Discharge against medical advice from inpatient psychiatric treatment: A literature review

Objective: A comprehensive review of the literature examined discharge from inpatient psychiatric settings against medical advice (excluding elopements) over the past 50 years. Specifically, definitions, prevalence, predictors, temporal patterns, consequences, and interventions pertaining to such discharge were explored. Methods: The authors searched the PubMed and PsycINFO databases and selected articles for review if studies had been conducted in an inpatient setting or included discharge against medical advice as one of the aims or results and if findings were based on formal statistical analyses. Results: Sixty-one articles met the selection criteria. Prevalence of discharge against medical advice ranged from 3 to 51 percent and increased over time. Discharge against medical advice was most commonly predicted by patient factors, such as young age; single marital status; male gender; comorbid diagnosis of personality or substance use disorders; pessimistic attitudes toward treatment; antisocial, aggressive, or disruptive behavior; and history of numerous hospitalizations ending in discharges against medical advice. It was also predicted by provider variables, such as failure to orient patients to hospitalization and failure to establish a supportive provider-patient relationship, and by temporal variables, such as evening and night shifts. Outcomes of patients discharged against medical advice were characterized by poor outcomes in several domains of functioning and more frequent rehospitalizations. Conclusions: Prediction of patients at risk of discharge against medical advice is possible with several defined variables. Awareness of the factors involved in discharge against medical advice should facilitate clinical decision making and the development of successful interventions for high-risk patients.