Commitment decisions: identification of indeterminate cases

Research shows that most involuntary commitments conform to legal criteria and that psychiatrists generally agree on which patients should be committed. There are many cases, however, that cause disagreement among psychiatrists making commitment decisions. No research has been done regarding types of cases causing disagreement. The authors developed 10 clinical vignettes termed "ambiguous case constructs" that could be proven to be indeterminate and explore what underlying themes these indeterminate cases might hold in common. A pilot study was conducted to develop a set of 10 clinical vignettes, which were found to be representative of psychiatric emergencies and likely to cause discordance among evaluating psychiatrists. These validated vignettes were then presented to 62 psychiatrists who were asked to determine the commitment disposition for each vignette patient. Seven of these vignettes elicited significant disagreement among respondents and were identified as indeterminate cases. The frequency and percentage of psychiatrists endorsing commitment for each vignette is listed. This study validates the existence of indeterminate cases which prompt disagreement among psychiatrists making commitment decisions. Upon retrospective review, disagreement evoked by the seven indeterminate cases is proposed to have originated from one of four themes. The implications for clinical practice are noted.