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April 8, 2019 by Brendan D Kelly | The Lancet

Variations in involuntary hospitalisation across countries

(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.”

Subsequent laws led to the construction of psychiatric institutions in many countries during the 1800s and 1900s, rooted in the idea that if some of the people who were mentally ill were to be deprived of liberty, this deprivation was best done in accordance with explicit public legislation, rather than privately by families. The resultant history of psychiatry is a complicated story of custody and care.2
Even today, two centuries later, whether mental health laws fulfil their original objective—ie, to facilitate treatment in a fashion that maximises liberty, minimises suffering, and is equitable, accountable, and fair—is still unclear.

Luke Sheridan Rains and colleagues3 add substantially to the literature on this topic by showing large, unexplained variations in patterns of involuntary hospitalisation in 22 countries across Europe, Australia, and New Zealand. The differences are great, varying from 282 involuntary hospitalisations per 100 000 people per year in Austria to 14·5 per 100 000 people per year in Italy. Although these findings are both convincing and consistent with previous literature, it is worth remembering that comparison across countries is difficult. In Italy, many people with mental illness are treated in residential facilities rather than hospital units, and these facilities are commonly excluded from bed-counts; when they are included, the number of beds in Italy is similar to that in the UK and elsewhere.4, 5

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.

The key message for practitioners and policy makers is that involuntary admission can possibly be avoided in certain cases, if services, such as community clinics, outreach teams, and peer-led support, are available. We need more of these services. The key message for researchers is that we need greater understanding of the operation of law in clinical practice, rooted firmly in patient and family experiences.

Finally, legislators should realise that mental health legislation is not immutable and needs regular review to reflect its evolving evidence base.8, 9, 10

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.


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