Threat to Self or Others among Involuntarily Hospitalized Patients in South Korea

Overview: Although South Korea requires a psychiatrically-driven threat to self or others to justify involuntary hospitalization, human rights advocates and witnesses suggests otherwise. This study examined whether persons with SMI hospitalized involuntarily had increased psychiatric crises, including threats to self or others, than those only voluntarily hospitalized or never hospitalized.Proposal text:

Background: Because of the possibility of violating human rights, involuntary hospitalization should not be the first choice of mental health care for persons with severe mental illness (SMI). It is only used in extraordinary circumstances, which are usually legally defined, and most countries, including South Korea, require a psychiatrically-driven threat to self or others to justify involuntary hospitalization. Involuntary hospitalized patients are more likely than voluntarily hospitalized patients to pose a threat to others in empirical studies largely undertaken in Western countries. This may not be the situation in South Korea, where many families are forced to hospitalize their loved ones due to a lack of community resources. There is insufficient empirical evidence to determine if involuntary hospitalization is being used notwithstanding the absence of a threat to self or others. This study examined whether persons with SMI hospitalized involuntarily in the previous 5 years had increased psychiatric crises, including threats to self or others, than those only voluntarily hospitalized or never hospitalized.

Methods: This study recruited 331 persons with SMI psychiatric rehabilitation agencies in South Korea. A survey was conducted either by a trained interviewer or self-administration. Eighteen psychiatric crises, including threats to self or others, were reported by respondents over the course of a year and those responses produced the following variables: 1) the total sum, 2) the total number of nonviolent crises, 3) suicidal ideation, 4) suicidal attempt, 5) verbal violence, and 6) physical violence. We compared four different types of hospitalization: 1) No hospitalization (71.3%), 2) Voluntary hospitalization only (8.2%), 3) Family or permission hospitalization (11.2%), and 4) Public entity hospitalization (9.4%). We used logistic regression analysis to compare the groups based on their 1-year psychiatric crisis experience.

Results: The majority of respondents were male (58.0%), had never married (76.7%), lived with others (59.5%), had a high school education (53.9%), were unemployed (61.3%), and had schizophrenia or schizo-affective disorder (73.5%). The four groups by hospitalization did not show difference as to the total sum of eighteen crises and the sum of twelve non-violent crises. Only suicidal attempt indicated a group difference in unadjusted analysis with a greater occurrence in the public entity hospitalization group (32.3%). When adjusted for demographic and clinical factors, the public entity hospitalization group was found to be more likely than the no hospitalization group to have attempted suicide (odds ratio [OR]=3.31; p=.017) and posed a threat to other (OR=3.14; p=.041). When compared to the no hospitalization group, the family or permission hospitalization group and the voluntary hospitalization group reported no difference in the chance of threatening self or others (p>.05).

Discussion: This study provides empirical evidence to determine if forcible hospitalization by family members is carried out in compliance with the legal requirement that threats to self or others be present at the time of admission. The findings add to the existing research, which does not adequately reflect the experiences of persons with SMI in non-Western countries. In the case of involuntary hospitalization started by family, better policy execution is required.