Sudden perturbations in the labor market may reduce tolerance of deviant/disordered behaviors in a population. Evidence of increase in involuntary psychiatric commitments during macroeconomic downturns in the US supports this notion.[12] In some cases, research also reports selective rise in involuntary psychiatric commitments among certain minority groups, aligning with expectations from the frustration-aggression-displacement hypothesis.[7] In the present study, we examined whether this relation holds for the Danish population using aggregated, quarterly time-series data on involuntary psychiatric commitments in the overall population and among Danes (excluding non-western immigrants) and non-western immigrants in Denmark. Results from time-series ARIMA analyses indicate an increase in involuntary psychiatric commitments in the overall Danish population one month following rise in unemployed persons (in thousands), with a pronounced increase among non-western immigrants but not among Danes. Our estimates suggest 31 additional involuntary commitments in the overall population, and 14 additional commitments among non-western immigrants following every 100,000 increase in number of unemployed persons in Denmark. Application of the base incidence (quarterly mean) of involuntary commitments and the standard deviation of unemployment (28.8) to our discovered coefficients yields a 6.8% [=(31/392)*((28.8*3)/100))] increase in involuntary commitments in the general Danish population and a 26.9% [=(14/45) *((28.8*3)/100))] increase among non-western immigrants one quarter after an extreme increase in unemployed persons by 3 standard deviations. These results support population-level expectations from reduced tolerance as well as frustration-aggression-displacement hypotheses during periods of macroeconomic contractions.
Strengths of our study include the use of high quality, register-based data that provide fine temporal resolution. Time-series ARIMA analyses account for seasonality, secular trends and temporal dependence in the outcome variables. We establish temporal order in that the exposure precedes the outcome, which reduces potential endogeneity from reverse causation. Our sensitivity tests rule out rival explanations in that variations in the volume of voluntary psychiatric inpatient admissions do not fully account for increased involuntary psychiatric commitments following economic downturns.
To our knowledge, this is the first study that jointly examines reduced tolerance and frustration-aggression hypotheses in a large population and accounts for simultaneous patterning of voluntary psychiatric patient volume. Our study not only offers greater methodological rigor relative to prior studies in this domain, but also lends external validity to findings from the US, suggesting that the phenomena of reduced tolerance and frustration-aggression-displacement during economic downturns may operate similarly across varied populations.
Limitations include that, as with most observational studies, we cannot rule out residual confounding from unmeasured factors. Such a factor would (1) correlate positively with unemployment but not be caused by it, (2) vary positively with involuntary psychiatric commitments, (3) not be accounted for by autocorrelation parameters included in our analyses, and (4) exhibit precisely timed association with the outcome at quarterly lag 1 but not at lag 0. We know of no such factor. High unemployment may correspond with negative income shocks and reduced access to psychiatric care that in turn, may correspond with higher volume of psychiatric patients among vulnerable communities. However, given our observation of selective increases in involuntary commitments among non-western immigrants, beyond parallel changes in voluntary admissions, we contend that the phenomenon of frustration-aggression-displacement offers a parsimonious explanation for our pattern of results. Other limitations include that whereas men typically show greater labor market attachment and comprise a larger share of involuntary psychiatric commitments, we do not examine sex-specific responses to unemployment owing to limitations in data availability.[43] We encourage future research to examine sex-based differences in involuntary commitments following economic contractions once these data become available.
We also do not examine clinical diagnoses underlying involuntary psychiatric commitments. These commitments may correspond with determination of violent and uncooperative traits as qualifying criteria for coercive treatment.[44] Research shows that individuals with psychosis-spectrum disorders present as a high-risk group for coercive treatment.[43] However, the clinical diagnosis of psychosis may suffer from subjective and structural bias.[45] For instance, cultural and language discordance between a diagnostician and a patient may lead to erroneous diagnosis and stricter treatment recommendations than medically warranted.[46, 47] In some cases, patients from certain sub-groups may be involuntarily committed at higher rates than their majority counterparts, despite higher cognitive functioning scores among the former.[7] In such circumstance, a potential confirmation of the reduced tolerance hypothesis would involve examination of diagnoses underlying excess involuntary psychiatric commitments following increased unemployment where one would expect an average decline in illness severity (based on diagnosis, length of inpatient stay or cognitive functioning scores). If this hypothesized relation between lower average severity of illness among involuntarily committed persons following ambient shocks does not hold, we contend that the reduced tolerance phenomena may correspond with higher rates of true discovery of mentally disordered persons who need compulsory treatment rather than (reduced tolerance-induced) over-reporting of relatively benign deviant behaviors.
We find that involuntary psychiatric commitments among non-western immigrants increase at disproportionately higher rates relative to Danes following ambient economic contractions. This observation aligns with evidence of frustration-aggression-displacement during economic recessions in the US.[7] It is plausible that macroeconomic downturns induce inhibitive behaviors in this sub-group, leading to lower healthcare utilization during economic downturns that, in turn, may exacerbate mental illness.[23, 24] National responses to economic downturns often coincide with stricter immigration policies to reduce local labor market competition, which may also increase psychiatric symptoms among non-western immigrants.[25, 26] We encourage future research to examine whether and to what extent health care utilization and immigration policies interact with macro-economic indicators in relation to involuntary psychiatric commitments among minority groups.
Involuntary psychiatric commitments among non-western immigrants and other vulnerable sub-groups (e.g. Muslims and other minorities) may also increase during periods of social unrest. Evidence from the US indicates that racially-targeted police brutality and corrosive political rhetoric may portend adverse psychiatric consequences among historically marginalized groups.[48, 49] Research also reports higher involuntary psychiatric holds immediately following terrorist attacks in the US.[11] Given recent political debates in Denmark on stricter immigration regulation[25–27], social unrest following anti-Islam protests[50], as well as Denmark’s proximity to terrorist attacks in Western Europe[51], we encourage future research to examine these sociopolitical and macrosocial stressors in relation to changes in involuntary psychiatric commitments among targeted sub-groups and the general population.
At the policy level, identification of population-level antecedents of increase in involuntary psychiatric commitments holds financial implications for national health systems.[6] Whereas these commitments occur at relatively lower frequencies compared to routine psychiatric visits or admissions, they impose substantially higher costs on both patients as well as providers. Involuntary commitments, on average, can last almost twice as long as other inpatient stays, with cost of care exceeding five times that of other psychiatric patients.[1, 52, 53] Denmark, akin to trends in other Western countries, has undergone rapid de-institutionalization, and involuntarily committed patients overwhelmingly occupy the limited number of inpatient psychiatric beds currently available to the Danish population.[54] We encourage future research to build upon the present study and conduct costing exercises to determine excess expenditure on potentially preventable (or unnecessary) involuntary commitments during economic contractions.