score 20 ± 5. 4.3. Days of commitment The mean duration of commitment was 31.7 ± 88.0 days (range 1–680). Thirty percent of the patients were released within 24 hours; 50% of these had a substance-related disorder or a dual diagnosis of psychotic disorder and drug abuse. Fifty percent of the remaining patients were discharged from their involuntary hospitalization within 28 days. Psychotic patient, detained for longer periods than other diagnostic groups, had a mean stay of 49.3 days ( P < .05) (Fig. 1). Duration of involuntary care showed no differences as to gender or age.
Fig. 1. Days of commitment (mean and one standard deviation) related to diagnosis in 200 committed patients from a psychiatric emergency unit.
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Table 2 Ethical benefits/costs regarding beneficence and autonomy for patients in percent assessed by physicians in a psychiatric emergency unit (N = 200) Patients Patients
Fulfilled autonomy
Violate autonomy
Neither fulfilled nor violate autonomy
Fulfilled beneficence Not fulfilled beneficence
29 1
50 6
14 0
4.4. The physicians Fifty-five physicians, 34 women and 21 men, participated in the study. Sixteen women and two men were accredited psychiatrists. Female residents wrote 36% of the certificates; female specialists wrote 16%. The mean age of the female physicians was 41 ± 8 years. Forty-four percent of the certificates were issued by male residents; 4% by male specialists. The mean age of the male physicians was 37 ± 6 years. 4.5. The ethical conflict between principles of beneficence and patients’ autonomy In 93% of the commitments, the physicians assessed that the compulsory care did benefit patients whereas 56% deemed that patients’ autonomy had been violated (Table 2). In 29% of the cases, the only assessments of ethical benefits were for these two principles; in 6%, the only assessment related to ethical costs. 4.6. The ethical benefits/costs regarding family, community, and patient The analysis of ethical benefits/costs for the family/community showed almost the same proportion of ethical benefits 29% and 25%, respectively. Forty-four percent assessed that patients’ autonomy had been violated. In 12% of the cases, there were only ethical costs (Table 3).
Table 3 Ethical benefits/costs regarding beneficence for families/community and autonomy for patients in percent assessed by physicians in a psychiatric emergency unit (N = 200) Patient Families/community
Fulfilled autonomy
Violate autonomy
Neither fulfilled nor violate autonomy
Fulfilled beneficence Not fulfilled beneficence
29 (25) 1 (5)
44 (44) 12 (12)
12 (11) 2 (3)
Data for community are shown in parenthesis.
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4.7. The ethical benefits/costs regarding physicians’ gender, accreditation, and age A greater proportion of male physicians judged the commitment to benefit the community ( P < .05). Residents more often than specialists believed the involuntary admission would benefit the community ( P < .01). Assessment of the ethical benefits/costs related to patients’ autonomy showed that older physicians more often concluded that the compulsory care would violate the patients’ autonomy ( P < .05). No statistically significant differences were found between male and female physicians or specialists and residents in evaluation of this variable. 4.8. Decision-making in compliance with the Compulsory Psychiatric Care Act All patients were assessed as having a severe psychiatric disorder. Suicidal thoughts were judged to have a major impact on the commitment decision in 30% of cases; whereas potentially dangerous ideas or impulses in 7%. Analysis of to what extent the patients fulfilled the criterion ‘‘opposes such care’’ or ‘‘due to his/her psychiatric condition, obviously lacks ability to express a considered decision on the issue’’ showed that 53% were assessed as negative to hospital care, 24% were ambivalent to hospitalization, and 23% were not able to effect or to communicate their decision as to hospitalization.
5. Discussion The clinical ratings showed that the committed patients were severely disturbed. The patients in this study had a mean GAF of 29.9 ± 12.0, somewhat lower than a mean GAF of 32.3 ± 11.5 in Kjellin and Westrin’s study (1998) of a group of committed patients from two Swedish counties. The present patient group’s mean BPRS of 33.4 ± 11.0 was higher than the 24.6 ± 11.9 in Kjellin et al.’s (1997) report. This reflects a larger incidence of symptoms. Schwartz et al. (1984) who investigated correlations between clinical variables and the decision to commit psychiatric patients, found that the most determinative factors were inability to care for oneself, mental illness, need of treatment, and psychosis. In the same study of 21 clinical features related to coercion, danger to self and/or others were ranked as 12 and 9, respectively. These findings are congruent with our results, where suicidal ideas and dangerousness were ranked as having a major impact on the decisionmaking process in, respectively, 30% and 7% of cases compared to 63% for severe psychiatric disorders. Analysis of the legal criteria pertinent to the patient’s consent to psychiatric hospitalization showed that nearly 50% of the patients were ambivalent or could not communicate their decision. A competency questionnaire exploring this issue could be of value to physicians. Physicians’ evaluation of the ethical costs regarding patients’ autonomy showed that more than half of the physicians considered that it had been violated and one third that it had been fulfilled. The physicians were instructed to mark ‘‘benefits’’ for increased
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possibilities for patients to decide about their lives, and ‘‘costs’’ for deprivation of the right for self-determination. When physicians assessed a patient’s autonomy higher than benefits of his/her care, commitment probably did not occur. Differences between physicians influence the commitment decision. This aspect will be analyzed in a project, which will investigate the type of care given to patients brought to the emergency unit by the police.
6. Conclusions
The most important determinant when a physician issued a certificate for compulsory care was severity of the patient’s psychiatric symptoms. Suicidal impulse was a relatively strong determinant of the decision to commit, whereas dangerousness to others was assessed as not especially important. Analysis of the legal criteria regarding consent to psychiatric hospitalization showed that nearly 50% of the patients were ambivalent or were unable to communicate their decision. A competency questionnaire exploring this issue could be valuable for physicians. Physicians assessed compulsory care on the one hand to benefit patients, on the other to violate their autonomy. Review of the conflict ‘‘benefits’’ of commitment versus ‘‘costs’’ showed that the benefits were valued higher by physicians who opted for commitment. Contemplated analysis of the decision-making process regarding a patient group consisting of both voluntary and committed patients might increase our knowledge about this aspect of coercion. Male physicians more often than female and residents more often than specialists judged that involuntary admission would benefit the community. Physicians who assessed that the care would violate the autonomy of the patient had a higher mean age.
Acknowledgments The study was supported by a grant from the Swedish Society of Medicine.
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