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Status and clinical influencing factors of involuntary admission in chinese patients with schizophrenia

BMC Psychiatry volume 22, Article number: 818 (2022) Cite this article

Abstract

Background

Though controversial for its various disadvantages, involuntary admission (IA) is necessary in providing mental health care for patients suffering from schizophrenia in China. This article examines the IA rate in a representative sample, and under which circumstances are these patients more likely to be admitted involuntarily.

Methods

Adult patients consecutively admitted to two typical hospitals in Shanghai between 2013 and 2014 with a diagnosis of ICD-10 schizophrenia were included. 2167 patients were included in this study. Sociodemographic and clinical data, as well as personal information of psychiatrists who made risk assessment, were collected. The whole sample was divided into voluntary and involuntary admission groups. Group comparisons were performed with SPSS 17.0, using one-way ANOVA, Wilcoxon rank sum test, Chi-squares and Logistic regression.

Results

Among 2167 inpatients, the majority (2003, 92.4%) were involuntarily admitted. Clinical features, including age of patients (p < 0.001, OR = 1.037), lacking of insight (p < 0.001, OR = 3.691), were statistically significant for IA. Psychiatrist’s age (p < 0.001, OR = 1.042) was independently associated with IA. However, risk behaviors had dramatically affected patients’ admission status, of which the strongest predictor of IA was noncompliance with treatment (p < 0.001, OR = 3.597). The areas under the curve of the ROC and accuracy for the regression model were 0.815 and 0.927, respectively.

Conclusion

IA patients account for a major proportion of all those hospitalized with schizophrenia in China. Insights and risk behaviors contributed the most reasons for admission status of patients. This research shed light on necessity of further qualitative studies learning detailed evaluation processes of IA and high-quality interventional studies aiming to limit the performance of IA among patients with schizophrenia.

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Introduction

Schizophrenia is a chronic mental disorder with disabling and early-occurred features [1]. In the latest national survey, weighted lifetime prevalence of schizophrenia and other psychotic disorder is 0.7% in China [2]. It’s estimated that there are more than 15 million schizophrenic patients in China, which results in heavy social and economic burden [3,4,5]. However, due to inadequate access of community mental health services, hospitalization remains the main way in China’s majority of families caring for mental illness patients [6, 7]. What’s worse, schizophrenic patients are more likely to be admitted involuntarily in hospital compared to other mental disorders according to previous studies [8,9,10,11,12].

Involuntary admission (IA) is necessary but disputed in psychiatry, due to its ethical complexity and possible multiple adverse outcomes in the future [13,14,15,16,17]. Discussions about its use and possible reduction are called for both professionally and politically [13, 18]. However, simply limiting the use of IA may lead to adverse consequences, for example, a stricter standard of IA would delay treatment but early intervention or rational prevention would make it more beneficial for patients [19]. Combined with high incidence of IA in schizophrenia patients and desire of reducing IA rate, we try to figure out risk factors of IA in patients with schizophrenia to provide suggestions for future work.

As many studies have revealed [7, 20,21,22,23], diagnosis of schizophrenia is one of the most influential factors of IA. This may be partly explained by the association between active psychotic symptoms and possible violent behaviors in patients with schizophrenia [24,25,26,27]. Though inconsistent results coexist [19], some reports [28,29,30] indicated that violence might be driven by symptoms of psychosis. Besides, lack of insight [14] would destroy patients’ competence in decision-making of hospitalization, which is also common in patients with schizophrenia in the period of onset. In general, symptoms of schizophrenia may partly explain why patients are more likely to be involuntarily admitted, but other factors might also exist and need to be figured out.

In order to apply IA rationally and protect human rights of psychotic patients, China enacted Mental Health Law of the People’s Republic of China (CMHL) on May 1st, 2013 [31]. The new law states that “inpatient treatment of mental disorders must largely be voluntary” and that IA should only be used when people with “serious mental disorders” endanger their own safety or the safety of others. It indicates that risk behavior or attempt is crucial to determining a patient’s status for admission, and patients with schizophrenia must present risk behaviors or attempts to themselves or others if they must be forced into hospital. [31] Aggressive actions or attempts would undoubtedly have an impact on the incidence of IA according to the new law. Besides, the admission process would be completed by the guardians (often family members in China) or the administrative department that refers the patients (beggars or the homeless) to the hospital for evaluation. The employer, rural village committee, or urban neighborhood committee may carry out IA procedures if the guardians decline to do so. In light of this, we speculate that the referral source may also have an impact on IA.

Before implementation of the national law, several local mental health legislations were used in local areas [32]. Shanghai was the first city to promulgate local mental health legislation in China (Mental Health Regulations of Shanghai Municipality), and “need for treatment criterion” for IA had been applied for more than ten years. The change in IA legislation was clear, dramatic and typical in Shanghai. Since pattern and influencing factors of IA in patients with schizophrenia remain unclear after the new law took effect, we try to figure these out in the study carried out in Shanghai. It is believed that status of IA in patients with schizophrenia in shanghai would be typical and representative.

In this study, rate of IA among inpatients with schizophrenia after the new law took effect was investigated, and differences of sociodemographic and clinical characteristics are compared between voluntarily and involuntarily hospitalized patients with schizophrenia to identify risk factors of IA. We hope that the present study would be the cornerstone of further study aiming to reduce the use of IA in the psychiatric institutions.

Methods

Patients and study sites

This was an observational study and cluster sampling was adopted. Data of medical records was collected mainly from two psychiatric hospitals in Shanghai, Shanghai Mental Health Center (SMHC, including Xuhui campus and Minhang campus) and Xuhui Mental Health Center (XMHC), between May 1, 2013, and April 30, 2014. SMHC is the only tertiary specialized psychiatric hospital with 24-hour outpatient services with 2100 psychiatric inpatient beds, as well as the largest psychiatric hospital in China. Inpatient care covered not only inhabitants in the 19 municipalities from Shanghai but also patients from other provinces. XMHC is a typical and representative district (secondary) level mental hospital (one district level hospital in each municipality and 19 ones in total) in Shanghai, which receives patients mainly from community. Persons who are suspected of having risk behaviors or intentions would be involuntarily admitted to these hospitals with consent forms signed by their family members or local civil and public security departments (only when they have no family members). As regulated in the CMHL, their situations would be estimated by a qualified psychiatrist and the final diagnosis would be made through 3-level rounds system in the hospitals [33]. In general, the IA process in China is not directly supervised by a court and the IA is usually upheld until discharge [7, 34]. But patients and family members are empowered to take the case to court if they believe the required procedures have been mismanaged. During the study period, all the data of consecutively admitted patients aged 18 years and above were extracted from medical record system. International Classification of Diseases 10th revision (ICD-10) was used for psychiatrists to make diagnosis. Patients diagnosed of schizophrenia, schizotypal and delusional disorders (F20–29) were included. Principal diagnosis was used if there was more than one diagnosis. For patients admitted more than one time within the study period, each admission of this patient was included in the study and counted separately, because they might be readmitted with different reasons and in different status (voluntary or in voluntary). Cases were excluded if the medical record data were incomplete at the time of data collection.

Instruments and measurements

Firstly, patients’ social-demographic and clinical characteristics were collected through medical records. Socio-demographic characteristics included patients’ age, gender, employment, marriage, insurance, socioeconomic status. Clinical characteristics incorporated family history, length of illness and times of hospitalization (in SMHC, XMHC or any other psychiatric hospital). Information related to the present admission was collected such as referring agent (family member or government) and admission status (voluntary/involuntary).

Secondly, clinical symptoms collected were comprised of psychotic positive symptoms (e.g. hallucination, delusion, experiences of influence), negative symptoms (e.g. affective flattening, paucity of speech, social withdrawal and lowering of social performance), history of drug and alcohol abuse, negative life events (e.g. death of a family member, or terminal illness) or other social psychological stimulation and status of insight. Insights of patients at admission were divided into two levels (i.e. with or without insight) to get a preliminary understanding of patients’ cognitive ability to their mental state. Insights of the patients were subjectively evaluated by psychiatrists according to the following questions: whether the patient believes that his/her abnormal experiences are symptoms; whether the patient believes his/her symptoms are attributed to mental disorder; whether he/she believes that the disorder is psychiatric; whether he/she believes that psychiatric treatment might benefit him/her; whether he would be willing to accept advice from a doctor regarding his/her treatment.

Thirdly, personal information (i.e. gender, age, education level and title) of psychiatrists who made the clinical assessment was collected in this study. In Shanghai, an attending psychiatrist or above evaluates the situation of the patients and simultaneously records their risk status in outpatient department before admission. A risk assessment checklist for admission [35] was specified used by all psychiatrists in the mental health hospitals of Shanghai, designed according to previous researches and IA criteria and issued by the local psychiatrist association since the CMHL was enacted. When the new law took effect, all staff received training on it as well as how to use a risk assessment checklist to make sure that everyone grasped the relevant regulation and evaluation criteria. This kind of checklist record would ensure psychiatrists rational deliberative decision making based on legal criterion for IA and succinctly document grounds for admission, which comprises three sections: harmful behaviors to self or others, current attempts of harmful behavior, history of harmful behaviors (details see in Table 1). With the help of structured checklist, risks to self or others displayed by the patients were recorded (yes/no).

Table 1 Social-demographic characteristics of patients with schizophrenia
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Statistical analysis

The data was analyzed using SPSS version 17.0 for Windows (SPSS Inc., Chicago, IL, USA). The sample was subdivided into two groups according to their legal status at time of admission (voluntary vs. involuntary). Descriptive statistics were used to calculate rates, means, and standard deviations. Comparison of basic social demographic and clinical characteristics between two groups were performed with one-way ANOVA analysis, Mann-Whitney U test, and Pearson’s Chi-square test, as appropriate. Binary logistic regressions (forward selection) were used to determine the independent contributors to the possible risk of IA in the whole sample. The possible risk factors of IA, which were statistically significant in univariate analysis, were entered as the dependent variables, i.e. age of patients, age of psychiatrists, marital status, insurance, insight, and length of illness, risk behaviors (violent behaviors against others at admission, suicidal or self-injurious behaviors at admission, running away from home, damage in life ability, violent intentions against others, noncompliance with treatment, violent behaviors against others in the past, violent intentions against others in the past). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. Then a receiver operating characteristic (ROC) curve was plotted to determine the predictive value of logistic regression model. The level of significance was set at 0.05 (two tailed).

Results

There was a total of 4459 admissions of adult patients during the study period. Of all 4459 inpatients, 2427 (54.4%) were diagnosed with schizophrenia and 2167 (89.29%) of them were included in this study. Among the 2167 patients, 2003 (92.4%) were involuntarily admitted, and 164 (7.6%) were admitted voluntarily. Male patients in the sample accounted for 46.5% (n = 1007). Mean age of the sample was 38.39 years old (standard deviation [SD] 15.08). About 32.7% of the participants were married, 56.5% were single, and 10.8% were divorced or widowed. 75.4% were unemployed or retired.

Social-demographic characteristics of the voluntary and involuntary admission groups

The social-demographic characteristics were compared between 164 voluntarily admitted patients (voluntary group) and 2003 involuntarily admitted patients (involuntary group) (Table 2). The IA patients with schizophrenia were more likely to be married, to have insurance, elder age, longer course of disorders, and their psychiatrists who made the assessment tended to be older than that of the voluntarily admitted patients.

Table 2 Clinical features of the voluntary and involuntary admission patients with schizophrenia
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Clinical features and risk assessment of the voluntary and involuntary admission groups

Tables 3 and 1 presented comparison of clinical features and risk assessment between the voluntary and involuntary groups. Compared to voluntary admission patients, IA patients were more likely to be lack of insight, to have harmful behaviors to self or others, damage in life ability, violent intentions against others, not comply to treatment, violent behaviors or intentions against others in the past (more than one week ago), and to run away from home or wander aimlessly in the past (all p < 0.05).

Table 3 Risk assessment comparison of the voluntary and involuntary admission patients with schizophrenia
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Predictors of admission status in patients with schizophrenia

The results of forward stepwise multivariate logistic regression analysis on admission status were presented in Table 4. The independent variables entered in the model were age of patients, age of psychiatrists, marital status, insurance, risk behaviors, insight, and length of illness. Predictors of involuntary admission in this model were age of patients (p = 0.001; odds ratio = 1.037), age of psychiatrists (p = 0.001; odds ratio = 1.042), suicidal or self-injurious behaviors (p = 0.007; odds ratio = 2.363), running away from home/wander aimlessly (p = 0.046; odds ratio = 1.611), damage in life ability (p = 0.006; odds ratio = 1.812), violent intentions against others (p = 0.001; odds ratio = 2.790), not comply to treatment (p = 0.001; odds ratio = 3.597), lack of insight (p = 0.001; odds ratio = 3.691). The ROC curve in Fig. 1 showed a good performance where the AUC of the ROC was 0.815 (95% CI, 0.781–0.848), and the accuracy of this model was 0.927.

Table 4 Independent contributors to IA status (multiple logistic regression analysis)
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Fig. 1
figure 1

Receiver operating characteristics (ROC) curve of logistic regression prediction model for IA patients with schizophrenia

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Discussion

As far as we know, there is few studies about the prevalence and risk factors of IA in patients with schizophrenia following the implementation of CMHL. It is revealed in our study that inpatients with schizophrenia accounted for about half of all the patients (54.4%), which is consistent with previous studies at home and abroad [7, 25, 36]. Because rate of inpatients with schizophrenia is larger than those with other diagnoses and the point prevalence of schizophrenia rose with the urbanization in China [6], it is particularly important to take precautionary measures for these people avoiding hospitalization.

Meanwhile, the high proportion of unemployment (75.4%) and single status (67.3%) in this study further hints that social maladjustment was a problem for the majority of the patients with schizophrenia. This phenomenon is not rarely seen in China and other countries [4, 37], which could be partly explained by schizophrenia-related symptoms as well as social discrimination and a lack of social support [36, 38]. Promoting schizophrenia patients’ integration into society and providing them with extensive assistance through a variety of interventions is crucial to reducing the likelihood of IA recurrence. For instance, our government may encourage the hiring of patients in remission in the public and private sectors by setting hiring quotas or offering incentives to businesses, as well as expanding opportunities for employment-related training.[39].

Majority of schizophrenic inpatients (92.4%) were involuntarily admitted in this study, which is consistent with our survey [10] of 2,333 patients in 2003 (93.2%). However, the proportion was larger than that of many previous studies (29.5-64%) [7, 20, 21, 40, 41]. As stipulated in our former report [9], IA rate was generally decreasing after the CMHL was implemented, while IA rate of schizophrenia remained stable compared to that of other diagnosis. Recent systematic reviews [42] also found that IA rate in China remained high, particularly for schizophrenia, much higher than overall IA rate in western countries (43.0%) [43]. In some country, IA rate in patient with schizophrenia is also relatively high, i.e. 80.7% in one study in Norway [25]. The issue might be considered in the context of very country. The contribution of reducing stigma across Shanghai cannot be overlooked. By educating the public and passing new local legislation on mental health, the government and health authorities have made enormous efforts to reduce the stigma associated with serious mental illness. Patients and their families are more likely to seek mental health care now that the legal landscape and social climate surrounding serious mental illness are changing.[42] Shanghai’s community has grown somewhat, but given the city’s vast population, it is still insufficient. Additionally, since the majority of the city’s psychiatric beds are located in hospitals like the SMHC, the amount of resources allocated for mental health care needs to be raised. [44] To clarify the precise causes of the high IA rate in patients with schizophrenia, this still require further exploration.

Assessing patient’s demographic and clinical characteristics can help recognize patients who are at risk of IA. Studies from different countries deem that predictors of IA would vary between countries, which might be explained by differences in cultural factors [45], factors related to social services [46], legal frameworks or procedures [13, 21]. Therefore, IA influencing factors in patients with schizophrenia found in this study require concrete analysis according to concrete circumstance to make it clear what need be taken into consideration in the future policy. We set up a regression model to predict the risk of IA in schizophrenic patients. ROC curves demonstrated these factors listed in Table 4 had comparable accuracy at predicting IA (AUC were 0.815).

In the aspect of clinical characteristics, lack of insight (p = 0.001; odds ratio = 3.691) was the most influential factor on IA status in patients with schizophrenia. Lack of insight was also found to be a significant factor in IA in many studies, and it was thought that poor insight would postpone therapy and increase the likelihood of harmful behavior toward oneself or others. [7, 47, 48] It also cannot be neglected that psychiatrists’ risk assessment in Shanghai might be influenced by the former IA criteria [49] of the Shanghai Municipality Mental Health Regulations. The very local mental health regulations had been implemented for 10 years, which stipulated that severe lack of insight is one of the criteria for IA. The previous regulation might influence psychiatrists’ assessment and evaluation on IA in practice to some extent.

Of all the factors in the risk assessment checklist, “noncompliance with treatment” (p = 0.001; odds ratio = 3.597), “violent intentions against others” (p = 0.001; odds ratio = 2.790) and “suicidal or self-injurious behaviors” (p = 0.007; odds ratio = 2.363) were the top three most influencing factors on IA. Need for and acceptance of treatment is one of the four elements of insight, which might partly explain poor treatment compliance to be the other most important factor of IA in patients with schizophrenia. Poor treatment compliance mainly refers to low medication adherence in patients with mental illness. Early findings [40, 50] support that lower medication compliance would lead to a greater need for IA and re-hospitalization. A meta-analysis in 2016 [51] shows the prevalence of aggressive behavior (verbal aggression, physical aggression toward others or himself/herself, and aggressive behavior toward objects) among schizophrenia patients ranges from 15.3 to 53.2%. Some reports suggest that percentage of violent behaviors or intentions in patients with schizophrenia is higher than that in other diagnosis [36], and agitation would occur throughout the entire course of the disease. The high proportion of IA might be related to the aggressive behavior in patients with schizophrenia. As many studies revealed [20, 52, 53], perceived violence (risk of dangerousness to self or others) is a central factor in psychiatrists’ judgments regarding IA, and this is true especially under the risk criteria provisions on IA in China. Psychiatrists’ assessment would reflect their evaluation of patients as well as their attitude and understanding of risk criteria on IA [54, 55]. In other words, the three factors above might be the most important for clinicians on IA decision making.

As for demographic factors, mean age of IA patients with schizophrenia were elder than that of voluntarily admitted ones, which was an independent influencing factor for IA status (p = 0.001; odds ratio = 1.037). This is consistent with many reports in both Asian and Western studies, which demonstrated higher rates of IA among the elders [26, 40]. However, some research [56] presents the opposite results. The finding in our study might be explained by the fact that older patients with schizophrenia generally have poorer insights [47, 57] and gradual destruction of social functions following its progressive course, and severity of the disorder grows with age, which would lead to higher possibility of involuntary hospitalization. We cannot exclude the assumption of psychiatrists’ habitual practice on IA decision-making [8, 49] when facing patients with longer course of schizophrenic patients. It’s also interesting to note that psychiatrists who made risk assessment for IA patients with schizophrenia were also elder than those for voluntary admitted patients (p = 0.001; odds ratio = 1.042). This phenomenon might be regarded to the following factors. On the one hand, older psychiatrists usually have higher professional qualifications and treat patients with more severe symptoms who would be more likely to be involuntarily admitted. On the other hand, our previous study [49] found that clinicians might show more arbitrarily attitudes in the admission process and prone to use their discretions in making clinical decision due to conservative values of the older generations [52]. Psychiatrists’ characteristics and assessments had significant impacts on IA of schizophrenia patients [58], which suggested the importance of systematic training to psychiatrists and third-party review systems. Establishment of regular and effective monitoring processes focusing on involuntary psychiatric hospitalizations would be an important step forward.

This study tries to find independent influencing factors between voluntary and involuntary admission in patients with schizophrenia, and attempts to make suggestions for future policy implementation in Shanghai and even China according to these factors. There are several limitations of this study should be noted. Firstly, the sample of this study is from only one city in China, but Shanghai is a typical city and representative for its change of legislation from “treatment criteria” to “risk criteria”. The present result still should be considered as preliminary and need to be confirmed with further studies. Secondly, this is quantitative research, and more details of risk assessment, such as evaluation process and attitudes and other consideration of decision-making, should be verified in future qualitative studies. Besides, the statistics were less precise because we only performed a retrospective analysis and did not discuss the connection between the severity of the symptoms and IA due to our inability to get more precise data. Due to the study method, other important variables were also missing, such as traumatic life events or other types of social psychological stimulation. Thus, longitudinal and prospective studies are required to support the current finding.

Conclusion

The present study revealed a high rate of IA in patients with schizophrenia. The principal contribution of this study was identification of independent influencing factors of IA in patients with schizophrenia, including older age of patients and psychiatrists who made assessment, lack of insight, noncompliance with treatment, risk behaviors, such as violent intentions against others, suicidal or self-injurious behaviors, running away from home/wander aimlessly and damage in life ability. To reduce IA rate of schizophrenia patients, more attentions should be paid to those risk factors and preventive measures should be made once these factors occurred. Besides, regular training should be made to make psychiatrists risk assessment more reasonable and effective. Further qualitative studies are needed to learn more about evaluation process of IA and high-quality interventional studies are needed to make it possible the reduction of IA rate in patients with schizophrenia.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due confidentiality reasons but are available from the corresponding author on reasonable request.

Abbreviations

IA:

Involuntary admission

CMHL:

Mental Health Law of the People’s Republic of China

SMHC:

Shanghai Mental Health Center

XMHC:

Xuhui Mental Health Center

References

  1. Picchioni MM, Murray RM. Schizophrenia. BMJ. 2007;335(7610):91–5. https://doi.org/10.1136/bmj.39227.616447.BE.

    Article  Google Scholar 

  2. Huang Y, Wang Y, Wang H, Liu Z, Yu X, Yan J, et al. Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatry. 2019;6(3):211–24. https://doi.org/10.1016/S2215-0366(18)30511-X.

    Article  Google Scholar 

  3. Feldman R, Bailey RA, Muller J, Le J, Dirani R. Cost of schizophrenia in the medicare program. Popul Health Manag. 2014;17(3):190–6. https://doi.org/10.1089/pop.2013.0062.

    Article  Google Scholar 

  4. Liu T, Song X, Chen G, Paradis AD, Zheng X. Prevalence of schizophrenia disability and associated mortality among chinese men and women. Psychiatry Res. 2014;220(1–2):181–7. https://doi.org/10.1016/j.psychres.2014.04.042.

    Article  Google Scholar 

  5. Yu Y, Li TX, Li YL, et al. A cross-sectional study on spouse and parent differences in caregiving experiences of people living with schizophrenia in rural China. BMC Psychiatry. 2020;20(1):226. https://doi.org/10.1186/s12888-020-02633-w. Published 2020 May 12.

    Article  Google Scholar 

  6. Chan KY, Zhao FF, Meng S, Demaio AR, Reed C, Theodoratou E, et al. Urbanization and the prevalence of schizophrenia in China between 1990 and 2010. World Psychiatry. 2015;14(2):251–2. https://doi.org/10.1002/wps.20222.

    Article  Google Scholar 

  7. Gou L, Zhou JS, Xiang YT, Zhu XM, Correll CU, Ungvari GS, et al. Frequency of involuntary admissions and its associations with demographic and clinical characteristics in China. Arch Psychiatr Nurs. 2014;28(4):272–6. https://doi.org/10.1016/j.apnu.2014.04.002.

    Article  Google Scholar 

  8. Jiang F, Zhou H, Rakofsky JJ, Hu L, Liu T, Liu H, et al. The implementation of China’s mental health law-defined risk criteria for involuntary admission: a national cross-sectional study of involuntarily hospitalized patients. Front Psychiatry. 2018;9:560–3. https://doi.org/10.3389/fpsyt.2018.00560.

    Article  Google Scholar 

  9. Ma HJ, Xie B, Shao Y, Huang JJ, Xiao ZP. Changing patterns and influencing factors of involuntary admissions following the implementation of China’s mental health law: a 4-year longitudinal investigation. Sci Rep. 2019;9(1):15252. https://doi.org/10.1038/s41598-019-51980-6.

    Article  CAS  Google Scholar 

  10. Pan ZD, Xie B, Zheng ZP. A survey on psychiatric hospital admission and relative factors in China (in Chinese). J Clin Psychol Med. 2003;13:270–2.

    Google Scholar 

  11. Ma HJ, Zheng YC, Xie B, Shao Y. Risk assessment and its influencingfactors of involuntary admission in patients with mental disorders in Shanghai. China Int J Soc Psychiatry. 2022;68(4):745–53. https://doi.org/10.1177/00207640211007154.

    Article  Google Scholar 

  12. Chatzisimeonidis S, Stylianidis S, Tzeferakos G, Giannoulis G. Insights into involuntary hospital admission procedures for psychiatric patients: a 3-year retrospective analysis of police records. Int J Law Psychiatry. 2021;78:101732. https://doi.org/10.1016/j.ijlp.2021.101732.

    Article  Google Scholar 

  13. Fiorillo A, Rosa CD, Vecchio VD, Jurjanz L, Schnall K, Onchev G, et al. How to improve clinical practice on involuntary hospital admissions of psychiatric patients: suggestions from the EUNOMIA study. Eur Psychiatry. 2011;26(4):201–7. https://doi.org/10.1016/j.eurpsy.2010.01.013.

    Article  CAS  Google Scholar 

  14. Feiring E, Ugstad KN. Interpretations of legal criteria for involuntary psychiatric admission: a qualitative analysis. BMC Health Serv Res. 2014;14:500. https://doi.org/10.1186/s12913-014-0500-x.

    Article  Google Scholar 

  15. Walter F, Carr MJ, Mok PLH, Antonsen S, Pedersen CB, Appleby L, et al. Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study. Lancet Psychiatry. 2019;6(7):582–9. https://doi.org/10.1016/S2215-0366(19)30180-4.

    Article  Google Scholar 

  16. Valevski A, Zalsman G, Tsafrir S, Lipschitz-Elhawi R, Weizman A, Shohat T. Rate of readmission and mortality risks of schizophrenia patients who were discharged against medical advice. Eur Psychiatry. 2012;27(7):496–9. https://doi.org/10.1016/j.eurpsy.2011.04.009.

    Article  CAS  Google Scholar 

  17. Iudici A, Girolimetto R, Bacioccola E, Faccio E, Turchi G. Implications of involuntary psychiatric admission: health, social, and clinical effects on patients. J Nerv Ment Dis. 2022;210(4):290–311. https://doi.org/10.1097/NMD.0000000000001448.

    Article  Google Scholar 

  18. Welsh S, Deahl MP. Modern psychiatric ethics. Lancet. 2002;359(9302):253–5. https://doi.org/10.1016/S0140-6736(02)07452-4.

    Article  Google Scholar 

  19. Keers R, Ullrich S, Destavola BL, Coid JW. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry. 2014;171(3):332–9. https://doi.org/10.1176/appi.ajp.2013.13010134.

    Article  Google Scholar 

  20. Mulder CL, Uitenbroek D, Broer J, Lendemeijer B, van Veldhuizen JR, van Tilburg W, et al. Changing patterns in emergency involuntary admissions in the Netherlands in the period 2000–2004. Int J Law Psychiatry. 2008;31(4):331–6. https://doi.org/10.1016/j.ijlp.2008.06.007.

    Article  CAS  Google Scholar 

  21. Salize HJ, Dressing H. Epidemiology of involuntary placement of mentally ill people across the European Union. Br J Psychiatry. 2004;184:163–8. https://doi.org/10.1192/bjp.184.2.163.

    Article  Google Scholar 

  22. Draghetti S, Alberti S, Borgiani G, Panariello F, De Ronchi D, Atti AR. Compulsory and voluntary admissions in comparison: a 9-year long observationalstudy. Int J Soc Psychiatry. 2021;68(8):1716–26. https://doi.org/10.1177/00207640211057731.

    Article  Google Scholar 

  23. Bakola M, Peritogiannis V, Stuckler D, Kitsou KS, Gourzis P, Hyphantis T, et al. Who is coercively admitted to psychiatric wards? Epidemiological analysis of inpatient records of involuntary psychiatric admissions to a University General Hospital in Greece for the years 2008–2017. Int J Soc Psychiatry. 2022. https://doi.org/10.1177/00207640221081793.

  24. Myklebust LH, Sørgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC Health Serv Res. 2014;14:64. https://doi.org/10.1186/1472-6963-14-64.

    Article  Google Scholar 

  25. Myklebust LH, Sørgaard K, Røtvold K, Wynn R. Factors of importance to involuntary admission. Nord J Psychiatry. 2012;66(3):178–82. https://doi.org/10.3109/08039488.2011.611252.

    Article  Google Scholar 

  26. Hustoft K, Larsen TK, Auestad B, Joa I, Johannessen JO, Ruud T. Predictors of involuntary hospitalizations to acute psychiatry. Int J Law Psychiatry. 2013;36(2):136–43. https://doi.org/10.1016/j.ijlp.2013.01.006.

    Article  Google Scholar 

  27. Long Y, Tong X, Awad M, Xi S, Yu Y. Violence, runaway, and suicide attempts among people living with schizophrenia in China: prevalence and correlates. Peer J. 2022;10:e13033. https://doi.org/10.7717/peerj.13033.

    Article  Google Scholar 

  28. Van Dorn R, Volavka J, Johnson N. Mental disorder and violence: is there a relationship beyond substance use. Soc Psychiatry Psychiatr Epidemiol. 2012;47(3):487–503. https://doi.org/10.1007/s00127-011-0356-x.

    Article  Google Scholar 

  29. Coid JW, Ullrich S, Kallis C, Keers R, Barker D, Cowden F, et al. The relationship between delusions and violence: findings from the East London first episode Psychosis Study. Jama Psychiatry. 2013;70(5):465–71. https://doi.org/10.1001/jamapsychiatry.2013.12.

    Article  Google Scholar 

  30. Kalisova L, Raboch J, Nawka A, Sampogna G, Cihal L, Kallert TW, et al. Do patient and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study. Soc Psychiatry Psychiatr Epidemiol. 2014;49(10):1619–29. https://doi.org/10.1007/s00127-014-0872-6.

    Article  Google Scholar 

  31. Chen HH, Phillips MR, Cheng H, Chen QQ, Chen XD, Fralick D, et al. Mental health law of the people’s Republic of China (English translation with annotations). Shanghai Archiv Psychiatry. 2012;24(6):305–21. https://doi.org/10.3969/j.issn.1002-0829.2012.06.001.

    Article  Google Scholar 

  32. Shao Y, Xie B. Approaches to involuntary admission of the mentally ill in the People’s Republic of China: changes in legislation from 2002 to 2012. J Am Acad Psychiatry Law. 2015;43(1):35–44.

    Google Scholar 

  33. Phillips MR, Chen H, Diesfeld K, et al. China’s new mental health law: reframing involuntary treatment. Am J Psychiatry. 2013;170(6):588–91. https://doi.org/10.1176/appi.ajp.2013.12121559.

    Article  Google Scholar 

  34. Xiang YT, Yu X, Chiu HF. Compulsory admission to psychiatric hospitals in China. Lancet. 2010;376(9747):1145–6. https://doi.org/10.1016/S0140-6736(10)61539-5.

    Article  Google Scholar 

  35. Xie F, Xie B, Jin ZX, Fei H. Preparation of risk assessment scale for admitting patients with mental disorders (in Chinese). J Shanghai Jiaotong Univ (Med Sci). 2015;35(10):1534–8. https://doi.org/10.3969/j.issn.1674-8115.2015.10.021.

    Article  Google Scholar 

  36. Di Lorenzo R, Vecchi L, Artoni C, Mongelli F, Ferri P. Demographic and clinical characteristics of patients involuntarily hospitalized in an italian psychiatric ward: a 1-year retrospective analysis. Acta Biomed. 2018;89(6-S):17–28. https://doi.org/10.23750/abm.v89i6-S.7392.

    Article  Google Scholar 

  37. Mi W, Zhang S, Liu Q, Yang F, Wang Y, Li T, et al. Prevalence and risk factors of agitation in newly hospitalized schizophrenia patients in China: an observational survey. Psychiatry Res. 2017;253:401–6. https://doi.org/10.1016/j.psychres.2017.02.065.

    Article  Google Scholar 

  38. Bechi M, Bosia M, Spangaro M, Buonocore M, Cavedoni S, Agostoni G, et al. Exploring functioning in schizophrenia: predictors of functional capacity and real-world behaviour. Psychiatry Res. 2017;251:118–24. https://doi.org/10.1016/j.psychres.2017.02.019.

    Article  Google Scholar 

  39. World Health Organization. WHO QualityRights guidance module. In: Qualityrights materials for training, guidance and transformation. 2019. https://www.who.int/publications/i/item/who-qualityrights-guidance-and-training-tools</i. Accessed 20 Sept 2022.

  40. Silva B, Golay P, Morandi S. Factors associated with involuntary hospitalisation for psychiatric patients in Switzerland: a retrospective study. BMC Psychiatry. 2018;18(1):401. https://doi.org/10.1186/s12888-018-1966-6.

    Article  Google Scholar 

  41. Kelly BD, Umama-Agada E, Curley A, Duffy RM, Asghar M, Gilhooley J. Does involuntary admission with bipolar disorder differ from involuntary admission with schizophrenia and related disorders? A report from the Dublin Involuntary Admission Study (DIAS). J Psychiatr Pract. 2018;24(3):209–16. https://doi.org/10.1097/PRA.0000000000000300.

    Article  Google Scholar 

  42. Yang Y, Li W, An FR, Wang YY, Ungvari GS, Balbuena L, et al. Voluntary and Involuntary admissions for severe mental illness in China: a systematic review and Meta-analysis. Psychiatr Serv. 2020;71(1):83–6. https://doi.org/10.1176/appi.ps.201900106.

    Article  Google Scholar 

  43. Yang Y, Li W, Lok KI, Zhang Q, Hong L, Ungvari GS, et al. Voluntary admissions for patients with schizophrenia: a systematic review and meta-analysis. Asian J Psychiatr. 2020;48:101902. https://doi.org/10.1016/j.ajp.2019.101902.

    Article  Google Scholar 

  44. Fan X, Guo YP, Cai J, Wang JY, Ma N, Zhang HY, et al. Research on the current situation of mental health service facilities and beds in Shanghai in 2015 (in chinese). Chin Health Econ. 2017;36(12):49–51. https://doi.org/10.7664/CHE20171213.

    Article  Google Scholar 

  45. Curley A, Agada E, Emechebe A, Anamdi C, Ng XT, Duffy R, et al. Exploring and explaining involuntary care: the relationship between psychiatric admission status, gender and other demographic and clinical variables. Int J Law Psychiatry. 2016;47:53–9. https://doi.org/10.1016/j.ijlp.2016.02.034.

    Article  Google Scholar 

  46. Maina G, Rosso G, Carezana C, Mehanović E, Risso F, Villari V, et al. Factors associated with involuntary admissions: a register-based cross-sectional multicenter study. Ann Gen Psychiatry. 2021;20(1):3. https://doi.org/10.1186/s12991-020-00323-1.

    Article  CAS  Google Scholar 

  47. Xiang YT, Wang Y, Wang CY, Chiu HF, Chen Q, Chan SS, et al. Association of insight with sociodemographic and clinical factors, quality of life, and cognition in chinese patients with schizophrenia. Compr Psychiatry. 2012;53(2):140–4. https://doi.org/10.1016/j.comppsych.2011.04.001.

    Article  Google Scholar 

  48. Smyth S, McFarland J, McGuiness D, Summerville S, Bainbridge E, Hallahan B, et al. A mixed methods study examining perceptions by service-users of their involuntary admission in relation to levels of insight. Int J Soc Psychiatry. 2022;68(8):1764–73. https://doi.org/10.1177/00207640211061983.

  49. Shao Y, Xie B, Wu Z. Psychiatrists’ attitudes towards the procedure of involuntary admission to mental hospitals in China. Int J Soc Psychiatry. 2012;58(4):440–7. https://doi.org/10.1177/0020764011408541.

    Article  Google Scholar 

  50. Bodén R, Brandt L, Kieler H, Andersen M, Reutfors J. Early non-adherence to medication and other risk factors for rehospitalization in schizophrenia and schizoaffective disorder. Schizophr Res. 2011;133(1–3):36–41. https://doi.org/10.1016/j.schres.2011.08.024.

    Article  Google Scholar 

  51. Zhou JS, Zhong BL, Xiang YT, Chen Q, Cao XL, Correll CU, et al. Prevalence of aggression in hospitalized patients with schizophrenia in China: a meta-analysis. Asia Pac Psychiatry. 2016;8(1):60–9. https://doi.org/10.1111/appy.12209.

    Article  Google Scholar 

  52. Lepping P, Steinert T, Gebhardt RP, Röttgers HR. Attitudes of mental health professionals and lay-people towards involuntary admission and treatment in England and Germany–a questionnaire analysis. Eur Psychiatry. 2004;19(2):91–5. https://doi.org/10.1016/j.eurpsy.2003.11.001.

    Article  Google Scholar 

  53. Luchins DJ, Cooper AE, Hanrahan P, Rasinski K. Psychiatrists’ attitudes toward involuntary hospitalization. Psychiatr Serv. 2004;55(9):1058–60. https://doi.org/10.1176/appi.ps.55.9.1058.

    Article  Google Scholar 

  54. Lebenbaum M, Chiu M, Holder L, Vigod S, Kurdyak P. Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study. Psychol Med. 2021;51(10):1666–75. https://doi.org/10.1017/S0033291720000392.

    Article  Google Scholar 

  55. Wormdahl I, Husum TL, Kjus SHH, Rugkåsa J, Hatling T, Rise MB. Between no help and coercion: toward referral to Involuntary Psychiatric Admission. A qualitative interview study of stakeholders’ perspectives. Front Psychiatry. 2021;12:708175. https://doi.org/10.3389/fpsyt.2021.708175.

    Article  Google Scholar 

  56. Høye A, Jacobsen BK, Hansen V. Increasing mortality in schizophrenia: are women at particular risk? A follow-up of 1111 patients admitted during 1980–2006 in Northern Norway. Schizophr Res. 2011;132(2–3):228–32. https://doi.org/10.1016/j.schres.2011.07.021.

    Article  Google Scholar 

  57. Tang YL, Gillespie CF, Epstein MP, Mao PX, Jiang F, Chen Q. Gender differences in 542 chinese inpatients with schizophrenia. Schizophr Res. 2007;97(1–3):88–96. https://doi.org/10.1016/j.schres.2007.05.025.

    Article  Google Scholar 

  58. Bhalla IP, Siegel K, Chaudhry M, et al. Involuntary Psychiatric hospitalization: how patient characteristics affect decision-making. Psychiatr Q. 2022;93(1):297–310. https://doi.org/10.1007/s11126-021-09939-2.

    Article  Google Scholar 

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Acknowledgements

We would like to thank Professor Ze-Ping Xiao for the valuable advices on design of the study. We also would like to thank the great help of Professor Gui-Lai Zhan in the process of data collection in XMHC.

Funding

This work was supported by Quantitative Research of Intervention Strategies for Schizophrenia Recurrence (grant number: 19411950800), Excellent Talent Training Program of Three-Year Action Plan on Public Health of Shanghai (2020–2022) (grant number: GWV-10.2-XD27), Health Law Research Association Program of Shanghai Law Society (grant number: 2020WF03), Neuroimaging Model Construction Based on Environmental Stimuli and Its Application in Predicting the Risk of Violence in Schizophrenia (grant number:82271924) and Shanghai Clinical Research Center for Mental Health (grant number: 19MC1911100).

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Authors and Affiliations

  1. Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 200030, Shanghai, P. R. China

    Hua-Jian Ma, Yu-Chen Zheng, Yang Shao & Bin Xie

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  1. Hua-Jian Ma
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by HM, YS and YZ. The first draft of the manuscript was written by HM. BX and YS commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Yang Shao or Bin Xie.

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This study was approved by the Research Ethical Committee at the Shanghai Mental Health Center. As this was a retrospective study, study consent to participate was not applicable. Informed consent was waived by Research Ethical Committee at the Shanghai Mental Health Center. All methods were carried out in accordance with relevant guidelines and regulations.

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The authors declare that they have no competing interests.

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Ma, HJ., Zheng, YC., Shao, Y. et al. Status and clinical influencing factors of involuntary admission in chinese patients with schizophrenia. BMC Psychiatry 22, 818 (2022). https://doi.org/10.1186/s12888-022-04480-3

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BMC Psychiatry

ISSN: 1471-244X

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