Diagnosis of a psychotic disorder and previous involuntary stays were the greatest risk factors associated with involuntary psychiatric hospitalizations in 22 countries, according to an article published in Lancet Psychiatry. Several other factors were also linked to involuntary hospitalization, including single marital status, unemployment, receiving welfare benefits, and not being a homeowner.

Involuntary hospitalization can often be traumatic for patients, leading to avoidance of care, and a prior companion paper had demonstrated an elevated risk for involuntary hospitalization in non-white ethnic groups.

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Susan Walker, MBBS, of the division of psychiatry at University College London in the United Kingdom, and colleagues performed a systematic review, meta-analysis, and narrative synthesis of studies from MEDLINE, PsycINFO, Embase, and the Cochrane Controlled Clinical Register of Trials published between January 1, 1983 and August 14, 2019. Ultimately, 77 studies (N=975,004) comparing involuntary and voluntary hospitalizations in 22 countries (18 high income, 4 middle income) were included, with 23% of patients admitted involuntarily.

Involuntary hospitalization was primarily linked with a diagnosis of a psychotic disorder (odds ratio [OR], 2.18; P <.0001) or bipolar disorder (OR, 1.48; P <.0001), and prior instances of involuntary inpatient stays (OR, 2.17; P <.0001). Based on demographics, involuntary hospitalization was associated with receiving welfare benefits (OR, 1.71; P <.0001), unemployment (OR, 1.43; P =.020), living in a rented home (OR, 1.49; P <.0001), being single (OR, 1.47; P <.0001) or previously married (OR, 1.26; P <.0001), and male gender (OR, 1.23; P <.0001).

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The narrative synthesis identified associations between involuntary psychiatric hospitalization and police involvement in admission, reduced insight into illness, positive symptoms of psychosis, perceived risk to others, and reduced adherence to treatment prior to hospitalization. There was also some evidence of elevated involuntary hospitalization in areas with greater deprivation.

A commentary on the study from 2 panelists with lived experience expressed concerns with providers relying on clinical risk factors such as those identified in the study rather than considering the needs and experiences of individual patients. They wrote, “we remain concerned about the paucity of legal safeguards against coercion during voluntary admissions, making some such admissions de facto detentions.”

Investigators commented that the majority of the studies analyzed were conducted in high-income countries, limiting the ability to investigate risk factors in low- or lower-middle-income countries. They concluded, “Understanding the mechanisms by which the risk factors we have identified contribute to involuntary hospitalization should be a priority for future research and policy investment, to ensure equitable access to psychiatric treatment and reduce health-care inequalities.” However, the analysis was unclear about the implications of the socioeconomic factors revealed in the study.

The investigators also called for crisis-planning interventions in the identified target groups, particularly given “the importance of liberty and autonomy over paternalism and authority…within mental health policy and practice internationally.”


Walker S, Mackay E, Barnett P, et al. Clinical and social factors associated with increased risk for involuntary psychiatric hospitalization: a systematic review, meta-analysis, and narrative synthesis. Lancet Psychiatry. 2019;6(12):1039-1053.