Compulsory admissions and preferences in decision-making in patients with psychotic and bipolar disorders

  • Inés Morán-SánchezEmail author
  • María A. Bernal-López
  • Maria D. Pérez-Cárceles
Original Paper



Participation in medical decisions and taking into account patients’ values and preferences are especially important for psychiatric patients who may be treated against their will. The increasing rates of coercive measures and the underlying clinical, ethical, and legal issues highlight the need to examine their use in psychiatry. Although limited congruence in decision-making preferences may be on the basis of these coercive practices, this issue has not been adequately addressed. We explore the relationship between compulsory admissions and congruence in decision-making preferences in mental health settings.


Cross-sectional study among 107 outpatients with DSM diagnoses of schizophrenia of bipolar disorder using the Control Preference Scale to assess congruence in decision-making experienced and preferred style. History of compulsory admissions was obtained through review of available records. Descriptive statistics and multivariate analyses were used.


70% of patients reported experiencing their preferred style of decision-making and 44% patients had history of compulsory admissions. These patients were more autonomous and preferred to take a more active role. The degree of congruence was lower in patients with previous compulsory admissions. The best predictors of compulsory admissions were not having a regular doctor and the unmatched participation preferences.


Patients who experienced a different level of participation in decision-making than desired more frequently had compulsory admissions. We propose to assess participation preferences each time a relevant treatment decision is about to be made and tailor care accordingly. We identified several factors leading to compulsory admissions that can be modified to prevent further coercive measures.


Coercion Patient admissions Risk factors Psychiatry Decision-making Patient participation 



We would like to thank everyone who participated in the study and Dr Ibañez-López and Dra Ruiz-Merino for their statistical advice.

Compliance with ethical standards

All authors declare that the submitted work has not been published before and that the work is not under consideration for publication elsewhere.

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical approval

This study has been approved by the ethics committee of our referral hospital and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Spanish laws have been observed, too.


  1. 1.
    European Parliament and the Council of the European Union. Convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine: convention on human rights and biomedicine. 4. 1997. European Treaty Series. No. 164 Accessed 01 May 2019
  2. 2.
    Official State Gazette (2002) Law 41/2002, of 14 November, regulating patient autonomy and rights and obligations of information and clinical documentation. 274, 40126–40132Google Scholar
  3. 3.
    Official State Gazette (2000) Law 1/2000, of 7 January on civil procedure. Article 763 compulsory internment due to psychic disorder. 7 708Google Scholar
  4. 4.
    Kallert TW, Glöckner M, Onchev G, Raboch J, Karastergiou A, Solomon Z, Magliano L, Dembinskas A, Kiejna A, Nawka P, Torres-Gonzales F, Priebe S, Kjellin L (2005) The EUNOMIA project on coercion in psychiatry: study design and preliminary data. World Psychiatr 4:168–172Google Scholar
  5. 5.
    Lay B, Kawohl W, Rössler W (2019) Predictors of compulsory re-admission to psychiatric inpatient care. Front Psychiatr 10:120. CrossRefGoogle Scholar
  6. 6.
    Sashidharan SP, Saraceno B (2017) Is psychiatry becoming more coercive? BMJ 357:j2904. CrossRefPubMedGoogle Scholar
  7. 7.
    Rodríguez-Jiménez J. UHB Map Project. III Jornada de Unidades de Hospitalización Breve. 2018. Valencia. Accessed 05 Jun 2019
  8. 8.
    Asociación Española de Neuropsiquiatría. Manifiesto de Cartagena. XXXVI Jornadas de la AEN. 2016. Cartagena. Accessed 28 May 2019
  9. 9.
    Comité Jurídico de Confederación SALUD MENTAL ESPAÑA (2018) Informe sobre el estado de los DERECHOS HUMANOS de las personas con trastorno mental en España 2017. Licencia de contenidos Creative Commons: Reconocimiento—No Comercial (by-nc), MadridGoogle Scholar
  10. 10.
    Mendez J (2013) Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment. United Nations: Human Rights Council, 22nd session. Accessed 01 Mar 2019
  11. 11.
    Zinkler M (2019) Supported decision making in the prevention of compulsory interventions in mental health care. Front Psychiatr 10:137. CrossRefGoogle Scholar
  12. 12.
    Metz MJ, Veerbeek MA, Twisk WR, van der Feltz-Cornelis CM, de Beurs E, Beekman AT (2019) Shared decision-making in mental health care using routine outcome monitoring: results of a cluster randomised-controlled trial. Soc Psychiatr Psychiatr Epidemiol 54:209–219. CrossRefGoogle Scholar
  13. 13.
    Metz MJ, Veerbeek MA, van der Feltz-Cornelis CM, de Beurs E, Beekman AT (2018) Decisional conflict in mental health care: a cross-sectional study. Soc Psychiatr Psychiatr Epidemiol 53:161–169. CrossRefGoogle Scholar
  14. 14.
    Valenti E, Banks C, Calcedo-Barba A, Bensimon CM, Hoffmann KM, Pelto-Piri V, Jurin T, Márquez-Mendoza O, Mundt AP, Rugkasa J, Tubini J, Priebe S (2015) Informal coercion in psychiatry: a focus group study of attitudes and experiences of mental health professionals in ten countries. Soc Psychiatr Psychiatr Epidemiol 50:1297–1308. CrossRefGoogle Scholar
  15. 15.
    de las Cuevas C, Peñate W, de Rivera L (2014) Psychiatric patients’ preferences and experiences in clinical decision-making: examining concordance and correlates of patients’ preferences. Patient Educ Couns 96:222–228. CrossRefGoogle Scholar
  16. 16.
    Morán-Sánchez I, Gómez-Vallés P, Bernal-López MA, Pérez-Cárceles MD (2019) Shared decision making in outpatients with mental disorders: patients’ preferences and associated factors. J Eval Clin Pract. CrossRefPubMedGoogle Scholar
  17. 17.
    Hamann J, Mendel R, Schebitz M, Reiter S, Búhner M, Cohen R, Berthele A, Kissling W (2010) Can psychiatrists and neurologists predict their patients’ participation preferences? J Nerv Ment Dis 198:309–311. CrossRefPubMedGoogle Scholar
  18. 18.
    Hamann J, Kohl S, McCabe R, Bühner M, Mendel R, Albus M (2016) What can patients do to facilitate shared decision making? A qualitative study of patients with depression or schizophrenia and psychiatrists. Soc Psychiatr Psychiatr Epidemiol 51:617–625. CrossRefGoogle Scholar
  19. 19.
    Sells D, Davidson L, Jewel C, Falzer P, Rowe M (2006) The treatment relationship in peer-based and regular case management for clients with severe mental illness. Psychiatr Serv 57:1179–1184CrossRefGoogle Scholar
  20. 20.
    Indu NV, Vidhukumar K, Sarma PS (2018) Determinants of compulsory admissions in a state psychiatric hospital–case control study. Asian J Psychiatr 35:141–145. CrossRefPubMedGoogle Scholar
  21. 21.
    Oliva F, Ostacoli L, Versino E, Portigliatti Pomeri A, Furlan PM, Carletto S, Picci RL (2019) Compulsory psychiatric admissions in an italian urban setting: are they actually compliant to the need for treatment criteria or arranged for dangerous not clinical condition? Front Psychiatr 9:740. CrossRefGoogle Scholar
  22. 22.
    American Psychiatric Association (2014) Diagnostic and statistical manual of mental disorders. American Psychiatric Publishing, WashingtonGoogle Scholar
  23. 23.
    Lobo A, Saz P, Marcos G, Día JL, de la Cámara C, Ventura T, Morales-Asín F, Fernando-Pascual L, Montañés JA, Aznar S (1999) Revalidation and standardization of the cognition mini-exam (first Spanish version of the Mini-Mental Status Examination) in the general geriatric population. Med Clin 112:767–774Google Scholar
  24. 24.
    Ventura MA, Green MF, Shaner A et al (1993) Training and quality assurance with the Brief Psychiatric Rating Scale: “The drift buster”. Int J Meth Psych Res 3:221–244Google Scholar
  25. 25.
    Degner LF, Sloan JA, Venkatesh P (1997) The control preferences scale. Can J Nurs Res 29:21–43PubMedGoogle Scholar
  26. 26.
    de las Cuevas C, Peñate W (2016) Validity of the control preferences scale in patients with emotional disorders. Patient Prefer Adher 10:2351–2356. CrossRefGoogle Scholar
  27. 27.
    de las Cuevas C, Peñate W, de Rivera L (2014) To what extent is treatment adherence of psychiatric patients influenced by their participation in shared decision making? Patient Prefer Adher 8:1547–1553. CrossRefGoogle Scholar
  28. 28.
    Ortega M, Cayuela A (2002) Regresión logística no condicionada y tamaño de muestra: una revisión bibliográfica. Rev Esp Salud Publica 76:85–93CrossRefGoogle Scholar
  29. 29.
    Perduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR (1996) A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 49:1373–1379CrossRefGoogle Scholar
  30. 30.
    Nuñez E, Steyerberg EW, Nuñez J (2011) Regression modeling strategies. Rev Esp Cardiol 64:501–507. CrossRefPubMedGoogle Scholar
  31. 31.
    Ford S, Schofield T, Hope T (2003) Are patients’ decision-making preferences being met? Health Expect 6:72–80CrossRefGoogle Scholar
  32. 32.
    Murray E, Pollack L, White M, Lo B (2007) Clinical decision-making: patients’ preferences and experiences. BMC Fam Pract 65:189–196. CrossRefGoogle Scholar
  33. 33.
    Stovell D, Morrison AP, Panayiotou M, Hutton P (2016) Shared treatment decision-making and empowerment-related outcomes in psychosis: systematic review and meta-analysis. Br J Psychiatr 209:23–28. CrossRefGoogle Scholar
  34. 34.
    Comitè de Bioètica de Catalunya (2017) El respeto a la voluntad de la persona con trastorno mental y/o adicción: documento de voluntades anticipadas y planificación de decisiones anticipadas. Accessed 02 Feb 2019
  35. 35.
    de las Cuevas C, Perestelo-Perez L, Rivero-Santana A, Cebolla-Martí A, Scholl I, Härter M (2014) Validation of the spanish version of the 9-item shared decision-making questionnaire. Health Expect 18:2143–2153. CrossRefGoogle Scholar
  36. 36.
    Farrelly S, Brown G, Rose D, Doherty E, Claire Henderson R, Birchwood M, Marshall M, Waheed W, Szmukler G, Thornicroft G (2014) What service users with psychotic disorders want in a mental health crisis or relapse: thematic analysis of joint crisis plans. Soc Psychiatr Psychiatr Epidemiol 49:1609–1617. CrossRefGoogle Scholar
  37. 37.
    Hamann J, Cohen R, Leucht S, Busch R, Kissling W (2005) Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatr 162:2382–2384. CrossRefPubMedGoogle Scholar
  38. 38.
    Hamann J, Mendel R, Cohen R, Heres S, Ziegler M, Buhner M, Kissling W (2009) Psychiatrists’ Use of shared decision making in the treatment of schizophrenia: patient characteristics and decision topics. Psychiatr Serv 60:1107–1112. CrossRefPubMedGoogle Scholar
  39. 39.
    Sweeney A, Gillard S, Wykes T, Rose D (2015) The role of fear in mental health service users’ experiences: a qualitative exploration. Soc Psychiatr Psychiatr Epidemiol 50:1079–1087. CrossRefGoogle Scholar
  40. 40.
    Wynn R (2018) Involuntary admission in Norwegian adult psychiatric hospitals: a systematic review. Int J Ment Health Syst 12:10. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Kasilova L, Raboch J, Sampogna G, Cihal L, Kallert TW, Onchev G, Karastergiou A, del Vecchio V, Kiejna A, Admowski T, Torres-Gonzales F, Cervilla JA, Priebe S, Giacco D, Kjellin L, Dembinskas A, Fiorillo A (2014) Do patients and ward-related characteristics influence the use of coercive measures? Results from the EUNOMIA international study. Soc Psychiatr Psychiatr Epidemiol 49:1619–1629. CrossRefGoogle Scholar
  42. 42.
    Myklebust LH, Sørgaard K, Røtvold K, Wynn R (2012) Factors of importance to involuntary admission. Nord J Psychiatr 66:178–182. CrossRefGoogle Scholar
  43. 43.
    Gabbard GO (1992) The therapeutic relationship in psychiatric hospital treatment. B Menninger Clin 56(1):4–19Google Scholar
  44. 44.
    Hill SA, Laugharne R (2006) Decision making and information seeking preferences among psychiatric patients. J Ment Health 15:75–84. CrossRefGoogle Scholar
  45. 45.
    Borry P, Schotsmans P, Dierickx K (2006) Evidence-based medicine and its role in ethical decision-making. J Eval Clin Pract 12:306–311. CrossRefPubMedGoogle Scholar
  46. 46.
    Brom L, Hopmans W, Pasman RW, Timmermans DR, Widdershoven GA, Onwuteaka-Philipsen BD (2014) Congruence between patients’ preferred and perceived participation in medical decision-making: a review of the literature. BMC Med Inform Decis Mak 14:1–16. CrossRefGoogle Scholar
  47. 47.
    de las Cuevas C, Rivero-Santana A, Perestelo-Perez L, Pérez-Ramos J, Serrano-Aguilar P (2012) Attitudes toward concordance in psychiatry: a comparative, cross-sectional study of psychiatric patients and mental health professionals. BMC Psychiatr 12:1–7. CrossRefGoogle Scholar
  48. 48.
    European Parliament and the Council of the European Union. Additional protocol to the convention on human rights and biomedicine concerning genetic testing for health purposes. 203. 2008. European Treaty Series. No. 203. Accessed 01 May 2019
  49. 49.
    United Nations. Committee on the rights of persons with disabilities. Eleventh Session. General comment No. 1. Article 12. (2014). Equal recognition before the law. Accessed 03 Feb 2019

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Mental Health CentreHealth Service of Murcia, CSM CartagenaMurciaSpain
  2. 2.Department of Legal and Forensic Medicine, Faculty of MedicineBiomedical Research Institute (IMIB), Regional Campus of International Excellence “Campus Mare Nostrum”, University of MurciaMurciaSpain

Personalised recommendations