A documentary comparative study about the practice of involuntary psychiatric admissions in Germany

Background/Objectives: Germany has one of the highest rates of involuntary psychiatric admissions in Europe, and rates vary substantially among the German Federal States. By and large, these variations are unexplained, even though one might assume them being due to differences between Federal States in psychiatric practice and legal regulations. Furthermore, the constant rise of involuntary psychiatric admissions in Germany during the last two decades is dramatic and also difficult to explain. The aim of the present study is to systematically document and compare of the practice of psychiatric involuntary admissions in five psychiatric clinics in the German Federal States of Bavaria, Baden Wuerttemberg, and Mecklenburg-Western-Pomerania.

Methods: All cases of psychiatric involuntary admission that took place at the five clinics were systematically documented for a period of three months by one researcher who rotated between the clinics recruiting patients and collecting data. The comparative research is based upon: (1) standard and open patient interviews to gain insight into the subjective appreciation of the involuntary commitment experience; (2) standardised questionnaires to ascertain professional decision making with regard to involuntary commitment; and (3) analysis of police reports, legal decisions and case notes.

Results: During 15 months, 244 cases of psychiatric involuntary admission were documented. Of these, 104 patients gave informed consent to participate in the study. Involuntary admission rates differed substantially among German Federal States (5 per 100,000 inhabitants in Baden-Wuerttemberg, 15.4 in Bavaria, and 17.5 in Mecklenburg-Western-Pomerania). Other important points of divergence were the diagnosis, the evaluation of risk factors by clinicians, and the legal basis of involuntary commitment. Also perception of the involuntary commitment situation diverged in most of the cases among patients, clinicians, and police officers. For the majority of patients, involuntary admission was an utterly negative experience.

Discussion/Conclusions: Results confirm large differences in involuntary psychiatric hospital admissions between the investigated Federal States. Differences in availability and access to psychiatric emergency services might substantially contribute to explaining these variations in the studied regions. The need for psychiatric involuntary admission could be reduced if people with mental illness were more effectively supported in crisis situations.

Funding: Federal Ministry of Education and Research (BMBF) through the Research Net Mental Health (‘Forschungsnetz Psychische Gesundheit', grant no. 01GIO451).

Keywords: Coercive treatment, involuntary admission, emergency services.