April 2023"Original Research: Trends in Involuntary Psychiatric Hospitalization in British Columbia:

Trends in Involuntary Psychiatric Hospitalization in British Columbia: Descriptive Analysis of Population-Based Linked Administrative Data from 2008 to 2018Tendances de l’hospitalisation psychiatrique involontaire en Colombie-Britannique : analyse descriptive des données administratives couplées basées sur la population de 2008 à 2018Jackson P. Loyal, MPH^1,2

, M. Ruth Lavergne, PhD³

, Mehdi Shirmaleki, MSc¹, Benedikt Fischer, PhD^4,5,6,7

, Ridhwana Kaoser, MPH¹, Jack Makolewksi, MSW, RSW¹ and Will Small, PhD^1,2img1

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie
2023, Vol. 68(4) 257‐268
© The Author(s) 2022img4

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DOI: 10.1177/07067437221128477
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AbstractIntroduction : Involuntary psychiatric hospitalization occurs when someone with a serious mental disorder requires treatment without their consent. Trends vary globally, and currently, there is limited data on involuntary hospitalization in Canada. We examine involuntary hospitalization trends in British Columbia, Canada, and describe the social and clinical characteristics of people ages 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018.
Method : We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender.Results : Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018. Apprehensions involving police increased from 3,502 to 8,009 (128.7%). Meanwhile, voluntary admissions remained relatively stable, with a minimal increase from 17,651 in 2008/2009 to 17,751 in 2017/2018 (0.5%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%), and substance use disorders (18.8%). From 2008/2009 to 2017/2018, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15–24 (162%) and men ages 15–34 (81%) and 85 and older (106%).Conclusion : Findings highlight the need to strengthen the voluntary care system for mental health and substance use, especially for younger adults, and people who use substances. They also signal a need for closer examination of the use of involuntary treatment for substance use disorders, as well as further research exploring forces driving police involvement and its implications. L’hospitalisation psychiatrique involontaire a lieu quand une personne souffrant d’un trouble mental grave demande un traitement sans son consentement. Les tendances varient de par le monde, et à l’heure actuelle, les données sur l’hospitalisation involontaire au Canada sont limitées. Nous examinons les tendances de l’hospitalisation involontaire en Colombie-Britannique, Canada, et décrivons les caractéristiques sociales et cliniques des personnes de 15 ans et plus qui ont été hospitalisées involontairement entre 2008/2009 et 2017/2018.Méthode : Nous avons utilisé les données administratives couplées basées sur la population pour examiner et comparer les tendances des hospitalisations volontaires et involontaires pour les troubles mentaux et d’utilisation de substances. Nous avons décrit les caractéristiques des patients (sexe/genre, âge, autorité de santé, revenu, urbanité/ruralité, et premier diagnostic) et suivi le compte de personnes hospitalisées involontairement avec le temps par diagnostic. Enfin, nous avons examiné la prévalence dans la population avec le temps selon l’âge et le sexe/genre.Résultats : Les hospitalisations involontaires chez les Britanno-Colombiens de 15 ans et plus sont passées de 14,195 à 23,531 (65,7%) entre 2008/2009 et 2017/2018. Les arrestations par la police se sont accrues de 3,502 à 8,009 (128,7%). Entre-temps, les hospitalisations volontaires sont demeurées relativement stables, avec un accroissement minimal de 17 651 en 2008/2009 à 17,751 en 2017/2018 (0,5%). Le diagnostic le plus fréquent pour les patients involontaires en 2017/2018 était les troubles de l’humeur (25,1%), suivis de la schizophrénie (22,3%), et des troubles d’utilisation de substances (18,8%). De 2008/2009 à 2017/2018, la plus grande augmentation a été observée pour les troubles d’utilisation de substances (139%). Avec le temps, la prévalence basée dans la population s’est accrue le plus rapidement chez les femmes de 15 à 24 ans (162%) et les hommes de 15 à 34 ans (81%) et de 85 ans et plus (106%).Conclusion : Les résultats soulignent le besoin de renforcer le système de soins volontaires pour la santé mentale et l’utilisation de substances, surtout pour les jeunes adultes, et les personnes qui utilisent des substances. Ils signalent aussi un besoin d’examiner de plus près le recours au traitement involontaire pour le trouble d’utilisation de substances, de même qu’une future recherche qui explorerait les forces derrière la participation de la police et ses implications.Keywords
involuntary hospitalization, coercive treatment, mental health, substance use, health administrative dataIntroductionInvoluntary hospitalization occurs when a person with a serious mental disorder is detained against their will in order to receive medical treatment and supervision. Globally, there is significant variation in trends in involuntary hospitalizations. Between 2008 and 2017, involuntary hospitalizations increased in 11 Western European countries, decreased in 4 Nordic countries, and remained relatively constant in New Zealand and Italy.¹ Meanwhile, involuntary hospitalizations were stable in Taiwan from 1998 to 2007.² Differences have also been observed within jurisdictions. In the United States between 2011 and 2018, increases were observed in 15 states while decreases were observed in 7 states.³ Differences in trends may be due to differences in demographics, economics, healthcare provision, and legal frameworks regarding involuntary hospitalization^1,4 and geographic variation of mental disorder prevalence.⁵While some factors are consistently associated with involuntary hospitalization across jurisdictions (e.g., psychotic disorder diagnosis),⁶ others may vary between countries. Male gender has been consistently associated with an increased risk of involuntary hospitalization,^6,7 however, others have observed increased risk in association with female gender.^8–10 Age has similar variability. Some have observed associations of increased risk of involuntary hospitalization with young age (generally <30),^8,11,12 middle age (30+),¹⁰ and old age (65+)¹² whereas others have seen no association.¹³ Low socioeconomic status has also correlated with involuntary hospitalization,⁶ but this has not been observed uniformly across settings.¹¹ Variations between jurisdictions highlight the need for targeted research to better understand involuntary hospitalization within specific regions and contexts for policy and service planning purposes, given that increased utilization can be interpreted as an indicator of service needs.Data on involuntary hospitalization in Canada is limited. The most recent national study examining involuntary hospitalization was conducted in the 1970s,¹⁴ while other studies have been limited to specific hospitals,^15,16 patient populations,¹⁷ and regions.¹¹ A recent study in Ontario observed an increase in involuntary hospitalization prevalence from 70.7% of psychiatric admissions in 2009 to 77.1% in 2013.¹¹ In British Columbia (BC), the number of involuntary hospitalizations increased 162% among children and youth between 2009 and 2018,¹⁸ and ∼71% across the whole population from 2006 to 2017.¹⁹ However, factors contributing to this growth, and whether this reflects an increase in psychiatric hospitalizations overall or a disproportionate change in involuntary admissions is not known. While BC reports have documented changes in involuntary hospitalization^18,19 and explored social and clinical characteristics of children and youth hospitalized involuntarily, research is still needed to understand trends among involuntarily hospitalized adults and factors shaping them. Our objective is to examine involuntary hospitalization trends in BC and describe the social and clinical characteristics of people aged 15 and older who were involuntarily hospitalized between 2008/2009 and 2017/2018.MethodsSettingBC is Canada’s westernmost province, with a population of roughly 5 million people in 2018.²⁰ Under the BC Mental Health Act (MHA), people may be involuntary hospitalized if they are assessed as having a serious mental disorder, and require treatment and supervision to protect them or others, or to prevent deterioration of their mental and/or physical health.²¹ Involuntary hospitalization for substance use may only occur in the presence of a concurrent mental disorder,¹⁸ however, some research suggests instances of involuntary hospitalization for substance use alone.^18,22,23 Section 28 of the BC MHA permits police to apprehend and take a person believed to have a mental disorder to a physician for examination.²¹ If deemed to require involuntary treatment, the physician completes a medical certificate (Form 4) which permits the patient to be admitted for up to 48 h. A second examination by another physician must be completed within this 48 h period to extend the involuntary admission up to 1 month (see Supplementary 1 for a breakdown of detention periods). Patients may request a review panel hearing to challenge their certification. When a patient is incapable of consenting to or otherwise refuses psychiatric treatment, the medical director of the psychiatric facility in which the patient is held consents on the patient’s behalf, which is unique to BC’s MHA.⁴Other Canadian MHAs are limited in scope compared to the BC MHA,⁴ however, BC is in the process of updating the MHA,²⁴ and recently considered amendments to the MHA in response to the ongoing illicit drug poisoning crisis. Bill 22 would have enabled physicians to involuntarily admit youth (<19) for up to 7 days following an overdose even in the absence of a mental disorder.²⁵ While Bill 22 has been dismissed, some stakeholders continue to call for the implementation of stabilization care for youth.²⁶Data SourcesWe used linked, de-identified health administrative data made accessible through Population Data BC. Details of the data linkage process are described elsewhere.²⁷ Data included hospitalization data from the Discharge Abstract Database²⁸ and demographic information from BC’s provincial health insurance plan, the Medical Services Plan.²⁹ Reporting of involuntary hospitalizations is mandatory in BC.³⁰Study PopulationWe included all people in BC ages 15 and older who were insured under BC’s Medical Service Plan, and were hospitalized between April 1, 2008, and March 31, 2018, with a discharge diagnosis for a mental or substance use disorder (diagnosis codes are listed in Supplementary 2) and/or had a record of involuntary admission. We excluded 11 records with missing information on age or sex/gender. Residents who were not eligible for coverage under the Medical Service Plan were excluded from our analysis.MeasuresHospitalizations. We defined voluntary psychiatric hospitalizations as a hospital admission with an associated discharge diagnosis code as listed in Supplementary 2. These codes were chosen to reflect conditions covered under the BC MHA. We defined involuntary psychiatric hospitalization as an admission under Form 4, “Medical Certificate (Involuntary Admission),” of the BC MHA. The presence of an MHIAPOLI flag indicated the person had been involuntarily admitted following apprehension by the police. Discharge diagnosis is based on the condition most responsible for hospital length of stay and may not be the mental disorder reflected on Form 4. As a result, some involuntary hospitalizations have non-mental disorders listed in the discharge diagnosis. The 10 most frequent non-mental disorders are listed in Supplementary 3.Characteristics. Age and sex/gender were obtained from BC’s Medical Service Plan registration file. We labelled this variable “sex/gender” because this is labelled “gender” on the registration form but only options for “M” and “F” are provided. Consequently, it is not possible to distinguish between sex at birth, legal sex, and gender. Health Authority was determined based on patient’s residential address, not where the hospitalization occurred. We used the Postal Code Conversion File Plus^31–33 to assign neighbourhood income quintile based on census enumeration area of residence (units with between 400 and 700 people). Urbanity/rurality was determined using Statistics Canada metropolitan influenced zones.³⁴ The primary diagnosis responsible for hospitalization was based on the diagnosis at discharge captured in the Discharge Abstract Database.AnalysisWe examined the total number of psychiatric hospitalizations as well as the number of individuals with psychiatric hospitalizations, stratified by involuntary and voluntary status from 2008/2009 to 2017/2018. We described the annual number of hospitalizations and individuals hospitalized subdivided by a grouping of mental and substance use disorders (MSUDs) based on discharge diagnosis and the proportion of all involuntary hospitalizations involving police apprehensions. We tracked the count of involuntary hospitalizations over time by discharge diagnosis. We reported annual counts and percentages to describe sociodemographic and clinical characteristics for all people who were involuntarily hospitalized and voluntarily hospitalized for MSUDs in 2017/2018. Finally, we examined population-based prevalence over time by strata based on age and sex/gender. This descriptive information was based on complete populationbased data capturing all hospitalizations, and so provides unbiased information on trends and patient characteristics.Ethics ApprovalThis study received harmonized ethics approval from the University of British Columbia, Providence Health Care Research Institute, and Simon Fraser University Research Ethics Board (REB number H17-00506).ResultsIn 2008/2009, involuntary hospitalizations accounted for 44.6% of all hospitalizations for MSUDs. By 2017/2018, this grew to 57.0%. Between 2008/2009 and 2017/2018, the population of BC grew 15.2% from approximately 4.3 million to 5 million people. Trends over time for hospitalizations are presented in Figure 1. Between 2008/2009 and 2017/2018, the number of involuntary hospitalizations among British Columbians ages 15 and older increased from 14,195 to 23,531 (65.7%), and those involving police apprehension increased from 3,502 to 8,009 (128.7%; Figure 1(a)). In the same period, voluntary admissions increased from 17,651 to 17,751 (0.5%; Figure 1(a)). When examining individuals, similar increases were observed for involuntary patients (66.8%) and patients apprehended by police (117.0%); however, the number of voluntary patients increased 16.0% (Figure 1(b)).In 2017/2018, 45.1% of involuntary patients and 49.3% of voluntary patients were female (Table 1). The majority (58.9%) of involuntary patients were between the ages of 15 and 44, while the age distribution was older for voluntary patients, in which the majority (63.0%) were people ages 45 and older. The distributions of involuntary and voluntary patients were similar across income quintiles. The greatest percentages of involuntary and voluntary patients were in Fraser Health (36.5% and 29.6%, respectively). Slightly higher percentages of involuntary patients (68.5%) resided in metropolitan areas compared with voluntary (54.3%). The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%) and substance use disorders (18.8%). For voluntary patients, the most common diagnoses were substance use disorders (33.7%), other mental disorders (33.5%), followed by mood disorders (20.3%). Although substance use disorders accounted for a large proportion of both voluntary and involuntary patients, when separating alcohol use disorder and other substance use disorders (which included cannabis, opioid, stimulant-related disorders, and other substance use/abuse), alcohol use disorder accounted for 22.1% of voluntary patients but only 6.7% of involuntary patients. Meanwhile, other substance use disorders accounted for 12.1% of involuntary patients and 11.6% of voluntary patients.Annual trends in primary diagnosis at discharge for involuntary hospitalization are presented in Figure 2, and population-based prevalence by age and sex/gender are presented in Figures 3 and 4. While the most common discharge diagnosis over time was schizophrenia, followed by mood disorders and substance use disorders, the greatest increase was observed for substance use disorders (139%). Over time, population-based prevalence increased most rapidly among women ages 15–24 (162%) and men ages 15–34 (81%) and 85 and older (106%).DiscussionOverall, involuntary hospitalizations among people ages 15 and older rose in BC, mirroring increases observed elsewhere in Canada,¹¹ and internationally.^1,3 While roughly half of the people hospitalized for MSUDs were admitted voluntarily in 2008/2009, by 2017/2018 this fell to approximately one-third. Over time, we observed the greatest increase in total hospitalizations related to substance use, and dramatic increases in involuntary hospitalizations of young adults, especially women ages 15–24. Meanwhile, police apprehensions also grew rapidly.Fig1There are several potential factors driving increasing involuntary hospitalizations. The observed increases may be indicative of structural limitations of the mental health care system to provide sufficient access to voluntary services. Between 2008/2009 and 2017/2018, we saw increases in both the number of involuntary hospitalizations and the number of individuals involuntarily hospitalized, demonstrating that increasing involuntary hospitalization was driven by both new patients and repeat admissions. Meanwhile, the number of voluntary hospitalizations was relatively stable while the number of voluntary patients increased. Increasing involuntary hospitalizations are concerning because previous involuntary hospitalization is associated with readmission, potentially because people delay or avoid seeking treatment due to fear of coercive treatment.³⁵ Our observations may indicate an increased reliance on involuntary treatment overall and may signal a need to strengthen the voluntary system of care. It may be that due to unmet care needs,^36,37 people are not receiving care until they are in crisis at which point they are involuntarily hospitalized. Decreasing availability of psychiatric treatment beds is one potential driver, given the association with involuntary hospitalization.^38,39 From 1988 to 2008, psychiatric treatment beds in the United Kingdom were halved, while involuntary hospitalizations rose 50%.³⁸ Deinstitutionalization saw the closure of psychiatric treatment beds throughout Canada.⁴⁰ In 2006/2007, there were 30 beds per 100,000 population in BC, and this dropped to 26 beds per 100,000 population in 2014/2015.⁴¹Tab1Primary and psychiatric care have been found to be protective against involuntary hospitalization,^11,42 but access is limited.⁴³ Roughly one million British Columbians are currently without a family physician,⁴⁴ and psychiatry and psychology services are not readily available.^45,46 Among British Columbians who had emergency department visits for an MSUDs in 2017/2018, ∼25% with a serious mental disorder, and 75% with a substance use disorder (of which over half had a concurrent mental disorder) had no psychiatry visits in the year preceding their emergency department visit.⁴⁷ Roughly 25% with a serious mental disorder, and with a substance use disorder also had no mental health-related primary care visits.⁴⁷ The expansion of community services may thus help reduce involuntary hospitalizations, while interventions such as assertive community treatment may help reduce psychiatric hospitalizations for people with high levels of hospital use.⁴⁸Fig2Increasing MSUD prevalence may also be contributing to rising involuntary hospitalizations. However, a recent systematic review found only a marginal increase in MSUD prevalence globally, potentially attributable to changing population demographics.⁴⁹ Although the review did not include studies on psychotic disorders, which has a well-established association with involuntary hospitalization,⁶ an older review found no evidence of an increase in psychotic disorder prevalence.⁵⁰ Moreover, if psychotic disorder prevalence was driving evident increases, we would reasonably expect a greater increase in involuntary admissions for schizophrenia than we observe in our data.Similar to Ontario,⁵¹ we observe increasing police apprehensions. Police contact is strongly associated with involuntary hospitalization,⁶ which may signal that police are connecting people with healthcare services rather than arresting them. However, this positions police as front-line mental health responders, which has been considered a misuse of police resources.⁵² Between 2009 and 2015, the number of police service calls involving people with severe mental illness increased by 9.7% per year in Fraser Health, which doubled the cost of police enforcement of the MHA.⁵³ This also represents an ethical issue, insofar as police involvement should not be a mediator of access to treatment.⁵³ In most instances police are not appropriately trained to respond to mental health crises,⁵⁴ though mental health training and education for police have been improving.⁵⁵ Additionally, apprehensions by police do not usually involve mental health professionals. Exceptions include designated services which pair police with a psychiatric nurse to attend to mental health emergency calls; however, these specialized services are only available in limited urban settings in BC.⁵⁶ Police apprehensions are often traumatic experiences that generate distrust and may discourage people from seeking care,^18,57 likely contributing to the poorer social and clinical outcomes observed among involuntarily hospitalized people.⁶ These encounters may even result in death. Between 2013 and 2017, there were 127 deaths in BC during or shortly after police–civilian encounters, of which more than two-thirds involved a mental health issue.⁵⁸ While police apprehensions play a role in connecting people to healthcare services, the potential for negative, sometimes fatal, encounters highlights the need to focus on minimizing police apprehension. Simultaneously, given increasing police involvement in mental health crises, efforts should also focus on expanding mental health crisis services, and better equipping police to handle mental health-related calls.Our data demonstrate that increased involuntary hospitalizations observed among children and youth (≤18) in BC¹⁸ extended into young adulthood. While this may be unsurprising given when many psychiatric disorders first present, precipitous increases among women ages 15 to 24 and men ages 15 to 34 are striking. An over two-fold increase among women ages 15 to 24 is unanticipated given that female gender is often associated with voluntary service use for MSUDs,³⁷ and male gender is a known factor associated with involuntary hospitalization in Euro-American countries.^6,42 These may signal that the current mental healthcare system is not adequately meeting the needs of young people in general, and young women in particular. Increases within younger cohorts are especially concerning as young people are less likely to request a review by a mental health review board.¹⁸ Youth have described involuntary hospitalization as traumatic, and dehumanizing punishment rather than therapeutic.^18,57 Even among involuntarily admitted youth who perceived benefits (e.g., greater family support) from their hospitalization, many reported reluctance to report suicidal thoughts to their care providers.⁵⁷ This points to a need for better oversight and support for children and youth in the context of involuntary admissions.¹⁸Fig3Fig4In 2017/2018, three-quarters of all hospitalizations for schizophrenia were involuntary, and this ratio remained consistent over time. While involuntary hospitalizations for schizophrenia are expected,⁶ consistent involuntary hospitalizations over time may signal a lack of effective interventions to reduce the involuntary treatment of schizophrenia. People with schizophrenia may be at increased risk of involuntary rehospitalization given the association between involuntary hospitalization and medication non-adherence.^59,60 It may be that involuntary admissions result in poor clinician–patient relationships,^18,57 which is associated with non-adherence.⁶⁰We observe increasing admissions for mood disorders among women, and substance use among men (Supplementary 4), reflecting consistently observed gendered prevalence of MSUDs.⁵ Substance use accounts for the greatest increase in involuntary hospitalizations over time, likely demonstrating that people with complex, concurrent disorders are increasingly affected,⁴² given admissions for substance use may only occur in the presence of a co-occurring mental disorder.¹⁸ However, some research suggests instances of involuntary hospitalization for substance use alone.^22,23 Thus, observed trends may also indicate cases of involuntary hospitalization of people with a primary substance use disorder, particularly among youth given documented involuntary admission of youth for stabilization care.¹⁸ Increases may be a consequence of the unmet need for people with substance use disorders,³⁶ and concurrent disorders,³⁷ such as limited access to treatment for medical and psychiatric comorbidities among people who use drugs.⁶¹ The illicit drug poisoning crisis in BC may also be contributing to growing involuntary hospitalizations for substance use. People with severe substance use disorders experience a high prevalence of concurrent mental disorders.⁶² In the presence of a comorbid mental disorder, repeated overdoses may be construed as imminent harm, which is grounds for involuntary hospitalization.²¹ Stimulants have been increasingly involved in illicit drug poisoning deaths⁶³ and stimulant use has become more common in BC.^64–66 Given the association between stimulant use and involuntary hospitalization,⁶⁷ growing use of stimulants may be contributing to the rise in involuntary hospitalizations for substance use.⁶⁷ Increasing admissions for substance use is concerning given the absence of treatment guidelines and legal frameworks surrounding involuntary treatment of substance use in BC,²² and the limited evidence of the benefits of involuntary care for substance use.⁶⁸ Indeed, people who use drugs and advocates have argued against involuntary care for substance use in BC, highlighting the need to enhance the voluntary systems of care and address structural and systemic issues that influence high-risk drug use, before expanding the scope of BC’s MHA, as was proposed with the introduction of Bill 22.^18,22,69Strengths and LimitationsWe comprehensively describe involuntary hospitalizations among British Columbians ages 15 and older, using province-wide population-based data. Our analysis is descriptive, so we cannot determine causal factors driving increasing involuntary hospitalizations, nor the impacts of involuntary hospitalization. Additionally, we cannot observe the impacts of racialization, nor sexual and gender identity in our data. Given observed associations between race/ethnicity and involuntary hospitalization,⁷⁰ the ability to understand how involuntary hospitalizations may be differentially impacting racialized communities is important. We cannot distinguish between sex at birth, legal sex, and gender. To match diagnostic codes, we used all involuntary admission codes as the best approximation for noninvoluntary admissions, rather than voluntary admission variables. However, we can only observe the diagnosis most responsible for the length of stay at the time of discharge, but not the diagnosis that was assessed in the context of certification. In some instances, this was not classified as a psychiatric disorder (e.g., poisonings), resulting in some differences between involuntary and voluntary hospitalizations. We cannot differentiate between substance use disorders except for alcohol because BC diagnostic codes do not include the fifth digit. Thus, we cannot observe involuntary hospitalization trends related to specific substance use disorders.ConclusionFrom 2008/2009 to 2017/2018, involuntary psychiatric hospitalizations among British Columbians ages 15 and older increased, and we observed the largest percentage change across time for substance use disorders. Meanwhile, voluntary hospitalizations remained relatively stable during this period. The greatest increases were observed among young adults, and police apprehensions also rose more than two-fold. Our observations highlight an urgent need to strengthen the voluntary system of care, especially regarding younger adults, and people who use substances. Additionally, our findings signal a need for legal provisions surrounding the involuntary treatment of substance use disorders, one which considers the experiences and perspectives of people who use substances and evidence of both harms and possible benefits of involuntary treatment for substance use. Increasing access to and capacity of community-based MSUD services may help prevent involuntary hospitalizations, and police apprehensions. However, the apparent inevitability of police involvement in mental health crises, and growing police apprehensions require an increased capacity for specialized services and improved police training for dealing with mental health crises. Further research exploring what is driving police involvement and its implications, and service use patterns and outcomes prior to and following involuntary hospitalizations, is warranted.Authors’ ContributionsAll authors approve this version of the paper and agree to act as guarantors of this research.Availability of Data and MaterialLinked, de-identified data holdings from the BC Ministry of Health linked and made accessible through Population Data BC were used for analysis. We are not permitted to share the research extract used in this analysis with other researchers, but all data are available through Population Data BC following submission of a data access request (https://www.popdata.bc.ca/data_access). All inferences, opinions, and conclusions drawn in this article are those of the authors and do not reflect the opinions or policies of the data stewards.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.FundingThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Michael Smith Foundation for Health Research, Canadian Institutes of Health Research (grant number 148170).ORCID iDsJackson P. Loyal

https://orcid.org/0000-0002-0397-4498M. Ruth Lavergne

https://orcid.org/0000-0002-4205-4600Benedikt Fischer

https://orcid.org/0000-0002-2186-4030Supplemental MaterialSupplemental material for this article is available online.References

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¹ Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada² BC Centre for Disease Control, Vancouver, British Columbia³ Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada⁴ Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada⁵ School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand⁶ Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada⁷ Department of Psychiatry, Federal University of Sao Paulo (UNIFESP), Sao Paulo, BrazilCorresponding author:
Will Small, PhD, Simon Fraser University, Faculty of Health Sciences, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, British Columbia, Canada V5A 1S6.
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