Assignment 2 WK7
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O R I G I N A L P A P E R
Involuntary commitment and detainment in adolescent psychiatric inpatient care
Riittakerttu Kaltiala-Heino
Received: 14 January 2009 / Accepted: 31 July 2009 / Published online: 19 August 2009
� Springer-Verlag 2009
Abstract
Objective To evaluate whether adolescents committed to
psychiatric inpatient care are the most disturbed, and
whether psychosocial factors other than psychiatric symp-
toms are associated with commitment to and detainment in
psychiatric care among adolescents.
Materials and methods The case histories of 187 13- to
17-year-old adolescents consecutively admitted to the
study clinic were scrutinized with the help of a structured
data collection form. Psychiatric, demographic and family-
related characteristics of those referred involuntarily
(n = 93) and voluntarily (n = 94), and those detained
involuntarily (n = 42) and treated on a voluntary basis
(n = 145) were compared.
Results Involuntary referral and involuntary detainment
were associated with psychotic symptoms, temper tantrums
and breaking property, involuntary referral also with vio-
lent and hostile behaviours and suicidal ideation and talk.
They were not associated to family adversities, previous
treatment history or sociodemographic factors. The risk for
being committed when presenting with aggressive behav-
iours was greater in girls.
Conclusion Involuntary referral and detainment in ado-
lescents is associated with symptom severity, and not with
aspects of the adolescent’s living conditions. This is in
agreement with the legislation. Gender bias resulting in
girls’ greater risk of being involuntarily committed if dis-
playing aggressive behaviours may be an ethical and legal
problem.
Keywords Involuntary treatment � Involuntary admission � Health services research � Adolescent psychiatry
Introduction
In Western democracies, individuals basically have a right
to make decisions concerning themselves, including deci-
sions concerning their health that experts consider harmful.
In psychiatry, however, the patient’s wish not to be treated
can be overridden both referring to her/his need for treat-
ment and to dangerousness to her/himself or others. Mental
illness is considered to alter the patient’s understanding of
her/his situation and the consequences of her/his choices so
that s/he can no longer be deemed competent to make
decisions. Therefore, others can, or even must intervene.
Compulsory intervention is assumed to result in greater
good than no (coercive) intervention [10, 12, 16, 18, 34,
35]. On the other hand, coercive treatment may result in
greater harm than good, if ‘‘costs’’ such as violation of
autonomy, not improving or even getting worse, or being
pushed away from psychiatric services due to negative
experiences weigh more than benefits received [21, 28].
In order to be competent to make decisions, a patient
must be able to understand information as relevant to her/
his situation, process that information and express a choice
[2]. Minors are seen by definition incompetent in many
ways, and therefore their self-determination is limited, and
parents are expected to see to their best interests, for
R. Kaltiala-Heino (&) Department of Adolescent Psychiatry,
Tampere University Hospital,
33380 Pitkäniemi, Finland
e-mail: [email protected]
R. Kaltiala-Heino
Medical School, University of Tampere,
30014 Tampere, Finland
123
Soc Psychiat Epidemiol (2010) 45:785–793
DOI 10.1007/s00127-009-0116-3
example, in decision-making concerning health care.
However, through the adolescent development, minors
gradually gain competence [44], and many ethically
problematic decisions around topics such as sexual health,
substance abuse treatments and the alike among minors are
a subject of debate in everyday clinical practice. It is by no
means clear at what age minors can have self-determina-
tion in various aspects of health care [3, 4, 6–8, 29, 30, 43].
In mental health care, ethical solutions may be even more
difficult to find, because mental disorders impair adolescent
development, and the capacity for decision-making may
essentially differ from that of same aged peers.
Involuntary psychiatric care in Western legislations is
carefully regulated. Mental health legislation usually first
defines the conditions which allow involuntary care. This
basic criterion, for example mental illness or severe mental
disorder, does not alone justify involuntary treatment, but
additional criteria are given. These usually comprise need
for treatment, dangerousness to self and dangerousness to
others, in different combinations, and lack of less restrictive
treatment alternative may also be included [1, 13, 31, 39].
In Finland, commitment criteria for minors differ from
those for adults. A minor can be involuntarily hospitalised
if she/he suffers from a severe mental disorder and, due to
the disorder, is in need of treatment because failure to treat
her/him would result in a deterioration of her/his severe
mental disorder (need for treatment), or would endanger
her/his health or safety (dangerousness to self), or other
persons’ health or safety (dangerousness to others), and
other treatment options are inadequate. For adults, the basic
criterion is mental illness (psychosis) [34]. Minors can,
therefore, be committed with broader criteria [24]. Separate
commitment criteria for minors are exceptional [39]. In
Finland, the process of admitting a patient for involuntary
psychiatric treatment starts from referral for observation
(MI), written by a physician independent of the admitting
hospital. In the hospital, a physician (a psychiatrist or a
trainee) decides about placing the patient under observa-
tion, if the commitment criteria appear to be fulfilled.
Within 4 days, the psychiatrist in charge of the observation
produces a written statement of whether or not the com-
mitment criteria are indeed fulfilled (MII), and finally, the
chief psychiatrist in charge decides about detainment
(MIII). Regarding minors, the decision is immediately
subjected to confirmation by an administrative district
court.
Before the 1991 Mental Health Act was passed, there
were discussions on whether the broad commitment criteria
for minors result in using psychiatric hospitalisation as
punishment, or a general solution to adolescent opposi-
tional behaviour [22]. After the Act was passed, involun-
tary commitment and detainment figures of minors started
to increase. The steady increase with considerable regional
variation has continued until the present decade [23, 41].
Concerns were immediately raised as to whether the con-
cept of ‘‘severe mental disorder’’ was too vague and
imprecise to keep the use of coercion appropriate, and
guarantee equality before the law. Much later, guidelines
for interpreting the concept of severe mental disorder were
produced [22, 24].
Variation in involuntary treatment figures within a leg-
islative area has been explained by variation in the epide-
miology of mental disorders, accessibility of psychiatric
services and treatment cultures [5, 15, 27, 32, 33, 37].
Involuntary treatment seems to relate not only to severity
of the disorder but also to factors such as ethnicity and
social deprivation [5, 11, 46]. Research has focused on the
involuntary treatment of adults. Few studies have focused
on aspects of the involuntary treatment of minors. The
ethical and legal aspects of the involuntary treatment of
minors are even more complicated than those related to
decisions concerning adults, as the decisions involve not
only the patient and society (heath care) but also the minor
patient’s parents, and, because minors are in a process of
continuous change, guidelines for decision-making always
have to take into account the developmental level of the
minor. In Finland, certain minors can actually become
targets of involuntary interventions both under the Mental
Health Act and under the Child Welfare Act, particularly
minors with conduct disorders and substance abuse disor-
ders [9, 24, 34, 41]. Those committed to psychiatric
treatment should be the most severely disturbed in psy-
chiatric terms, and family-related issues or previous treat-
ment history should theoretically not influence psychiatric
commitment. However, it is not known how well these
principles are met in practice.
The aim of this study is to evaluate whether adolescents
committed to care are most disturbed in psychiatric terms,
and whether other psychosocial factors such as family
circumstances and previous treatment history are associ-
ated with commitment to and detainment in psychiatric
care, by comparing the sociodemographic, family-related
and psychiatric characteristics of
1. adolescents referred involuntarily and voluntarily, and
2. adolescents detained involuntarily and those treated on
a voluntary basis.
Materials and methods
Setting
Tampere University Hospital provides all adolescent psy-
chiatric inpatient care for the inhabitants of a catchment
area of 33 municipalities including both urban and rural
786 Soc Psychiat Epidemiol (2010) 45:785–793
123
areas. The 13- to 17-year-old population numbers about
32,000. Young people up to 17 years old can be admitted
to the two wards with 12 beds each. The lower age limit of
patients is not defined in terms of years but it is connected
to adolescent development. In practice, young people under
13 are usually admitted to child psychiatric wards if hos-
pitalisation is required.
Data collection
All the admissions to the adolescent psychiatric wards of
Tampere University Hospital in 2004–2006 were identified
in hospital databases. Adolescents referred involuntarily
for the first time during the data collection period were
included in the study as involuntary patients. The next
voluntarily referred patient after each involuntary com-
mitment was always included as a control. Readmissions
occur relatively frequently. If an adolescent was already
included in the study, the next admission was included in
the data so that nobody was taken into the study more than
once. A retrospective chart review with a structured data
collection form was involved. The data collection did not
include personal interviews or surveys with the patients.
The study received approval from the ethics committee of
Pirkanmaa Hospital District.
The study group
There were 214 admissions, 106 with voluntary and 108
involuntary referrals, to the study unit in 2004–2006. As
each adolescent was included in the study only once, the
final study sample comprised 187 adolescent psychiatric
patients of whom 93 were referred on an involuntary basis
and 94 voluntarily according to the Finnish Mental Health
Act. In the hospital, 42 of these adolescents were detained
in involuntary treatment, and 145 were treated on a
voluntary basis.
Measures
Sociodemographic characteristics collected were age, sex
and family situation (living with at least one parent/with
foster parent(s)/in child welfare institution/independently).
Previous treatment history was recorded whether or not
the adolescent had been treated in specialist level adoles-
cent psychiatric community care (yes/no/unclear based on
charts) or inpatient care (yes/no/unclear based on charts).
Exact details of previous treatment history may not always
be found in the charts of the study unit if the adolescent had
earlier lived and been treated in another hospital district.
When unclear, previous treatment was coded ‘‘no’’.
Information related to the present admission was col-
lected the referring agent (primary care, GP/child or
adolescent psychiatrist/other medical specialist), mode of
referral (voluntary/involuntary), dates of admission and
discharge, and involuntary detainment decision (yes/no).
Symptoms displayed by the adolescents were collected
from the referral and the medical charts written during the
first 4 days of the stay in the hospital. The period of the
first 4 days was selected because this is the length of
the observation period (see ‘‘Introduction’’) defined in the
Mental Health Act. 21 core symptoms of adolescent
inpatients were recorded (yes/no) in a checklist. The list
was originally developed as an aid in admission situations
and is currently being used in clinical work in the study
clinic.
With the help of a structured 10-item checklist, adverse
family life events were recorded. The list was originally
developed as an aid in admission situations and is currently
being used in clinical work in the study clinic. Adverse
family life events were recorded from referral and/or
medical charts written during the first 4 days of the stay in
the hospital, similarly as were the symptoms (see above).
Length of treatment was calculated from the date of
admission to discharge.
Psychiatric main diagnoses were collected as given at
discharge by the treating psychiatrist according to the ICD-
10. Diagnoses are used in the analyses classified as follows:
substance abuse related disorders (f10–19), schizophrenia
spectrum psychoses (f20–29), mood disorders (f30–39),
anxiety disorders (f40–49), somatoform disorders (f50–59),
personality disorders (f60–69), mental retardation (f70–
79), developmental disorders (f80–89), conduct disorders
(f90–99) and non-psychiatric main diagnosis.
Medications started for continuous use and PRN medi-
cations were recorded as prescribed during the first 3 days
of treatment and at discharge. Medications were classified
by therapeutic category level as follows: neuroleptics,
antidepressants, antiepileptics, anxiolytes and hypnotics.
Statistical analyses
Frequencies of the features studied are given. Sociode-
mographic characteristics, previous treatment, referring
agents, symptoms, diagnoses and adverse family life events
and conditions, continuous and PRN medications pre-
scribed and length of treatment are compared between
those referred involuntarily and voluntarily, and those
detained in involuntary care and treated on a voluntary
basis using cross-tabulations with Chi-square statistics and
t test where appropriate. Age- and sex-adjusted associa-
tions between the studied correlates and involuntary legal
status are studied using logistic regression, entering
involuntary referral (yes/no) and involuntary detainment
(yes/no) in turn as the dependent variable, and sex, age
and the correlates each in turn as independent variables.
Soc Psychiat Epidemiol (2010) 45:785–793 787
123
Age- and sex-adjusted odds ratios with 95% confidence
intervals are given for risk of involuntary legal status
according to psychiatric symptoms and family adversities.
Results
The hospitalised adolescents
Of the study group, 67 (35.8%) were boys and 120 (64.2%)
were girls. Their age ranged from 11 to 17, mean (SD)
15.03 years (1.22), median 15.05 years, mode 15 years.
42.2% were referred by doctors in primary care, 50.5% by
child or adolescent psychiatrists and 7.2% by other spe-
cialists. Prior to hospitalisation, 74.3% of the adolescents
were living with parent(s), 5.7% with foster parent(s),
17.1% in child welfare institutions and 2.9% independently
(in boarding schools, communes and with partner). Of the
adolescents, 74.9% had previously been treated in spe-
cialist level adolescent (or child) psychiatric services and
35.7% had been hospitalised before.
Most common symptoms recorded were depression,
suicidal ideation and psychotic symptoms (Table 1). Most
common main diagnoses at discharge were mood disorders,
schizophrenia spectrum disorders and conduct disorders
(Table 2). Most common adverse family life events or
conditions were family violence and parental substance
abuse problems (Table 3).
Within the three-first inpatient days, 52.9% of the ado-
lescents had been prescribed neuroleptic medication,
15.5% antidepressants, 4.8% antiepileptics, 8.0% anxio-
lytes and 1.1% hypnotics. PRN medication was prescribed
as follows: neuroleptics 55.1%, antiepileptics 0.5%, anxi-
olytes 40.6% and hypnotics 44.4%. At discharge, 65.8% of
the adolescents were on neuroleptics, 15.0% on antide-
pressants, 5.9% on antiepileptics, 4.3% on anxiolytes and
3.7% on hypnotics.
Mean (SD) length of stay was 47.8 days (56.1), median
28 days.
Correlates of involuntary referral and detainment
Age and sex distributions were comparable among invol-
untarily and voluntarily referred adolescents, as well as
among involuntarily detained and voluntarily treated young
people.
Table 1 Prevalence (%) of emotional and behavioural symptoms in involuntarily and voluntarily referred, and involuntarily detained and voluntarily treated adolescent psychiatric patients, and risk (OR, 95% confidence intervals) for involuntary referral/detainment according to
symptoms, controlled for age and sex
Involuntarily
referred
(n = 93)
Voluntarily
referred
(n = 94)
P OR (95% CI)
Involuntarily
detained
(n = 42)
Voluntarily
treated
(n = 145)
P OR (95% CI)
Suicidal ideation and talk 73.1 53.2 0.004 2.0 (1.0–3.8) 61.9 63.4 0.50 0.9 (0.4–2.0)
Suicide attempt 21.5 18.1 0.34 1.9 (0.5–2.3) 16.7 20.7 0.37 0.7 (0.3–1.8)
Self-harming behaviours 46.2 34.0 0.06 1.4 (0.7–2.7) 35.7 41.4 0.32 0.5 (0.4–1.6)
Psychotic symptoms 55.9 41.5 0.03 1.9 (1.0–3.3) 78.6 40.0 <0.001 5.6 (2.4–12.9)
Depression 73.1 76.6 0.35 0.7 (0.3–1.4) 61.9 78.6 0.03 0.4 (0.2–0.9)
Manic behaviour 5.4 7.4 0.39 0.7 (0.2–2.5) 9.5 5.5 0.27 1.4 (0.4–5.2)
Hostile behaviour 33.3 20.2 0.03 2.3 (1.1–4.8) 33.3 24.8 0.18 1.9 (0.9–4.2)
Temper tantrums 19.4 10.6 0.07 2.4 (1.0–5.9) 31.0 10.3 0.002 5.5 (2.1–14.2)
Violent behaviour 39.8 17.0 <0.001 4.2 (2.0–9.1) 35.7 26.2 0.16 2.0 (0.9–4.4)
Breaking property 16.1 4.3 0.006 5.5 (1.6–18.4) 21.4 6.89 0.01 4.3 (1.5–12.1)
Inappropriate sexual behaviour 10.8 5.4 0.14 2.1 (0.6–6.6) 4.8 9.0 0.30 0.5 (0.1–2.2)
Alcohol abuse 34.4 29.8 0.30 1.2 (0.6–2.4) 23.8 34.5 0.13 0.6 (0.2–1.2)
Substance use 16.1 11.7 0.25 1.3 (0.6–3.2) 11.9 14.5 0.45 0.7 (0.2–2.1)
Truancy/school refusal 33.3 40.4 0.20 0.8 (0.4.1.5) 28.6 39.3 0.14 0.6 (0.3–1.3)
Property crimes 8.6 10.6 0.41 0.8 (0.3–2.4) 7.1 10.3 0.39 0.8 (0.2–3.0)
ED symptoms 23.7 23.4 0.55 0.9 (0.4–1.8) 31.0 21.4 0.14 1.7 (0.7–3.7)
Isolation 5.4 5.3 0.62 1.3 (0.3–4.9) 7.1 4.8 0.40 1.6 (0.4–6.9)
Impulse control problems 3.2 3.2 0.65 0.9 (0.2–5.1) 2.4 3.5 0.59 0.7 (0.1–6.3)
Running away 16.1 11.7 0.25 1.7 (0.7–4.1) 21.4 11.7 0.09 2.2 (0.9–5.6)
Attention problems – 1.1 0.53 1.3 (0.5–3.5) – 0.7 0.78 –
Anxiety 7.5 11.7 0.24 0.6 (0.2–1.6) 9.5 9.7 0.62 0.8 (0.3–2.8)
Other 22.6 41.5 0.004 0.4 (0.2–7.6) 23.8 34.5 0.13 0.6 (0.3–1.3)
788 Soc Psychiat Epidemiol (2010) 45:785–793
123
Involuntarily referred adolescents were more frequently
referred by primary care level (54.9 vs. 29.2%) or non-
psychiatric specialities (12.1 vs. 2.2%), whereas voluntarily
referred young people were more commonly referred by
child or adolescent psychiatrists (68.5 vs. 33.0%)
(P \ 0.001). Prior to index hospitalisation, involuntarily and voluntarily referred adolescents lived equally fre-
quently with parents, foster parents, in institutions and
independently. Of those referred involuntarily, 67.7% had
previously received psychiatric community care, of those
referred voluntarily, 81.9% (P = 0.02). There were no
differences in previous psychiatric inpatient treatment
received according to legal status at referral. Similarly,
young people detained involuntarily had more frequently
been referred by primary care (57.9 vs. 38.0%) or non-
psychiatric specialists (13.2 vs. 5.6%), whereas those who
were not detained had mainly been referred by adolescent
psychiatrists (56.3 vs. 28.9%) (P = 0.01). Decision on
detainment was unrelated to living conditions or previous
psychiatric treatment of the adolescent. Controlling for age
and sex did not alter the associations of referring agent,
living conditions and previous psychiatric treatment with
legal status at referral or during treatment.
Involuntarily referred adolescents presented more often
with suicidal ideation and talk, psychotic symptoms, hos-
tile and violent behaviour towards people and property
Table 2 Main diagnoses of the hospitalised adolescents
Involuntarily and voluntarily
referred, and involuntarily and
voluntarily detained adolescents
are compared (%)
Involuntarily
referred
(n = 93)
Voluntarily
referred
(n = 94)
P Involuntarily treated
(n = 42)
Voluntarily
treated
(n = 145)
P
Main diagnosis
f10–19 1.1 – 0.50 – 0.7 0.76
f20–29 23.7 19.1 0.28 54.8 11.7 \0.001 f30–39 38.7 38.3 0.54 19.0 44.1 0.002
f40–49 5.4 8.5 0.29 2.4 8.3 0.17
f50–59 3.2 6.4 0.25 7.1 4.1 0.33
f60–69 1.1 2.1 0.50 – 2.1 0.46
f70–79 – – – – – –
f80–89 6.5 3.2 0.24 2.4 5.5 0.36
f90–99 19.4 19.1 0.56 14.3 20.7 0.25
Non-psychiatric 1.1 3.2 0.32 – 2.8 0.36
Table 3 Prevalence (%) of adverse family life events or conditions among the hospitalised adolescents among involuntarily and voluntarily referred, and involuntarily and voluntarily detained adolescents, and risk (OR, 95% CI) of being involuntarily referred and detained according to
family adversities, controlled for age and sex
Involuntarily
referred
(n = 93)
Voluntarily
referred
(n = 94)
P OR (95% CI)
involuntarily
detained
(n = 42)
Voluntarily
treated
(n = 145)
P OR (95% CI)
Event/condition
Family violence 18.3 14.9 0.36 1.3 (0.6–2.8) 16.7 16.6 0.58 1.2 (0.4–3.0)
Parental substance use problems 14.0 20.2 0.17 0.6 (0.3–1.8) 4.8 20.7 0.009 0.2 (0.04–0.8)
Divorce or separation 4.3 7.4 0.27 0.5 (0.1–2.0) 4.8 6.2 0.53 0.9 (0.2–4.5)
Bereavement 15.1 10.6 0.25 1.6 (0.6–4.0) 4.8 15.2 0.06 0.3 (0.1–1.2)
Parental severe somatic illness 5.4 2.1 0.22 2.9 (0.5–15.4) 2.4 4.1 0.51 0.6 (0.1–5.1)
Parental severe mental disorder 12.9 10.6 0.40 1.6 (0.6–4.1) 11.9 11.7 0.58 1.2 (0.4–3.5)
Severe financial difficulties,
unemployment, etc.
4.3 5.3 0.51 0.7 (0.2–3.0) 4.8 4.8 0.67 1.2 (0.2–6.6)
Severe problems related to siblings 8.6 5.3 0.28 2.0 (0.6–6.7) 4.8 7.6 0.41 0.7 (0.2–3.5)
(Suspected) sexual abuse within the family 3.2 4.3 0.51 0.6 (0.1–2.7) 2.4 4.1 0.51 0.5 (0.1–4.0)
Other a
23.7 20.2 0.35 1.0 (0.5–2.2) 14.3 24.1 0.12 0.5 (0.2–1.3)
a Suicide of a relative, severe illness of a relative, unsatisfactory relationship with parent(s), problems in right to meet a parent, psychiatric
problems of a dating partner, sexual abuse by someone not from the nuclear family (uncle, mother’s ex boyfriend)
Soc Psychiat Epidemiol (2010) 45:785–793 789
123
breaking than adolescents referred on a voluntary basis
(Table 1). Being involuntarily detained was associated
with psychotic symptoms, temper tantrums and property
breaking, whereas depression was more common among
the voluntarily treated patients (Table 1). Controlling for
sex and age did not level out any of the associations
detected in univariate level between legal status and psy-
chiatric symptoms, but when age and sex were controlled
for, temper tantrums were also associated with involuntary
referral.
Psychiatric diagnostic groups were not statistically sig-
nificantly associated with being involuntarily referred.
Involuntarily detained young people were more often
diagnosed with schizophrenia spectrum disorders (f20–29),
and less frequently with mood disorders than those treated
on a voluntary basis (f30–39) (Table 2). Controlling for
age and sex did not alter the associations between psy-
chiatric main diagnosis and involuntary detainment [odds
ratios controlling for sex and age: schizophrenia group 8.6
(95% CI 3.8–19.6), mood disorders 0.3, 95% CI 0.1–0.7].
Involuntary referral of the adolescent was not associated
with any of the adverse family life events or conditions
studied. Among those detained and not detained, adverse
family life events and conditions were otherwise equally
frequent, but parental substance abuse problems were more
common among those treated on a voluntary basis
(Table 3). Adjusting for sex and age confirmed lack of
associations between adverse family life events and legal
status at referral or during care.
Continuous medication prescribed during the first 3 days
of treatment did not otherwise differ between those com-
mitted involuntarily and those referred voluntarily, but
anxiolytes were more often prescribed to the involuntarily
referred adolescents (11.8 vs. 4.3%, P = 0.05). Of the
involuntarily referred, 54.8% were prescribed PRN anxio-
lytes, of the voluntarily referred 26.6% (P \ 0.001), and PRN hypnotics were prescribed to 52.7% of the involun-
tarily and 36.2% of the voluntarily referred (P = 0.02).
Medication at discharge did not differ according to legal
status at referral. These associations did not change when
adjusted for sex and age.
Those detained in involuntary care were more often put
on neuroleptic medication (71.4 vs. 47.6%, P = 0.005) and
on anxiolytes (26.2 vs. 2.8%, P \ 0.001) at the beginning of treatment than those treated on a voluntary basis. Those
detained were also more frequently prescribed PRN anxi-
olytes (60.0 vs. 32.4%, P \ 0.001) and PRN hypnotics (59.5 vs. 40.0%, P = 0.02) than those treated on a volun-
tary basis. At discharge, those detained in involuntary care
were more commonly on neuroleptics (83.3 vs. 60.7%,
P = 0.004) and anxiolytes (14.3 vs. 1.4%, P = 0.002),
whereas those treated on voluntary basis were more com-
monly on antidepressants (17.9 vs. 4.8%, P = 0.02). The
associations between medication and involuntary detain-
ment persisted after controlling for sex and age.
Length of treatment did not differ according to type
of referral (involuntary/voluntary), but those detained
involuntarily stayed longer than those not so detained
[82.0 days (69.3) vs. 37.8 days (47.5) (P \ 0.001)].
Are the associations between symptoms and coercion
different among girls and boys?
When multivariate associations between the correlates
studied of involuntary referral/detainment were analysed in
logistic regression controlling for age and sex, sex emerged
as a significant risk factor for involuntary referral in
combination with symptoms related to aggression: hostil-
ity, temper tantrums, violence against people and breaking
property. Therefore, interaction of sex and these four
externalising symptoms were further explored by entering
interaction terms of these symptoms and sex each in turn as
independent variables in logistic regression. Being invol-
untarily referred was entered as the dependent variable.
The interaction terms were entered controlling for age and
main effects of sex and the symptom in questions. The
interaction term of sex and hostility emerged as significant
(P = 0.03). Interaction term of temper tantrums emerged
as nearly significant (P = 0.06). The interaction term of
violent behaviour and sex emerged as significant
(P = 0.001). The interaction term of breaking property and
sex was also significantly associated with being involun-
tarily referred (P = 0.02).
The significant effects of the interaction terms necessi-
tated further analysis separately among girls and boys and
the association between these four externalising symptoms
and being involuntarily referred. The separate analyses
revealed that the risk of being committed to psychiatric
care according to these aggression-related symptoms con-
cerned almost exclusively girls. Among boys alone, hos-
tility was not significantly associated with involuntary
referral (OR 1.5, 95% CI 0.6–3.9), but among girls it was
(OR 5.9, 95% CI 1.7–20.0). Among boys, temper tantrums
did not emerge as associated with risk of being committed
(OR 1.1, 95% CI 0.3–4.1), but among girls, a significant
risk emerged (OR 4.8, 95% CI 1.3–17.1). Violent behav-
iour was associated with risk of being committed among
boys (OR 3.3, 95% CI 1.1–9.6), but the risk was stronger in
girls (OR 6.2, 95% CI 2.0–19.4). Breaking property was
also only significantly associated with being involuntarily
referred among girls (OR 5.1, 95% CI 1.2–22.1) (among
boys OR 5.7, 95% CI 0.64–50.46). Finally, the sex-specific
associations between aggression-related symptoms and
involuntary referral were further studied controlling for
main diagnostic groups. Diagnostic groups (f00–09, f10–
19, f20–29, etc.) were added into the analyses separately
790 Soc Psychiat Epidemiol (2010) 45:785–793
123
each in turn (present/not present). Also controlled for main
diagnosis, hostility, temper tantrums and breaking prop-
erty, was only associated with involuntary referral among
girls and violent behaviour in both sexes.
No such emergence of sex as significantly related to
involuntary referral or detainment was found in any other
analyses, when the associations detected in cross-tabula-
tions were controlled for age and sex.
Discussion
Adolescents referred involuntarily to psychiatric treatment
were more commonly referred by physicians not specia-
lised in adolescent psychiatry or child psychiatry. They
presented more often with suicidal ideation and talk, psy-
chotic symptoms, hostile and violent behaviour towards
people and property breaking than adolescents referred on
a voluntary basis, and at the beginning of the inpatient
treatment they were more commonly prescribed PRN
minor tranquilisers than those referred voluntarily. Ado-
lescents who were detained in psychiatric treatment were
similarly more often originally referred by physicians other
than adolescent (or child) psychiatrists. They displayed
more commonly psychotic symptoms, temper tantrums and
property breaking. They were diagnosed with schizophre-
nia spectrum disorders, and they were more frequently
medicated both with minor and major tranquilisers than
adolescents treated on a voluntary basis.
Aggressive and psychotic symptom profiles, heavier
medications and diagnoses of severe mental illness suggest
that adolescents referred involuntarily to psychiatric hos-
pital, and particularly adolescents detained on an involun-
tary basis, were more seriously disturbed than voluntary
patients, which should be the case according to the Mental
Health Act. Previously, involuntary psychiatric commit-
ment of adolescents has been associated with conduct
disorders and schizophrenia spectrum disorders, suicidal
behaviour and alcohol and substance abuse [14, 20, 23, 26].
However, earlier research is very scarce and does not allow
for much international comparison. More research is
clearly needed on the very basic aspects of adolescent
involuntary treatment, even if our results seem to confirm
that it is the severity of the illness and not external con-
ditions that thresholds compulsory interventions.
The route to psychiatric hospital through primary care or
somatic specialities may also suggest that involuntarily
committed and detained adolescents were referred in acute
situations where adolescent psychiatric consultation could
not be waited for. Involuntary referral could, of course, be
due to inferior skills of non-psychiatrists to assess the
adolescent or negotiate an agreement, but it is noticeable
that within the specialist level service those referred by
non-psychiatrists were also more commonly detained. This
rather points to the actual severity of disturbance than lack
of skills in the referring agent.
Living conditions and family circumstances including
family-related factors that might negatively influence the
adolescent’s mental health were not as such associated with
involuntary referral or detainment. Even if adolescent
mental disorders are influenced by family factors, and
psychiatric assessment of an adolescent should always
include assessment of family and network circumstances
that may support the adolescent development and func-
tioning or also threaten deterioration [25, 42], it is still
important that decisions on compulsory interventions under
the Mental Health Act take place focusing on the adoles-
cent’s symptoms and disorder, not family circumstances.
Involuntary referral and detainment were also not related to
previous treatment history. In adult studies it has some-
times been suggested that stigmatisation, or labelling, by a
patient’s previous treatment history may guide the deci-
sions of clinicians even more than the patient’s current
mental status [17, 38, 40], but in the present study among
adolescents, no support was found for this assumption.
Those detained involuntarily also stayed longer in the
hospital than those treated on a voluntary basis. Mode of
referral (voluntary/involuntary), however, did not predict
length of stay. This suggests that the ideal of independent
assessments by several doctors stipulated in the Finnish
Mental Health Act truly takes place, and the initial act of
involuntary referral does not determine the patient’s route
within hospital care more than her/his clinical status.
Similar observation has been reported of adult psychiatric
inpatient treatment in Finland [45].
In bivariate analyses, being involuntarily referred/
detained were not associated with the adolescent’s age and
sex, but in multivariate analyses, a greater risk for invol-
untary referral among girls emerged when several exter-
nalising symptoms were entered in the analysis with age
and sex. Girls with disruptive behaviours have a greater
risk of being committed to involuntary care than boys with
similar behaviours. It is a serious ethical and legal problem
if similar symptoms result in different interventions in girls
and boys. There may be a risk of unnecessarily depriving
girls of their liberty when they break rules in a way that is
accepted for boys. On the other hand, there is also the risk
that severe symptoms in boys will be ignored and treatment
they need is denied.
Methodological considerations
The present study was based on register data. It suffers no
bias due to refusal to participate. The retrospective study
design ensures that practices of interest were not influenced
by the study, as might be a risk in a prospective study on
Soc Psychiat Epidemiol (2010) 45:785–793 791
123
ethically problematic topics such as involuntary treatment.
The material collected was readily available for all the
cases, and it was recorded in a structured way, which adds
to the data quality. Symptoms and family risk factors were
rated as present if clearly so stated in the medical charts. It
is possible that the actual symptoms of the subjects were
more than recorded in the data, as in case of uncertainty or
no explicit comments on certain types of symptoms, they
were rated as not present. The same concerns family risk
factors. It is also noticeable that only symptoms and family
adversities recorded in the referral and/or the medical
charts during the first 4 days of the inpatient stay were
studied, in order to focus on information that may influence
decision-making about involuntary detainment. It is pos-
sible that later during the adolescent’s inpatient treatment,
more family adversities were uncovered and new symp-
toms emerged that may have influenced, for example, the
length of stay. These would remain beyond the reach of the
present study. However, if there were family adversities in
a referred adolescent’s life that were not mentioned in the
referral and/or medical charts, it is unlikely that they would
directly have influenced the assessing doctors’ decision-
making, even if they of course may have influenced the
adolescent’s symptoms.
Diagnoses were recorded as given by the treating psy-
chiatrists according to ICD-10, which is the diagnostic
classification officially used in Finland. While structured
research diagnosis could have added to the reliability of the
diagnostic information, it has nevertheless been shown that
diagnoses set in Finnish specialist level psychiatric health
services are adequately reliable, particularly as to the most
severe diagnoses [19, 36].
Conclusion
Adolescents referred to and detained involuntarily in psy-
chiatric inpatient care in Finland suffer from more severe
disorders and display psychotic and aggressive symptoms
more often than those hospitalised on a voluntary basis.
This is in agreement with the regulation of involuntary
inpatient care in the Finnish Mental Health Act. Adolescent
involuntary hospitalisation is not associated with adverse
family circumstances, which indeed, if very severe, should
be dealt with through the child welfare legislation, and
neither is it associated with previous treatment history and
stigma brought about by it. However, the inequality
between sexes demonstrated by the greater risk of girls to
be involuntarily hospitalised if displaying externalising
symptoms may be a serious ethical problem and needs to
be addressed in service quality control. There is a risk of
unnecessarily subjecting girls to coercion, but also of
ignoring severe symptoms in boys.
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