(The Lancet) – In 1817, the UK House of Commons set up a Select Committee to study the plight of “the lunatic poor in Ireland”.1
The evidence they heard, in the language of the era, was stark: “There is nothing so shocking as madness in the cabin of the peasant […] When a strong young man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin not high enough for the person to stand up in, with a crib over it to prevent his getting up, the hole is about five feet deep, and they give the wretched being his food there, and there he generally dies.”
However, Rains and colleagues3 focus on involuntary hospitalisation and present a compelling case for substantial variations both across countries and over time, with annual rates increasing in some jurisdictions (eg, Spain) and decreasing in others (eg, Italy). These divergent trends lead to substantial variations between countries that appear comparable in other ways: the annual rate of involuntary hospitalisation in England is double that of Ireland—why?6
Rains and colleagues3 suggest that “overall there is no association between differences in legislation and rates of involuntary hospitalisation.” Their extremely useful comparison of legislation across jurisdictions certainly supports the idea that law as written cannot explain these differences, but it is, of course, the day-to-day operation of specific elements of law that has the greatest effect. For example, some patients find statutory mental health review panels so intensely unpleasant that they ask for their status to be changed from involuntary to voluntary hospitalisation solely to avoid the review process.
In addition, most clinicians will be aware of colleagues with differing thresholds for applying legislation; not everyone who fulfils legal criteria for involuntary care is subjected to it and legal definitions can be difficult to apply in real-world settings. These variations in clinical practice are probably relevant to differences both within and between countries.7
Therefore, what are the take-home messages from this Article? The authors conclude that “these large variations do not seem to have clear relationships with any differences in clinical need” and suggest that possible explanations include “what alternatives to detention can be offered in the community or in the family, and societal responses to people with mental illness.” Rains and colleagues3 are correct; psychiatry, throughout its short history, has always had a strong social dimension, and the net of involvement and responsibility is broad.
In 1891, the Committee on Lunacy Administration wrote, in the language of the times, that “good lunacy laws should make it possible to obtain care and treatment in asylums with ease, but they should make unnecessary detention difficult”.11
More than a century later, we still need to do better.