Understanding increasing rates of psychiatric hospital detentions in England: development and preliminary testing of an explanatory model

Abstract

Background The steep rise in the rate of psychiatric hospital detentions in England is poorly understood. Aims To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions. Method Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions. Results Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers. Conclusions Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.

Clinical and social factors associated with involuntary psychiatric hospitalisation in children and adolescents: a systematic review, meta-analysis, and narrative synthesis

“… 5 In addition, growing evidence indicates that factors outside of those specified in mental health legislation can affect and potentially systematically bias decisions around who needs involuntary treatment. 6 , 7 , 8 …”

Trends in inpatient care for psychiatric disorders in NHS hospitals across England, 1998/99–2019/20: an observational time series analysis

“…These comparisons indicate that the threshold for admitting people with severe mental illness has increased, while thresholds for discharging patients have fallen. In addition, compulsory detentions under the Mental Health Act have more than doubled over the last 30 years [ 19 , 20 ]. It is unclear to what extent this is because improved community services are able to look after people with severe mental illness in the community with only the most severely ill needing hospital admission, or because the shortage of mental health beds means they have to be prioritised for the most unwell [ 20 – 22 ].…”

“…In addition, compulsory detentions under the Mental Health Act have more than doubled over the last 30 years [ 19 , 20 ]. It is unclear to what extent this is because improved community services are able to look after people with severe mental illness in the community with only the most severely ill needing hospital admission, or because the shortage of mental health beds means they have to be prioritised for the most unwell [ 20 – 22 ]. Nevertheless, the fact that compulsory detentions make up a higher proportion of mental health bed occupancy reflects the severity of illness in those receiving hospital care.…”

Investigating geographical variation in the use of mental health services by area of England: a cross-sectional ecological study

“…Data for this study was obtained from Public health England fingertips data which likely represents the best available routinely collected data on this area. However other studies have highlighted the generally poor quality of NHS routine data in mental health services, an issue highlighted in recent work examining the rising number of detentions under the mental health act [ 43 ]. For the majority of variables data was not available at the same time point as the outcome (see Table 1 ) and so the most recent data was used, therefore the validity of this data will be affected by to what degree these variables have changed over time.…”