Predictors of Perceived Benefit Among Patients Committed by Court Order in the Netherlands: One-Year Follow-Up

Article (PDF Available)inPsychiatric services (Washington, D.C.) 61(10):1024-7 · October 2010with8 Reads
DOI: 10.1176/appi.ps.61.10.1024 · Source: PubMed
Abstract
This study identified predictors of perceived benefit resulting from court-ordered hospitalization in the Netherlands. This prospective study included 174 psychiatric inpatients committed under court order. Logistic regression was used to examine the relationship between predictor variables and perceived benefit. At one year, 52% of patients evaluated their involuntary hospitalization as beneficial. These patients were more likely to be homeless (odds ratio [OR]=4.13, 95% confidence interval [CI]=1.33-12.84), to have been previously hospitalized voluntarily (OR=2.30, CI=1.18-4.48), and to have high service engagement (OR=2.79, CI=1.19-6.53) or more illness insight (OR=2.78, 95% CI=1.13-6.89). Having a psychotic disorder or higher severity of symptoms at baseline was correlated with an improved perception of benefit. Perceived benefits were predicted by living condition, hospitalization history, service engagement, and illness insight. Clinical characteristics were associated with improvement in perceived benefit. Additional research should focus on causality of associations before effective intervention programs can be developed.
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Objective: This study identified
predictors of perceived benefit
resulting from court-ordered hos-
pitalization in the Netherlands.
Methods: This prospective study
included 174 psychiatric inpa-
tients committed under court or-
der. Logistic regression was used
to examine the relationship be-
tween predictor variables and
perceived benefit. Results: At one
year, 52% of patients evaluated
their involuntary hospitalization
as beneficial. These patients were
more likely to be homeless (odds
ratio [OR]=4.13, 95% confidence
interval [CI]=1.33–12.84), to have
been previously hospitalized vol-
untarily (OR=2.30, CI=1.18–4.48),
and to have high service engage-
ment (OR=2.79, CI=1.19-6.53) or
more illness insight (OR=2.78,
95% CI=1.13–6.89). Having a psy-
chotic disorder or higher severity
of symptoms at baseline was cor-
related with an improved percep-
tion of benefit. Conclusions: Per-
ceived benefits were predicted by
living condition, hospitalization
history, service engagement, and
illness insight. Clinical character-
istics were associated with im-
provement in perceived benefit.
identify main baseline factors associ-
ated with perceived benefit of invol-
untary hospitalization. The study in-
volved all psychiatric inpatient servic-
es in a circumscribed catchment area
in the Netherlands, the greater Rot-
terdam district. The district has a mix
of urban and rural areas and about 1.2
million inhabitants. In line with com-
mon patterns of legal regulations
across Europe (7), the Dutch Act on
Exceptional Admissions to Psychi-
atric Hospitals stipulates that persons
with mental illness who are aged 12
or older can be involuntarily hospital-
ized if their mental disorder poses a
danger to themselves or others and if
involuntary admission is the only way
to prevent this danger. Recognition of
the civil rights of psychiatric patients
includes their right to refuse treat-
ment. Additional types of coercive
treatment, such as seclusion or forced
medication, are documented and re-
ported to the national Healthcare In-
spectorate. In most cases, patients
will first be detained in psychiatric
admission wards under an emergency
procedure, after which a court-or-
dered admission can provide a legal
basis for a prolonged involuntary stay
in a general psychiatric hospital. At
the request of the public prosecutor,
an appointed judge can authorize de-
tention, initially allowing hospitaliza-
tion for a maximum of six months.
In a prospective observational
study of court-ordered admissions,
we evaluated four groups of variables
as possible predictors of perceived
benefit: demographic variables (in-
Predictors of Perceived Benefit Among
Patients Committed by Court Order in
the Netherlands: One-Year Follow-Up
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The authors are affiliated with the Depart-
ment of Psychiatry, Erasmus MC, Rotter-
dam, the Netherlands. Send correspon-
dence to Dr. Wierdsma at the Department
of Psychiatry, Erasmus MC, P.O. Box 2040,
Rotterdam 3000 CA, the Netherlands (e-
mail: a.wierdsma@erasmusmc.nl).
Additional research should focus
on causality of associations before
effective intervention programs
can be developed. (Psychiatric
Services 61:1024–1027, 2010)
A
review of the outcomes of com-
pulsory admission showed that
between 39% and 81% of patients la-
ter regarded their involuntary admis-
sion to have been justified or benefi-
cial (1). Patients who realize in retro-
spect that they have benefited from
commitment might be better able to
derive greater benefit from future
psychiatric treatment. If main factors
associated with benefit perception
could be identified, specific interven-
tions might help alleviate negative ef-
fects of involuntary admission. How-
ever, few studies have examined pre-
dictors of retrospective evaluations of
compulsory admission (2–5). Study
results on associations between per-
ceived benefit and age, gender, mari-
tal status, diagnosis, and past admis-
sions were inconclusive. Living alone,
poor global functioning at the time of
admission, and initial satisfaction with
treatment have been found to be as-
sociated with a more positive retro-
spective judgment of involuntary ad-
mission (6), but these factors create
little opportunity for further improve-
ment. Additional patient characteris-
tics and aspects of service delivery
have to be identified to develop and
tailor intervention programs that sup-
port a positive assessment of compul-
sory admission.
The study presented here aimed to
BBrriieeff RReeppoorrttss
cluding ethnicity, education level,
and housing), psychiatric history,
clinical variables (including severity
of symptoms, substance dependence,
and reason for admission), and psy-
chosocial variables (illness insight,
service engagement, and perceived
coercion).
Methods
Over an 18-month period from Janu-
ary 2005 until July 2006, patients
from all of the psychiatric services in
the greater Rotterdam district (three
general psychiatric hospitals and the
psychiatric department of a university
medical center) were asked to partic-
ipate in our study. Clinicians regis-
tered court-ordered admissions for
403 individual patients. Study partici-
pants had to meet the following inclu-
sion criteria: court-order procedure
had officially started, patients were 18
years or older at the time that they
were asked to participate, and base-
line measurements were able to be
gathered within one month of patient
agreement to participate. Inclusion
terms were applied strictly to achieve
comparable admission duration at
baseline. In 127 cases (32%) re-
searchers were unable to contact the
patient soon after hospitalization,
mainly because of logistical problems.
Diagnosis of organic psychiatric dis-
ease (such as Alzheimer’s disease) was
an exclusion criterion. We also ex-
cluded patients who themselves had
requested a court-ordered admission,
patients who had already been com-
mitted on this basis, and patients for
whom a prolongation of a court order
had been requested by the clinician.
The research protocol was ap-
proved by the local research ethics
committee (Erasmus MC, Rotter-
dam). Patients were given a complete
description of the study, and written
informed consent was obtained.
A total of 276 eligible patients were
contacted for participation in the
study. Fourteen patients (5%) were
reluctant to sign the informed con-
sent but were included because they
orally agreed to participate. Sixty-
nine patients (25%) refused to partic-
ipate, in most cases because they did
not want to be interviewed. In terms
of age, sex, and diagnosis, nonrespon-
dents did not differ from respon-
dents. Twenty-eight of the 207 partic-
ipants were excluded because the re-
quest for the index court-ordered ad-
mission was rejected (N=21) or be-
cause an outpatient commitment or-
der was issued (N=7). The remaining
179 patients (86%) were all commit-
ted by court order and were inter-
viewed at baseline. Five patients (3%)
were lost to follow-up, leaving a final
sample of 174 patients.
Data on demographic characteris-
tics and the use of psychiatric services
were collected from medical records.
Psychiatric diagnosis was established
with the Composite International Di-
agnostic Interview (8), and symptom
severity was scored with the 24-item
version of the Brief Psychiatric Rating
Scale (BPRS) (9,10). (Possible BPRS
scores range from 24 to 168, with
higher scores indicating more severe
psychopathology.) Functioning was
assessed with the Global Assessment
of Functioning (GAF) (11). (Possible
GAF scores range from 0 to 100, with
higher scores indicating better func-
tioning.) Reasons for admission
(whether patients were dangerous to
themselves or others) were docu-
mented as part of the involuntary ad-
mission procedure. Psychosocial data
consisted of illness insight, which was
measured by the Schedule for the As-
sessment of Insight (12,13); service
engagement, which was measured by
the 14-item Service Engagement
Scale (14); and perceived coercion,
which was measured with a 15-item
questionnaire (15). (Possible Sched-
ule for the Assessment of Insight
scores range from 0 to 28, with high-
er scores indicating more illness in-
sight. Possible Service Engagement
Scale scores range from 0 to 42, with
higher scores indicating lower en-
gagement. Possible scores on the
perceived coercion questionnaire
range from 15 to 75, with higher
scores indicating higher levels of per-
ceived coercion.)
Perceived benefit from involuntary
hospitalization was assessed at the six-
and 12-month follow-ups. Partici-
pants were asked, “Do you think you
have benefited from your index court-
ordered admission?” Answering op-
tions ranged from 5, disagree greatly,
to 1, agree greatly, and included an
answer of “don’t know/neutral” (score
of 3). Level of perceived benefit at 12
months was dichotomized into mod-
erate or full perceived benefit (score
of 1 to 2) versus neutral or no per-
ceived benefit (score of 3 to 5).
SPSS for Windows, version 15.0, was
used for correlations and logistic re-
gression analyses. [Tables showing
characteristics at baseline and correla-
tions with perceived benefit and posi-
tive change in perceived benefit (de-
fined as a negative or neutral response
at the six-month follow-up and a posi-
tive response at the 12-month follow-
up) are available as an online supple-
ment at ps.psychiatryonline.org.]
Results
The sample consisted of 118 (68%)
men and 56 (32%) women; the
mean±SD age was 35±14 years. In
line with findings from an earlier
study on compulsory admission in
Rotterdam (22), we found that most
patients were of non-Dutch origin
(N=101, 58%). Most patients were
not married (N=127, 73%) and had a
lower level of education (lower-sec-
ondary education: N=88, 51%).
(Lower-secondary education is equiv-
alent to seventh to tenth grade in the
United States.) Twenty-one patients
(12%) were homeless. Almost half of
the patients had previously been hos-
pitalized voluntarily (N=82, 47%).
The mean length of hospitalization
was 28±20 weeks. Most patients were
involuntarily hospitalized because
they were a danger to themselves
(N=109, 63%); 65 (37%) were consid-
ered to be dangerous to others or to
public safety. A majority of patients
(N=138, 79%) had schizophrenia or
another psychotic disorder. The aver-
age BPRS sum score at baseline was
58±12, and the mean GAF score at
admission was 28±10, indicating a
group of markedly ill patients. The
mean score for illness insight was
12±6, and service engagement scores
averaged 25±9, indicating a moderate
impairment of insight and somewhat
poor engagement with mental health
services. At baseline, patients report-
ed medium-high levels of perceived
coercion (mean score of 55±12 on the
perceived coercion questionnaire).
At the six-month follow-up, 75 pa-
tients (43%) reported that they had
derived benefit from their commit-
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11002255
ment, 42 (24%) did not know or gave
a neutral answer, and 57 (33%) felt
they had not benefited. At the 12-
month follow-up, we found modest
improvement: 90 patients (52%) re-
ported perceived benefit from their
commitment. Twenty-two of the 99
patients (22%) who did not respond
positively after six months reported at
least some benefit at 12 months.
Results of logistic regression analy-
ses identifying characteristics associat-
ed with perceived benefit are summa-
rized in Table 1. We included all can-
didate predictors that were signifi-
cantly associated with perceived ben-
efit at an alpha level of .10. Clinical
characteristics were included in the
regression model because psychotic
disorder and symptom severity at
baseline were correlated with an im-
proved perception of benefit (Pear-
son’s r=–.13 and –.18, respectively).
The final regression model included
homelessness, previous voluntary hos-
pitalization, service engagement, and
illness insight (Nagelkerke R
2
=.24;
Hosmer-Lemeshow test χ
2
=4.85,
df=8, p>.10). Patients who reported
perceived benefit were more likely to
be homeless (odds ratio [OR]=4.13)
or to have been previously hospital-
ized voluntarily (OR=2.30). Perceived
benefit was also more likely to be re-
ported by patients with a high level of
service engagement (OR=2.79) or
with more illness insight (OR=2.78).
Sensitivity analyses were performed in
which the neutral response category
was moved to the moderate or full
perceived benefit category, and simi-
lar patterns were seen.
Discussion
Preventing negative consequences of
compulsory admission can help re-
duce the number of patients who are
reluctant to accept treatment. This
prospective study identified several
predictors combining information on
demographic, administrative, clinical,
and psychosocial factors. All inpatient
services in the area participated in the
study, and all admissions were regu-
lated by the same judicial procedures,
thereby limiting confounding effects
of specific admission policies and
varying implementations of the judi-
cial process. There was minimal loss
to follow-up, even though this group
of patients is often difficult to contact.
However, a limitation of the study
was the loss of nearly one-third of 403
patients because of the inclusion cri-
teria or patients’ refusal to partici-
pate. Although in most cases patients
were excluded for logistical reasons,
some patients actively hid from staff
or escaped just after the court-or-
dered admission request had been is-
sued. In addition, although refusal to
participate in the study was relatively
low (25%), selection bias could have
occurred. Patients who are more re-
luctant to be in contact with mental
health care might be in a worse men-
tal state and have more negative
views about compulsory admission.
We also lacked data on additional
types of compulsion that could miti-
gate patients’ perspective on involun-
tary admission. However, perceived
coercion as a subjective indicator of
the use of compulsory measures did
not independently contribute to per-
ceived benefit.
Studies on perceived effects of
compulsory admission are difficult to
compare because of differences in
design and study characteristics.
These differences may account for
inconsistencies in research out-
comes. Kane and colleagues (4)
found that more female patients eval-
uated the involuntary hospitalization
as beneficial, and Beck and Golowka
(2) reported that younger age pre-
dicted a perception of benefit. Ef-
fects of age or gender may have been
confounded by service use or psy-
chosocial factors not accounted for in
studies with small samples. Other
studies found no significant relation-
ship between age, gender, or marital
status and perceived benefit (3,5). In
the study by Priebe and colleagues
(6) perceived justification for invol-
untary hospitalization was related to
living condition and satisfaction with
treatment. In accordance with these
findings, our study showed that
homelessness and psychosocial fac-
tors—for example, service engage-
ment and illness insight—were asso-
ciated with perceived benefit. The
living conditions of homeless patients
before hospitalization were likely in
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TTaabbllee 11
Logistic regression analyses identifying characteristics associated with perceived benefit after 12 months of court-ordered
hospitalization
a
Variable Coefficient SE Wald χ
2
df p OR 95% CI
Homelessness (reference: not homeless) 1.42 .579 6.01 1 .014 4.13 1.33–12.84
Previous voluntary admission (reference:
no previous voluntary admission) .83 .341 5.95 1 .015 2.30 1.18–4.48
Service engagement (reference: low)
b
10.45 2 .005
Middle 1.35 .428 9.92 1 .002 3.85 1.66–8.91
High 1.02 .434 5.56 1 .018 2.79 1.19–6.53
Self-assessment of insight (reference: low)
b
5.81 2 .055
Middle .10 .395 .07 1 .790 1.11 .51–2.41
High 1.03 .461 4.95 1 .026 2.78 1.13–6.89
a
Entered baseline variables—step 1: gender, age, ever married (yes or no), education level (high or low), and homelessness (yes or no); step 2: home-
lessness, age upon first psychotic symptoms, and previous voluntary admission (yes or no); step 3: homelessness, previous voluntary admission, danger
to self (yes or no), psychotic disorder (yes or no), comorbid substance use disorder (yes or no), Brief Psychiatric Rating Scale score, and Global As-
sessment of Functioning score; step 4: homelessness, previous voluntary admission, Global Assessment of Functioning, perceived coercion sum score,
service engagement score, and illness insight sum score.
b
Scores presented here as contrast groups are based on sum scores by tercile; high categories have better service engagement and illness insight.
PSYCHIATRIC SERVICES o ps.psychiatryonline.org o October 2010 Vol. 61 No. 10
11002277
sharp contrast to the structured set-
ting of the psychiatric hospital. Previ-
ous voluntary admission was also as-
sociated with perceived benefit—this
group of patients may have had a bet-
ter understanding of the course of
their illness and the circumstances in
which compulsory admission is justi-
fied. In addition, service engagement
and illness insight contributed to a
perception of a positive benefit.
These factors seem to reflect willing-
ness and cognitive ability to create a
working alliance between patients
and staff that supports quality of
care.
Bradford and colleagues (3) and
Kjellin and colleagues (5) found no
association between perceived bene-
fit and types of symptom or diagnosis.
Beck and Golowka (2) found that
more patients with a diagnosis of ei-
ther schizophrenia or affective disor-
ders reported benefit. Priebe and col-
leagues (6) reported that patients
with higher levels of functioning were
less likely to view their involuntary
admission as justified. We found no
relationship between diagnosis or
symptom level and perceived benefit
one year after involuntary hospitaliza-
tion, although clinical characteristics
were related to a positive change in
benefit perception between the six-
and 12-month follow-up. These find-
ings indicate that causality of associa-
tions needs further attention before
effective intervention programs can
be developed.
Conclusions
Twelve months after court-ordered
admission about half the patients
(52%) reported at least some benefit
from involuntary hospitalization.
Higher level of service engagement
and illness insight were associated
with more perceived benefit from in-
voluntary hospitalization. After a re-
quest for involuntary commitment is
issued, clinicians might focus more on
strategies to improve psychosocial
factors.
Acknowledgments and disclosures
The study was carried out with the support of
the Dutch Ministry of Health, Welfare, and
Sports (ZonMw research grant 100-002-004).
The authors thank all of the participating pa-
tients, caregivers, and medical and paramedical
staff of Parnassia Bavo Group, Delta Psychiatric
Center, Delfland Mental Health Center, and the
Department of Psychiatry at Erasmus MC.
The authors report no competing interests.
References
1. Katsakou C, Priebe S: Outcomes of invol-
untary hospital admission: a review. Acta
Psychiatrica Scandinavica 114:65–71, 2006
2. Beck JC, Golowka EA: A study of enforced
treatment in relation to Stone’s “thank you”
theory. Behavioral Sciences and the Law
6:559–566, 1988
3. Bradford B, McCann S, Merskey H: A sur-
vey of involuntary patients’ attitudes to-
wards their commitment. Psychiatric Jour-
nal of the University of Ottawa 11:163–
165, 1986
4. Kane J, Quitkin F, Rifkin A, et al: Attitudi-
nal changes of involuntarily committed pa-
tients following treatment. Archives of
General Psychiatry 40:374–377, 1983
5. Kjellin L, Andersson K, Candefjord IL, et
al: Ethical benefits and costs of coercion in
short-term inpatient psychiatric care. Psy-
chiatric Services 48:1567–1570, 1997
6. Priebe S, Katsakou C, Amos T, et al: Pa-
tients’ views and readmissions 1 year after
involuntary hospitalisation. British Journal
of Psychiatry 194:49–54, 2009
7. Dressing H, Salize HJ: Compulsory admis-
sion of mentally ill patients in European
Union Member States. Social Psychiatry and
Psychiatric Epidemiology 39:797–803, 2004
8. Composite International Diagnostic Inter-
view, Version 2.1 Auto. Geneva, World
Health Organization, 1997
9. Lukoff D, Nuechterlein KH, Ventura J:
Manual for expanded Brief Psychiatric
Rating Scale (BPRS): Appendix A. Schizo-
phrenia Bulletin 12:594–602, 1986
10. Overall JE, Gorham DR: The Brief Psychi-
atric Rating Scale. Psychological Reports
10:799–812, 1962
11. Diagnostic and Statistical Manual of Men-
tal Disorders, 4th ed, Text Revision. Wash-
ington, DC, American Psychiatric Associa-
tion, 2000
12. Kemp R, David A: Insight and compliance;
in Treatment Compliance and the Thera-
peutic Alliance in Serious Mental Illness.
Edited by Blackwell B. Newark, NJ, Har-
wood Academic Publishers, 1997
13. Sanz M, Constable G, Lopez-Ibor I, et al:
A comparative study of insight scales and
their relationship to psychopathological
and clinical variables. Psychological Medi-
cine 28:437–446, 1998
14. Tait L, Birchwood M, Trower P: A new
scale (SES) to measure engagement with
community mental health services. Journal
of Mental Health 11:191–198, 2002
15. Gardner W, Hoge SK, Bennett N, et al:
Two scales for measuring patients’ percep-
tions of coercion during mental hospital
admission. Behavioral Sciences and the
Law 11:307–321, 1993