The number of involuntary psychiatric detentions has risen sharply over the past decade, according to the authors of a recent study.1
Researchers struggled to find these data. “Anyone can easily look up information about how many people in the U.S. are arrested for what types of criminal offenses ... No one can look this up for people taken by the police to a facility to be examined involuntarily and detained,” says David Cohen, PhD, one of the study’s authors and a professor of social welfare at UCLA Luskin School of Public Affairs in Los Angeles.
Cohen and a colleague analyzed state health and court websites in the 38 states for which data were available. In the 22 states with available continuous data from 2012 to 2016, the average rate per 100,000 people rose from 273 to 309.
Only 25 states are included in the study because they had what the researchers judged to be usable data. “The other 13 states had some data, but labeled them simply using the words ‘mental health,’ with zero other definition or description, or mixed civil and criminal commitments, [which] were excluded,” Cohen says.
There is no national database on involuntary detentions. States and jurisdictions inconsistently report rates. States differ as to what label they use for detentions; whether they count events or unique persons; whether they report the age group (adult or child), sex, or ethnicity; whether the detention is short- or long-term; how long people are held; whether all eligible counties or institutions are reporting; who prepares the data; and time frames to release data.
“Except for about five states, which still have important but not terrible data shortcomings, it’s a mess,” Cohen laments.
It is difficult to explain why states vary widely in duration and rates of commitments, or to find out what happens to people who are involuntary committed. Only one of the 25 states included in Cohen’s study provided any data on how long people were held.
“Without any national numbers in 40 years, the lowest-inference work — how many, where, and how long — had not been done,” Cohen explains. “Commitment is our main response to people’s breakdowns, but it is acknowledged to be traumatizing and stigmatizing — and might lead to suicide because it accentuates powerlessness.”
Central ethical concerns with involuntary psychiatric hospitalizations include autonomy of the detained person, stigma of psychiatric populations, and the desire to prevent harm (to the person or others), says William R. Smith, MD, PhD, a psychiatry resident in the Scattergood Program for Applied Ethics of Behavioral Health Care in the Penn Department of Medical Ethics and Health Policy.
These all are important ethical principles that sometimes conflict, making decision-making difficult. “In my experience, many psychiatrists do struggle with decisions that they have had to make on these fronts, often keeping them awake at night,” Smith says.
Ethicists can help psychiatrists become more familiar with the analysis of ethical principles that come into play. Every quarter, members of Penn’s Scattergood program analyze emergency psychiatric evaluations, with a strong focus on the ethics of recent cases.
“Just about any medical trainee is going to be familiar with standard bioethical concepts,” Smith says. “Being able to name terms and then being able to apply them to hard cases are two different things.”
- Lee G, Cohen D. Incidences of involuntary psychiatric detentions in 25 U.S. states. Psychiatr Serv 2020; Nov 3;appips201900477. doi: 10.1176/appi.ps.201900477. [Online ahead of print].