Innovative trial aims to curb involuntary hospitalizations

Every year in the U.S., more than 1 million people experiencing some form of mental health crisis are admitted to the hospital without their consent. These involuntary hospitalizations – also called 302s in Pennsylvania – are intended to keep patients and communities safe while providing medications or services that can foster stability. But these psychiatric holds are often associated with adverse outcomes, too: data shows that in the months and years after evaluation, the risk of violent crime charges, repeat hospitalization, and even death is high.

In Allegheny County, Pennsylvania, a county of about 1.2 million people, over 3,700 residents undergo involuntary hospitalization each year. To better serve residents with severe mental illness, the county determined it “wanted more answers” about the causal impacts of psychiatric holds, said Valentin Bolotnyy, an applied economist and Kleinheinz Fellow at Stanford University's Hoover Institution.

In response, Bolotnyy, who has researched the economic impacts of mental health in other communities, worked with a team to analyze the county’s uniquely in-depth data on involuntary hospitalizations and other public services. The adverse outcomes Bolotnyy and his co-authors Natalia Emanuel and Pim Welle identified, documented in a July working paper, “astonished us,” said Alex Jutca, a director at the county’s Department of Human Services.

Understanding the problem

Assessing the impact of involuntary hospitalizations on those who experience them was made possible thanks to Allegheny County’s approach to collecting data; the county has “probably the finest integrated data system in the country, among local governments,” according to Jutca.

Bolotnyy and his co-authors drew on data from the criminal justice system, unemployment insurance system, housing services, Medicaid, 302 system, and the medical examiner to get a much broader picture of the impacts of involuntary hospitalization than was previously possible.

Though involuntary hospitalization is intended to improve a patient’s outcomes – by connecting them with needed services, medications, and therapeutic support  the team’s analysis of Allegheny County’s data showed that hospitalizing people did not necessarily increase their use of continued care or continuation of prescribed medications.

The study focused on a subset of patients, about 43% of all evaluated patients, about whom doctors made a “judgment call” on commitment – as happens in the absence of clear, cut-and-dry instances of necessary hospitalization. In these cases, the data showed that hospitalization led to almost a doubling of the probability of the patient being charged with a violent crime or dying by suicide or overdose in the three months following commitment. The disruption effects of involuntary hospitalization, captured by the researchers in income and employment declines and increased homeless shelter usage, appeared to outweigh the benefits of the process for “judgment call” patients.

“There's a lot more that we could be doing to improve outcomes among this population, and it’s really a ripe area for innovation,” said Jutca, of the county’s involuntary hospitalizations.

Exploring alternative interventions

Now, with funding from Stanford Impact Labs, the research team has partnered with the University of Pittsburgh Medical Center, Pittsburgh Mercy, and the county to conduct a randomized controlled trial designed to reduce 302s in the first place through improved medication adherence. Specifically, the study will examine whether financial rewards – known to help those who are trying to reduce dependence on harmful and addictive substances – can improve medication adherence by encouraging people who are prescribed long-acting, injectable antipsychotic drugs to take them and return to clinics to re-up their medication.

Medications, while not without side effects, can help people with acute mental illness find stability in housing, employment, and other areas of life. That stability should make acute mental health crises, which may lead to involuntary hospitalizations, less likely to occur. In addition to reducing the pain and suffering that patients with severe mental illness and their families experience, the hope is that this intervention can also save society the significant costs that come with emergency care, mortality, and violent crime.

“Major health crises, including mental health crises, are very painful and costly to the individual, to their families, and to society at large,” said Bolotnyy. “Prevention is often less costly than a crisis moment, but what we have in growing numbers across the country is more and more of these kinds of crises.”

Allegheny County is focused not only on improving outcomes for patients, but also on effectively using its limited resources. “We have a real responsibility to make sure that we are maximizing the impact of the dollars that we spend,” said Jutca.

Investing in care

More than 60% of Allegheny County patients hospitalized without consent use an emergency room within a year, services that are considerably more expensive than preventative care. Despite being only 1.5% of the Medicaid population in the county and only 8% of those on Medicaid using behavioral health services, individuals who have been involuntarily hospitalized account for 23% of Medicaid spending on behavioral health services in the county, or over $65 million every year.

“From a social science and an economics perspective, what you want to do is figure out ways that policy can reduce pain and suffering, can help people lead the most fruitful, productive lives where they reach their full potential, and where society and taxpayer dollars don't have to be spent on these really costly interventions in emergency departments and hospitals in extreme circumstances,” said Bolotnyy.

The team expects to wrap up its randomized controlled trial by 2029. It’s the first in the U.S. that would offer financial rewards for adherence to long-acting injectables of anti-psychotic medications, and whether it succeeds remains to be seen. But similar techniques have been tested elsewhere: in one study in the U.K. and another in the Netherlands, financial rewards appeared to be an effective tool for maintaining medication adherence with long-acting injectables.

“We’re hoping that we can come out of this research with strong evidence as to whether medication adherence incentives are an effective tool,” said Jutca. “Were hopeful about both the possibility of setting a template that other jurisdictions can use, and the ways that data and problem identification then filter into a creative new solution.”