Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth

Even though hospitalization it is a major life event, it is sometimes necessary, especially to stabilize and treat young people in a psychiatric crisis. While the overall prevalence of mental health conditions in youth has remained relatively stable [1], many recent studies have reported an increase in psychiatric emergencies in children and adolescents. Such increase has been noted in the United States [2‐5], Canada [6‐8], and Europe [9‐11]. Over the same period, most countries have reduced the number of child and adolescent psychiatric inpatient beds [12‐14]. Together with this reduction in inpatient beds, the increase in psychiatric emergencies makes it important to identify factors leading children and adolescents in an emergency situation to be admitted to a psychiatric hospital. Possible modifiable factors associated with emergency admission in youth should be identified, as these factors may be a target for preventing these admissions.

Various studies have identified demographic characteristics and clinical factors as predictors of voluntary admission of young patients seen in psychiatric crisis situations [15‐18]. Demographic characteristics that were found to be associated with decisions to hospitalize children and adolescents after emergency consultation were relatively older age, minority status, and having been adopted [16‐19]. Clinical factors that were associated with a higher chance of admission were suicide attempt or self-injurious behavior, the clinician’s appraisal of high suicide risk, the presence of a depressive or bipolar disorder, the severity of psychiatric symptoms, comorbidity, a lower score on the global assessment of functioning (GAF), and prior admission. The likelihood of hospitalization was also increased by a prior emergency consultation, substance abuse or dependence, and being on psychotropic medication [15‐19]. However, both these demographic characteristics and the clinical factors cannot be modified to prevent emergency admissions.

While factors leading to voluntary admission have been described widely, we found no studies specifically describing factors leading to compulsory admission of minors in an emergency psychiatric situation. Studies comparing adolescents who had been admitted voluntarily to a psychiatric clinic with those who had been admitted compulsorily identified several clinical factors [19‐21]. Compulsory detainment in adolescents was associated with symptom severity, mental retardation, substance abuse, and psychotic disorders. Compared to adolescents who had been admitted voluntarily, those who had been admitted compulsorily were also older, more often had black ethnicity, and more often had been admitted outside working hours [19‐21].

To prevent emergency admissions in psychiatric crisis situations in youth with severe psychiatric problems, contextual characteristic may be an important target for home interventions. Some clinicians argue that psychiatric crisis situations are best dealt with in a patient’s home, where systemic interventions can take place directly within a child’s environment [22]. Family factors may influence decisions to admit a child to a psychiatric hospital after emergency consultation. Contextual characteristics that were found to be associated with the decision to hospitalize children and adolescents after emergency consultation were the absence of parents at consultation; the time and day of consultation (there being a greater chance of admission at night and in school weeks rather than during school holidays); and a rural location [15, 17, 18]. The source of referral was also associated with the decision to hospitalize: in cases of self-referral and referral by a family member or someone from a school, there was less chance of admission [16].

A systematic review of randomized-controlled trials reporting the efficacy of a variety of home-based interventions as alternatives to inpatient care in youth found these interventions to be associated with similar clinical improvement, greater patient satisfaction, and lower costs compared to inpatient care [23]. However, most studies in this review excluded children and adolescents with severe danger to self or others, so it is not clear if these results apply to children as well as adolescents with immediate and severe risks.

One study compared the effect of a special designed discharge service by an intensive home-treatment team to care as usual for youth admitted to a psychiatric hospital [24]. This study found no differences in inpatient days or treatment effect. However, patients in the intensive home-treatment group reported better school integration, more reduced self-harm, and less hospital use after discharge.

In literature, the proportion of psychiatric emergency consultations of minors that led to an admission ranges from 1.9 to 54.0% [15, 25]. As emergency psychiatric services for children and adolescents vary between countries [2, 6, 9, 15, 25], the comparison of the results is complicated. In The Netherlands, patients of all ages are examined at the patient’s location by outpatient psychiatric emergency services, which may offer an opportunity to intervene in some contextual characteristics.

Because most studies are based on data from children and adolescents in crisis that present to emergency departments (EDs), we aimed to identify factors upon which the outreaching emergency services in The Netherlands base their decisions on the emergency admission of minors. On the basis of previous research, we hypothesized that an important role in decisions to hospitalize children or adolescents after psychiatric emergency consultation may be played by contextual factors such as family support, living situation, and referral by the psychiatric services. We intended to identify factors that lead to the compulsory admission of young people in an emergency situation, as well. Due to the conditions imposed by Dutch law on compulsory admissions, we expected compulsory admission to be associated with the severity of psychiatric symptoms, danger to self or others, and lack of motivation for treatment.

Two hundred and twenty-seven of the 1194 consultations (19.0%) had resulted in an admission, 137 patients (11.5%) being admitted voluntarily and 90 (7.5%) being admitted compulsorily.

Table 1 presents the demographic and contextual characteristics. Most patients were girls; the mean age was 14.90 years (SD 2.3); the most common reason for referral was risk of suicide or self-harm, and most consultations had taken place in the daytime. While most children had been living with their parent(s), the living situation had been registered as unknown in 19.9% of the consultations. The second and third columns of Table 1 contrast the characteristics of the young people who had been admitted (whether voluntarily or compulsorily) against those of the young people who had not been admitted. Compared to the group of children who had not been admitted, the mean age of those admitted was higher, fewer were living with both parents, fewer consultations had taken place at home, and more consultations had taken place at night. The fourth and fifth columns of Table 1 contrast the characteristics of the young people who had been admitted voluntarily against those who had been admitted compulsorily. Compared to those admitted voluntarily, the children admitted compulsorily had a higher mean age, were less likely to be living with both parents, and had a higher rate of referral by psychiatric services.

Clinical characteristics are presented in Table 2. The classifications used most were those for externalizing disorders, with a DSM-IV classification indicating relational problems including abuse or an adjustment disorder being registered in over 25% of all consultations.

As shown in the second, third, fourth, and fifth columns of Table 2, the mean severity of problems was greater in children who had been admitted after emergency consultation than in children who had not been admitted, and higher in those admitted compulsorily than in those admitted voluntarily. Other SPI item scores show the same pattern.

This study was intended to identify possible modifiable factors associated with the voluntary and involuntary admission of children and adolescents who had had a psychiatric emergency consultation.

We found that the chance that a minor would be admitted after an emergency consultation, independently of the legal status, had been smaller if the consultation had taken place in his or her home, and in families that received regular outpatient care before consultation. The chance of admission had been increased if there had been a high level of family disruption.

Not surprisingly, our findings also indicate that the decision to hospitalize had been influenced by clinical factors: children who had been hospitalized after emergency consultation had had more serious symptoms, externalizing problems, and higher scores on the SPI for risk of suicide and severity of problems.

The results of our comparison of factors associated with compulsory and voluntary admission were consistent with what we had expected on the basis of the Dutch law on compulsory admissions: young people had a higher risk of being admitted compulsorily if they had severe psychiatric problems, if they had a higher risk of suicide, if they were a danger to others, and if, due to a lack of motivation and lack of compliance, there were no voluntary alternatives for preventing the danger.

We found two potentially modifiable factors for reducing psychiatric emergency admissions in minors: the location in which the consultation took place and family disruption. As most studies on psychiatric emergency admissions of minors have described the outcome of ED visits in hospitals only, our finding that the risk of psychiatric emergency admission is lower if the consultation takes place in the patient’s home is new and has to be replicated. Based on the association between home assessment and a reduced chance of hospital admission, future studies could investigate whether emergency consultation in the patients’ home indeed is lowering the chance for hospital admission. After emergency consultation at home, it may be easier arranged to have a supervising adult closely monitor the behavior of young person with psychiatric problems.

Our finding that family disruption was associated with the outcome of an emergency consultation is consistent with the literature. If the family system is unable or unwilling to take care of the patient—due to exhaustion, for example—a clinician may opt for hospitalization, independently of the patient’s clinical condition. A reduced chance of admission in families that received regular outpatient care before the emergency consultation suggests that wider use of regular outpatient care may be helpful. Because involvement in evidence-based services is related to both symptom reduction and improvement in functioning [30], it is important to engage youth and families in these services. With timely interventions to decrease family distress, it may be possible to stabilize the situation before it requires more extreme measures. Parents are often best at identifying early behavioral changes in their children, and by having regularly scheduled follow-up appointments that involve monitoring of child’s health and refinement of treatment plans, relapse might be reduced. Also, regular outpatient care may facilitate immediate de-escalation. The development of an individualized, strengths-based safety/crisis plan with the child and family can possibly prevent high levels of family disruption [31]. The fact that an unstable family situation proved to be a predictor of emergency admission adds to the findings of previous studies. Two factors increased the chance that a child would be admitted after emergency consultation: the parents’ absence from the consultation and if a child’s having been adopted [15, 16]. Similarly, the risk of psychiatric hospitalization of children in regular psychiatric outpatient care has been found to be influenced by a family’s level of distress, parental capacity to contain the child, and the primary caregivers’ marital status [32, 33].

Finally, our finding that young people who had been admitted compulsorily had more severe psychiatric problems and a higher suicide risk than those admitted voluntarily is also consistent with prior studies [20, 21]. However, unlike Jendreyschak et al. [21], we did not find that mental retardation was associated with higher compulsory admission rates. This may be because our study included emergency compulsory admissions alone, and not compulsory admissions after a planned court order.

Despite the differences between countries regarding the organization of the emergency services for minors, our findings were generally in line with the literature: a majority of the patients seen for emergency consultation were girls, over half of the patients were already receiving regular outpatient care, and the risk of suicide or self-harm was the commonest reason for referral [2, 15, 34]. In line with the previous studies, patients who were hospitalized after emergency consultation had more severe psychiatric disorders. As described in other studies, we also found older age to be associated with hospitalization after emergency consultation [16, 18, 35].

Seeing minors in their homes and addressing family disruption may help to prevent emergency admissions. Implementation studies should now be used to further test the hypothesis that emergency admissions in young people can be reduced by intensive outpatient treatment that focuses simultaneously on their psychiatric problems, supporting their parents’ needs, and deploying strategies that increase motivation and compliance.

The Medical Ethics Committee confirmed that the Medical Research Involving Human Subjects Act (Dutch acronym: WMO) did not apply to this study, and thus, that no informed consent was required.