Social Psychiatry and Psychiatric Epidemiology

, Volume 48, Issue 11, pp 1787–1796 | Cite as

Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion

  • Susanne JaegerEmail author
  • Carmen Pfiffner
  • Prisca Weiser
  • Gerhard Längle
  • Daniela Croissant
  • Wiltrud Schepp
  • Reinhold Kilian
  • Thomas Becker
  • Gerhard Eschweiler
  • Tilman Steinert
Original Paper



The purpose of the study was to examine the long-term influence of involuntary hospitalization on medication adherence, engagement in out-patient treatment and perceived coercion to treatment participation.


In a naturalistic observational multi-centre study, 290 voluntarily and 84 involuntarily hospitalized patients with schizophrenia or schizoaffective disorder had been followed up over a period of 2 years with half-yearly assessments. Assessments included self-rated medication adherence, externally judged medication adherence by blood levels, engagement in treatment and perceived coercion. The statistical analyses were based on multilevel hierarchical modelling of longitudinal data. Level and development of the outcome was controlled for involuntariness, for sociodemographic characteristics and clinical history.


Involuntariness of the index-hospitalization did not have an effect on the development of treatment engagement or medication adherence judged by blood levels in the course of the follow-up period when the models were controlled for sociodemographic variables and clinical history. It was associated, though, with a continuously lower self-rated medication adherence. Moreover, former involuntarily hospitalized patients more often felt coerced in several treatment aspects at the follow-up assessments. Yet, there was no difference between the voluntary and involuntary group with regard to the development of the levels of adherence or coercion experiences over time.


Involuntary hospitalization does not seem to impair future treatment engagement in patients with schizophrenia, but formerly involuntarily hospitalized patients continue to be more sensitive to subjective or real coercion in their treatment and more vulnerable to medication non-adherence. Hereby, their risk of future involuntary hospitalization might be increased.


Involuntary hospitalization Adherence Treatment engagement Schizophrenia 



The ELAN study was funded as an investigator-initiated research project by a grant from AstraZeneca Deutschland to the University of Tübingen (Project Nr. 229/2004V—Version 2, 27.09.04). AstraZeneca had no role in the development of the research questions, the design of the study, the collection, analyses and interpretation of data, and the writing of the manuscript. AstraZeneca had the right to comment on the final draft of the article before the submission to the journal. We wish to thank all participants who participated in the study. We also thank Heike Wiesner, Filiz Özfirat, Tanja Gieselmann and Simone Triem for data collection and data entry and Ildiko Baumgartner for her work in processing data.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Steinert T, Lepping P (2009) Legal provisions and practice in the management of violent patients. A case vignette study in 16 European countries. Eur Psychiatry 24:135–141PubMedCrossRefGoogle Scholar
  2. 2.
    Zinkler M, Priebe S (2002) Detention of the mentally ill in Europe-a review. Acta Psychiatr Scand 106:3–8PubMedCrossRefGoogle Scholar
  3. 3.
    Salize HJ, Dressing H (2004) Epidemiology of involuntary placement of mentally ill people across the European Union. Br J Psychiatry 184:163–168PubMedCrossRefGoogle Scholar
  4. 4.
    Dressing H, Salize HJ (2004) Compulsory admission of mentally ill patients in European Union Member States. Soc Psychiatry Psychiatr Epidemiol 39:797–803PubMedGoogle Scholar
  5. 5.
    Sanguineti VR, Samuel SE, Schwartz SL, Robeson MR (1996) Retrospective study of 2,200 involuntary psychiatric admissions and readmissions. Am J Psychiatry 153:392–396PubMedGoogle Scholar
  6. 6.
    Bruns G (1991) Zwangseinweisungspatienten—eine psychiatrische Risikogruppe. Nervenarzt 62:308–312PubMedGoogle Scholar
  7. 7.
    Szmukler GI, Bird AS, Button EJ (1981) Compulsory admission in a London borough: I. Social and clinical features and a follow-up. Psychol Med 11:617–636PubMedCrossRefGoogle Scholar
  8. 8.
    McEvoy JP, Applebaum PS, Apperson J, Geller JL, Freter S (1989) Why must some schizophrenic patients be involuntarily committed? The role of insight. Compr Psychiatry 30:13–17PubMedCrossRefGoogle Scholar
  9. 9.
    Mohamed S, Rosenheck R, McEvoy J, Swartz M, Stroup S, Lieberman JA (2009) Cross-sectional and longitudinal relationships between insight and attitudes toward medication and clinical outcomes in chronic schizophrenia. Schizophrenia Bull 35:336–346CrossRefGoogle Scholar
  10. 10.
    Priebe S, Katsakou C, Amos T, Leese M, Morriss R, Rose D, Wykes T, Yeeles K (2009) Patients’ views and readmissions 1 year after involuntary hospitalisation. Br J Psychiatry 194:49–54PubMedCrossRefGoogle Scholar
  11. 11.
    O’Donoghue B, Lyne J, Hill M, Larkin C, Feeney L, O’Callaghan E (2010) Involuntary admission from the patients’ perspective. Soc Psychiatry Psychiatr Epidemiol 45:631–638PubMedCrossRefGoogle Scholar
  12. 12.
    Oluwatayo O, Gater R (2004) The role of engagement with services in compulsory admission of African/Caribbean patients. Soc Psychiatry Psychiatr Epidemiol 39:739–743PubMedCrossRefGoogle Scholar
  13. 13.
    Munk-Jørgensen P, Mortensen PB, Machón RA (1991) Hospitalization patterns in schizophrenia. A 13-year follow-up. Schizophr Res 4:1–9PubMedCrossRefGoogle Scholar
  14. 14.
    Fennig S, Rabinowitz J, Fennig S (1999) Involuntary first admission of patients with schizophrenia as a predictor of future admissions. Psychiatr Serv 50:1049–1052PubMedGoogle Scholar
  15. 15.
    Van der Post LF, Peen J, Visch I, Mulder CL, Beekman AT, Dekker JJ (2013) Patient perspectives and the risk of compulsory admission: the Amsterdam study of acute psychiatry V. Int J Soc Psychiatry. doi: 10.1177/0020764012470234 (epub ahead of print)Google Scholar
  16. 16.
    Viguera AC, Baldessarini RJ, Hegarty JD, van Kammen DP, Tohen M (1997) Clinical risk following abrupt and gradual withdrawal of maintenance neuroleptic treatment. Arch Gen Psychiatry 54:49–55PubMedCrossRefGoogle Scholar
  17. 17.
    Kallert TW, Glöckner M, Schützwohl M (2008) Involuntary vs. voluntary hospital admission. A systematic literature review on outcome diversity. Eur Arch Psychiatry Clin Neurosci 258:195–209PubMedCrossRefGoogle Scholar
  18. 18.
    Opjordsmoen S, Friis S, Melle I, Haahr U, Johannessen JO, Larsen TK, Røssberg JI, Rund BR, Simonsen E, Vaglum P, McGlashan TH (2010) A 2-year follow-up of involuntary admission’s influence upon adherence and outcome in first-episode psychosis. Acta Psychiatr Scand 121:371–376PubMedCrossRefGoogle Scholar
  19. 19.
    Kilian R, Steinert T, Schepp W, Weiser P, Jaeger S, Pfiffner C, Frasch K, Eschweiler GW, Messer T, Croissant D, Becker T, Längle G (2012) Effectiveness of antipsychotic maintenance therapy with quetiapine in comparison with risperidone and olanzapine in routine schizophrenia treatment: results of a prospective observational trial. Eur Arch Psychiatry Clin Neurosci 262:589–598PubMedCrossRefGoogle Scholar
  20. 20.
    Längle G, Steinert T, Weiser P, Bayer W, Jaeger S, Pfiffner C, Frasch K, Eschweiler G, Messer T, Croissant D, Becker T, Kilian R (2012) Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment. Acta Psychiatr Scand 125:372–381PubMedCrossRefGoogle Scholar
  21. 21.
    Frasch K, Weiser P, Becker T, Längle G, Steinert T, Niederreiner C, Pfiffner C, Jäger S, Bayer W, Eschweiler GW, Kilian R (2012) Psychotropic drug treatment, clinical characteristics and cognitive processing speed in patients with schizophrenia: results from the ELAN study. Pharmacopsychiatry 45:138–145PubMedCrossRefGoogle Scholar
  22. 22.
    Jaeger S, Pfiffner C, Weiser P, Kilian R, Becker T, Längle G, Eschweiler GW, Croissant D, Schepp W, Steinert T (2012) Adherence styles of schizophrenia patients identified by a latent class analysis of the Medication Adherence Rating Scale (MARS): a six-month follow-up study. Psychiatry Res 200:83–88PubMedCrossRefGoogle Scholar
  23. 23.
    Kay SR, Opler LA, Lindemeyer JP (1998) The Positive and Negative Syndrome Scale (PANSS): rationale and standardisation. Br J Psychiatry 155:59–65Google Scholar
  24. 24.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders. DSM-IV-TR. 4th Edition, Text revision. American Psychiatric Association, Washington, DCGoogle Scholar
  25. 25.
    Jaeger S, Gebhardt RP, Pfiffner C, Bayer W, Weiser P, Wiesner H, Steinert T (2009) Akzeptanz und Umsetzung von Empfehlungen zur Rückfallverhütung–Entwicklung der Compliance Selbst-Rating Instrumente CSRI-E und CSRI-K. In: Schneider F, Grözinger M (eds) Psychische Erkrankungen in der Lebensspanne–Abstractband zum DGPPN Kongress 2009 in Berlin. Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde, BerlinGoogle Scholar
  26. 26.
    Thompson K, Kulkarni J, Sergejew AA (2000) Reliability and validity of a new medication adherence rating scale (MARS) for the psychoses. Schizophr Res 42:241–247PubMedCrossRefGoogle Scholar
  27. 27.
    Muthén B, Asparouhov T (2011) Beyond multilevel regression modeling: Multilevel analysis in a general latent variable framework. In: Hox JJ, Roberts JK (eds) Handbook of advanced multilevel analysis. Taylor and Francis, New York, pp 15–40Google Scholar
  28. 28.
    Muthén LK, Muthen BO (1998–2010) Mplus user’s guide. Sixth edition. Muthén & Muthén, Los Angeles, CAGoogle Scholar
  29. 29.
    Pieters V (2003) Macht—Zwang—Sinn Subjektives Erleben, Behandlungsbewertungen und Therapieerfolge bei gerichtlichen Unterbringungen schizophrener Patienten. Psychiatrie-Verlag, BonnGoogle Scholar
  30. 30.
    Verdoux H, Lengronne J, Liraud F, Gonzales B, Assens F, Abalan F, van Os J (2000) Medication adherence in psychosis: predictors and impact on outcome. A 2-year follow-up of first-admitted subjects. Acta Psychiatr Scand 102:203–210PubMedCrossRefGoogle Scholar
  31. 31.
    Leung PK, Faulkner LR, McFarland BH, Riley C (1993) Indochinese patients in the civil commitment process. Bull Am Acad Psychiatry Law 21:81–89PubMedGoogle Scholar
  32. 32.
    De Haan L, van Amelsvoort T, Dingemans P, Linszen D (2007) Risk factors for medication non-adherence in patients with first episode schizophrenia and related disorders; a prospective 5 year follow-up. Pharmacopsychiatry 40:264–268PubMedCrossRefGoogle Scholar
  33. 33.
    Kortrijk HE, Staring AB, van Baars AW, Mulder CL (2010) Involuntary admission may support treatment outcome and motivation in patients receiving assertive community treatment. Soc Psychiatry Psychiatr Epidemiol 45:245–252PubMedCrossRefGoogle Scholar
  34. 34.
    Fialko L, Garety PA, Kuipers E, Dunn G, Bebbington PE, Fowler D, Freeman D (2008) A large-scale validation study of the medication adherence rating scale (MARS). Schizophr Res 100:53–59PubMedCrossRefGoogle Scholar
  35. 35.
    Byerly MJ, Thompson A, Carmody T, Bugno R, Erwin T, Kashner M, Rush AJ (2007) Validity of electronically monitored medication adherence and conventional adherence measures in schizophrenia. Psychiatr Serv 58:817–844CrossRefGoogle Scholar
  36. 36.
    Velligan DI, Lam YW, Glahn DC, Barrett JA, Maples NJ, Ereshefsky L, Miller AL (2006) Defining and assessing adherence to oral antipsychotics: a review of the literature. Schizophr Bull 32:724–742PubMedCrossRefGoogle Scholar
  37. 37.
    Wright EC (1993) Non-compliance–or how many aunts has Matilda? Lancet 342:909–913PubMedCrossRefGoogle Scholar
  38. 38.
    Fenton WS, Blyler CR, Heinssen RK (1997) Determinants of medication compliance in schizophrenia: empirical and clinical findings. Schizophr Bull 23:637–651PubMedCrossRefGoogle Scholar
  39. 39.
    Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV (2002) Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin Psychiatry 63:892–909PubMedCrossRefGoogle Scholar
  40. 40.
    Day JC (2003) How reflections on concordance in mental health can affect research and clinical practice in adherence. Pharm J 271:505–507Google Scholar
  41. 41.
    Fleischhacker WW, Oehl MA, Hummer M (2003) Factors influencing compliance in schizophrenia patients. J Clin Psychiatry 64(Suppl):S10–S13Google Scholar
  42. 42.
    Perkins DO (2002) Predictors of noncompliance in patients with schizophrenia. J Clin Psychiatry 63:1121–1128PubMedCrossRefGoogle Scholar
  43. 43.
    Acosta FJ, Hernández JL, Pereira J, Herrera J, Rodríguez CJ (2012) Medication adherence in schizophrenia. World J Psychiatr 2:74–82CrossRefGoogle Scholar
  44. 44.
    Krivoy A, Fischel T, Zahalka H, Shoval G, Weizman A, Valevski A (2012) Outcomes of compulsorily admitted schizophrenia patients who agreed or disagreed to prolong their hospitalization. Compr Psychiatry 53:995–999PubMedCrossRefGoogle Scholar
  45. 45.
    Nitzan U, Bukobza G, Aviram S, Fennig S, Lev-Ran S, Braw Y, Bloch Y (2013) Rebelliousness in patients suffering from schizophrenia-spectrum disorders. A possible predictor of attitudes towards medication. Psychiatry Res. doi: 10.1016/j.psychres.2012.12.028 (epub ahead of print)PubMedGoogle Scholar
  46. 46.
    Rain SD, Williams VF, Robbins PC, Monahan J, Steadman HJ, Vesselinov R (2003) Perceived coercion at hospital admission and adherence to mental health treatment after discharge. Psychiatr Serv 54:103–105PubMedCrossRefGoogle Scholar
  47. 47.
    Bindman J, Reid Y, Szmukler G, Tiller J, Thornicroft G, Leese M (2005) Perceived coercion at admission to psychiatric hospital and engagement with follow-up–a cohort study. Soc Psychiatry Psychiatr Epidemiol 40:160–166PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Susanne Jaeger
    • 1
    Email author
  • Carmen Pfiffner
    • 1
  • Prisca Weiser
    • 2
  • Gerhard Längle
    • 3
    • 4
  • Daniela Croissant
    • 4
  • Wiltrud Schepp
    • 5
  • Reinhold Kilian
    • 2
  • Thomas Becker
    • 2
  • Gerhard Eschweiler
    • 3
  • Tilman Steinert
    • 1
  1. 1.Department of Psychiatry and Psychotherapy IUlm UniversityRavensburgGermany
  2. 2.Department of Psychiatry and Psychotherapy IIUlm UniversityBKH GünzburgGermany
  3. 3.Department of Psychiatry and PsychotherapyUniversity of TübingenTübingenGermany
  4. 4.Zentrum für Psychiatrie SüdwürttembergKlinik für Psychiatrie und Psychotherapie ZwiefaltenZwiefaltenGermany
  5. 5.Department of Forensic Psychiatry and PsychotherapyBezirksklinikum RegensburgRegensburgGermany

Personalised recommendations