A prospective evaluation of involuntary admission from the viewpoint of service users
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Introduction: Involuntary admission is often a traumatic experience for patients and it is associated with negative attitudes which can persist after the episode of illness has abated. Aims: The aims of the study were to prospectively assess attitudes to care and treatment both at involuntary admission and when the individual had recovered to their baseline and to identify clinical predictors of attitudes. Methods Consecutively admitted involuntary patients across three psychiatric admission units were invited to participate in the study. Comprehensive assessments of attitudes and a range of clinical measures, including symptoms, functioning, insight and care experiences, were obtained at admission and 3 months after discharge. Attitudes were assessed using the Client Assessment of Treatment scale (CAT) and a study specific Attitudes Scale to capture aspects of care and treatment specific to involuntary admission. Multiple linear regression modelling was used to identify the optimal explanatory variables for attitudes towards care during acute admission and at the point of recovery to baseline. Results: Two hundred and sixty three individual presentations were included at baseline and onehundred and fifty six (59%) also completed follow-up assessments. Individuals improved significantly over time both clinically and in their attitudes to their involuntary admission and treatment. At follow-up, 65.3% stated that they believed that their involuntary admission was necessary. A multiple linear main effects regression model demonstrated that at baseline having greater awareness of illness (b = 0.041, p < 0.001), being older (b = 0.009, p = 0.003), having had fewer numbers of previous involuntary admissions (b = -0.036, p = 0.001), not having a lifetime history of illicit substance abuse (b = -0.247, p = 0.048) and having a history of lifetime alcohol abuse (b = 0.249, p = 0.015) was associated with more positive attitudes towards involuntary admission and care, adjusting for multiple other factors. Furthermore greater awareness of illness at baseline (b = 0.042, p = 0.006), male gender (b = -0.280, p = 0.045), not having a history of illicit drug use (b = -0.443, p = 0.012), being older (b = 0.012, p = 0.014) and having a diagnosis of a non psychotic illness (b = 0.653, p = 0.050) were 7 associated with more positive attitudes towards involuntary treatment and care at follow up. Over time having a greater improvement in awareness of illness (b = 0.022, p < 0.001), male gender (b = -0.281, p = 0.014) as well as having a diagnosis of a non psychotic illness (b = 0.732, p = 0.009) was associated with more positive attitudes to involuntary treatment and care. There was no significant association between experiencing coercive practices such as seclusion, restraint or forced intramuscular medication and attitudes towards care. Conclusion: At the point of recovery most patients considered their involuntary admission as necessary at the time. Positive attitudes towards involuntary admission and care both at the point of acute admission and at recovery are better predicted by factors related to the illness and its treatability, such as awareness of illness and level of symptoms, than factors related to the service received or extent of coercion employed. Patients who are likely to have persistently negative attitudes to their care could be identified during the admission phase by their clinical characteristics and potentially targeted with additional support to ameliorate their negative experiences.