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RESEARCH WEEKLY: Measuring the Effectiveness of Involuntary Hospitalization
By Shanti Silver
(March 1, 2023) Every state in the United States allows some type of involuntary psychiatric hold for people who are a danger to themselves or others. These interventions can be lifesaving and necessary but may also cause distress to those who experience them. A recent article from Psychiatric Services discusses some of the challenges of measuring the impact of involuntary psychiatric hospitalization and makes a call for increased research in this area.
The problem with randomized controlled trials for involuntary hospitalization
Randomized controlled trials are a type of study in which participants are randomly assigned to receive an intervention or an alternative treatment. This methodology makes it possible to determine if an intervention is more, less or equally effective as other treatment. Randomized controlled trials are considered the strongest evidence for the effectiveness of an intervention in clinical research.
In a recent interview, Dr. Nathaniel Morris, one of the article’s authors, notes that, while “the medical community is often almost, to an obsession, focused on randomized controlled trials,” randomized controlled trials may not be realistic for some interventions. Dr. Morris goes on to describe how conducting a randomized controlled trial on the effectiveness of involuntary hospitalization for people who pose a danger to themselves or others would be the same as conducting a randomized controlled trial on the effectiveness of parachutes for people about to jump out of an airplane.
“There are some interventions that are obvious,” Dr. Morris continues “[…] but again, if you take a step back and you actually think at a population level. Well, we don't know how many people actually would hurt themselves if they're outside the hospital, and being locked in a hospital unit can be really traumatic and distressing for people.”
Currently, observational studies are the most common way of evaluating the impact of involuntary hospitalization. In clinical, observational studies, researchers do not assign participants to different treatments, but instead, simply observe or compare changes in participants’ outcomes following the treatment. While these studies have certain methodological concerns about measuring cause and effect, they may be more appropriate than randomized controlled trials for measuring the impact of involuntary hospitalization. However, even observational studies are limited by the lack of available data surrounding involuntary hospitalization in the United States.
A call for increased research and data collection on involuntary hospitalization
Many states do not currently track the number of involuntary psychiatric holds, including emergency and inpatient commitments, that occur in the state. Dr. Morris has described how “in many places, patients and their families might ask simple, important questions about civil commitment (e.g., ‘how long does involuntary hospitalization typically last?’ or ‘how frequently are civil commitments overturned during hearings?’), to which first responders, clinicians, judges and other authorities may not have accurate answers.”
With several states moving to expand the use of involuntary hospitalization, it is more critical than ever to systematically monitor and improve involuntary hospitalization practices. Beginning to collect basic data is an important step toward determining the impact of involuntary hospitalization. According to the authors, a national coordination of data collection efforts would help determine the prevalence of involuntary psychiatric hospitalization in the United States and the circumstances under which an involuntary hospitalization is most likely to take place. The authors additionally suggest monitoring short and long-term outcomes such as self-harm, violence, emergency department use and incarceration rates following an involuntary hospitalization. With this data, it would be easier to examine the relationship between involuntary hospitalization and positive outcomes through observational studies.
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