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— Pim Welle, Chief Data Scientist, Allegheny County Department of Human Services
In Pennsylvania, as in every state, there is a provision to involuntarily hold individuals experiencing a psychiatric episode in inpatient psychiatric care. Emergency department physicians determine whether the individual poses a danger to themselves or others due to mental illness, and individuals are then treated in an inpatient facility.
Across the country, it is estimated that about 1.2 million involuntary psychiatric hospitalizations occur every year. In Allegheny County (PA), involuntary hospitalizations affect over 3,700 individuals each year.
In 2023, Brocade partnered with the Allegheny County Department of Human Services to investigate the impacts of involuntary hospitalization in the region and found that individuals who are evaluated for involuntary hospitalization have elevated mortality risks upon release from the hospital. More recently, we collaborated on research that shows that, in cases where physicians may disagree as to whether hospitalization is needed (judgment call cases), involuntary hospitalization “nearly doubles both the probability of dying by suicide or overdose and also nearly doubles the probability of being charged with a violent crime in the three months after evaluation.”
Individual stories and qualitative research have shown that experiences with coercive, involuntary mental health treatment degrade trust in public institutions. In a PublicSource interview, a woman who experienced involuntary hospitalization shared that she feels “way less safe to be honest with people about where [her] mental health is. [1]” We’ve heard stories like this repeatedly in our research. A UN Human Rights Council report asserted that “coercion in psychiatry perpetuates power imbalances in care relationships, [and] causes mistrust, exacerbates stigma and discrimination and has made many turn away, fearful of seeking help within mainstream mental health services. [2]”
In 2023, Brocade partnered with the Allegheny County Department of Human Services to investigate the impacts of involuntary hospitalization in the region: “We find that individuals who are evaluated for hospitalization have elevated mortality risks upon release—within 5 years of their first evaluation, fully 20% of the population has died, a rate that is higher than that for clients exiting jail, enrolling in homeless shelters, or receiving food assistance (SNAP). [3]” This chilling result is largely consistent with research in other jurisdictions. [4]
Often, individuals leaving an involuntary stay in a psychiatric hospital are already involved in County services. Roughly 70% of Medicaid enrolled survivors of involuntary hospitalization had used behavioral health services in the year before their hospitalization. Roughly 50% did so in the month preceding their petition.
In Pennsylvania, the specific section of the law that governs the intake process of an individual who might be involuntarily hospitalized is Section 302, which is why the entire program is sometimes called the 302 program.
The figure on the left compares five-year mortality rates for people exiting a 302, compared to other populations in Allegheny County. The figure on the right shows mortality rates and cause of death in the five years after a person’s first involuntary hospitalization.
Since that time, we have continued to support research on the topic of involuntary hospitalization. Most recently we contributed to causal research into the long-term impacts of involuntary hospitalization on individuals in Allegheny County.
The key finding of this research is that in cases where physicians may disagree as to whether hospitalization is needed (judgment call cases), “hospitalization nearly doubles both the probability of dying by suicide or overdose and also nearly doubles the probability of being charged with a violent crime in the three months after evaluation. [5]”
The figure above shows rates of self harm among individuals who have been involuntarily hospitalized. “The Y-axis shows the share of people have died as a result of suicide or overdose. The ribbons indicate 95-percent confidence intervals based on standard errors clustered at the physician level.”
All of this raises a critical question—what to do next?
We are presently working with Allegheny County Department of Human Services to support a pilot of a step-down treatment approach for individuals with dual diagnosis who are exiting an involuntary stay in a psychiatric hospital.
The goal is to better support a cohort for whom the system is not working.
[1] Pittsburgh's Public Source, "Healing or dehumanizing: Experts explore the rise in ‘302’ involuntary psychiatric commitment petitions"
[2] UN Human Rights Council, "Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical
and mental health"
[3] Analysis of Allegheny County’s Involuntary Hospitalization (302) Program
[4] Harvard Review of Psychiatry, "Suicidal Risk Following Hospital Discharge: A Review"
[5] Federal Reserve Bank of New York Staff Reports, "A Danger to Self and Others: Health and Criminal Consequences of Involuntary Hospitalization"
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