Do Involuntary (vs. Voluntary) Patients Have Higher Severity or Less Improvement?


Do Involuntary (vs. Voluntary) Patients Have Higher Severity or Less Improvement?
December 29, 2023 MHO

While deemed necessary in crisis situations, the debate continues whether involuntary admission may negatively influence clinical outcomes. Previous research indicates involuntary patients have higher clinical severity at admission, including overall symptom severity, suicidal risk, and lower levels of social functioning[1],[2],[3].  Research on the impact of involuntary admission in treatment outcomes is inconclusive. Some studies report no difference in improvement between voluntary and involuntary patients3,[4].  Other studies showed that coercing patients into hospitalization can have a negative effect in the experience of treatment[5], thus it is likely that involuntary patients can sometimes benefit less from treatment.

To explore these ideas, we examined the impact of admission status – voluntary vs. involuntary admission – on symptom severity upon admission and patient outcomes at the end of treatment.  Specifically, do involuntary (vs. voluntary) patients have higher clinical severity, or lower rates of improvement?


Our dataset contained a total of 345,881 admissions from adult inpatient stays to 116 facilities in 38 states and 1 U.S. territory August 1, 2022, or later.  Ten facilities and their admissions were excluded due to more than half of each facility’s admissions having an unknown voluntary/involuntary status in our database. Of the remaining facilities, 99.6% of the 345,881 admissions had voluntary status data.

Rates of Involuntary Admission

Overall, 48.1% of inpatient admissions were involuntary, and these rates varied by state (Figure 1). This is to be expected, though, given U.S. states differ in their legal criteria for involuntary admissions. Our data are somewhat limited, however, in that over half of states in our data are represented by no more than 3 facilities.



Symptom Severity and Clinical Outcomes

To analyze MHO’s data on admission severity, discharge severity, and admission-to-discharge Statistically Meaningful Improvement (SMI)[6], we examined scores on three clinical measures: self-report patient functioning (BASIS-32[7]; n = 115,582), clinician-reported psychiatric symptoms (BPRS[8]; n = 9,936), and self-report depression (PHQ-9[9]; n = 86,876) where some patients contributed data to more than one measure.

Within our sample, involuntary patients were less likely to complete admission assessments (49.9% vs. 57%), thus were more likely to be excluded from the clinical severity and improvement analyses.  As a result, involuntary patients in our sample may not necessarily be representative of the greater population.  Future analyses should explore these, and additional, factors for better clarity.

Upon admission, patient functioning and psychiatric symptoms did not meaningfully differ by voluntary status. However, a moderate difference was observed in depression symptom severity, with involuntary patients showing less severity. Upon discharge, there was not a meaningful difference in patient functioning, but voluntary (vs. involuntary) patients had slightly higher depression severity and moderately higher psychiatric symptom severity. In terms of admission-to-discharge improvement, patient functioning improved similarly for voluntary and involuntary patients. Notably, patients with a voluntary admission showed slightly more improvement in depression symptoms, but slightly less improvement in psychiatric symptoms.

Concluding Words

Our data suggest that, upon admission, involuntary patients may face similar challenges in overall functioning and exhibit similar psychiatric severity levels, but likely experience less severe depression symptoms compared to voluntary patients. The difference in severity, however, may be in specific symptoms rather than overall severity. For example, involuntary patients may have higher disorientation, suicidal ideation, or homicidal ideation. As mentioned earlier, involuntary patients were less likely to complete admission assessments in our sample. It is possible that more severe involuntary patients are unwilling, or unable, to complete admission assessments, which would suppress the average clinical severity for involuntary patients. Importantly, all patients, regardless of admission status, demonstrated the potential for improvement during treatment.



[1] Kallert, T.W., Glöckner, M. & Schützwohl, M. (2008). Involuntary vs. voluntary hospital admission. European Archives of Psychiatry and Clinical Neuroscience, 258, 195–209.

[2] So, P., Wierdsma, A.I., Kasius, M.C. et al. (2021). Predictors of voluntary and compulsory admissions after psychiatric emergency consultation in youth. European Child and Adolescent Psychiatry, 30, 747–756.

[3] Castelpietra G, Guadagno S, Pischiutta L, et al. (2022). Are patients improving during and after a psychiatric hospitalisation? Continuity of care outcomes of compulsory and voluntary admissions to an Italian psychiatric ward. Journal of Public Health Research, 1, 2382.

[4] Drakonakis, N., Stylianidis, S., Peppou, L.E. et al. (2022). Outcome of voluntary vs involuntary admissions in Greece over 2 years after discharge: A cohort study in the psychiatric hospital of Attica “Dafni”. Community Mental Health Journal58, 633–644.

[5] Silva, B., Bachelard, M., Amoussou, et al. (2023). Feeling coerced during voluntary and involuntary psychiatric hospitalisation: A review and meta-aggregation of qualitative studies. Heliyon, 9.

[6] Note: SMI refers to a metric used to determine the degree of statistical change from admission to discharge.  Based on the amount of change, patients are categorized into one of five SMI categories: Large improvement, small improvement, no effect, small decline, or large decline.

[7] BASIS-32: The Behavior and Symptom Identification Scale is a self-report measure of a patient’s functioning, rated on a scale of 0 ‘no difficulties’ to 4 ‘extreme difficulties’. BASIS-32 © Mclean Hospital, used by licensee with permission from Mclean Hospital.

[8] BPRS: The Brief Psychiatric Rating Scale (BPRS) is an 18-item clinician’s rating of a patient’s functioning and symptoms obtained through a structured interview conducted with the patient. The BPRS is scored on a scale of 0 to 108, where higher scores indicate greater severity.  Developed by J.E. Overall and D.R. Gorham.

[9] PHQ-9: The Patient Health Questionnaire is a self-report measure of a patient’s depression, rated on a Scale of 0 ‘Not at all’ to 3 ‘Nearly every day’. Developed by Drs. Robert L. Spitzer, Janet B. W. Wiliams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.