Research Article,  Int J Ment Health Psychiatry Vol: 11 Issue: 2

Stress and Trauma Symptoms Associated with Psychiatric Hospitalization in Canada

Adam Neufeld^1*, Nnamdi Nkire², Nneka Orakwue-Ononye³, Hajin Lee⁴, Obianuju Unaigwe¹, Anuja Ashok³, Lawrence Onwuegbuchunam³, Agu Chukwuebuka³ and Izu Nwachukwu^2,3

¹Department of Family Medicine, University of Calgary, Cumming School of Medicine, Calgary, AB, Canada

²Department of Psychiatry, University of Alberta, Edmonton, AB, Canada

³Department of Psychiatry, University of Calgary, Calgary, AB, Canada; 4Women’s College Hospital, Toronto, ON, Canada

*Corresponding Author: Adam Neufeld
Department of Family Medicine, University
of Calgary, Cumming School of Medicine, Calgary, AB, Canada
E-mail: adam.neufeld@ucalgary.ca

Received date: 25 May, 2025, Manuscript No. IJMHP-25-166061; Editor assigned date: 27 May, 2025, PreQC No. IJMHP-25-166061 (PQ); Reviewed date: 10 June, 2025, QC No. IJMHP-25-166061; Revised date: 17 June, 2025, Manuscript No. IJMHP-25-166061 (R); Published date: 24 June, 2025, DOI: 10.4172/2471-4372.1000286.

Citation: Neufeld A, Nkire N, Ononye ON, Lee H, Unaigwe O, et al. (2025) Stress and Trauma Symptoms Associated with Psychiatric Hospitalization in Canada.11:286.

Abstract

Keywords: Psychiatric; Protein; Trauma; Stress; ANOVA; Healthcare

Introduction

Psychiatric hospitalization is a significant life event that can have profound psychological impacts on patients, particularly when treatment is involuntary [1]. While mental health treatment is essential for managing psychiatric conditions, the process of hospitalization itself can introduce stress and trauma [2,3,4]. This trauma may arise from factors such as coercion, loss of autonomy, mistreatment, and the use of restraints or seclusion [5]. Though much of the existing research focuses on involuntary admission, the scope of iatrogenic trauma extends beyond this, with additional factors like hospitalization length, hospital environment, and the implementation of control measures contributing to the psychological impact on patients.

The stress and trauma associated with psychiatric hospitalization are significant yet underexplored issues. While previous studies have highlighted the detrimental effects of coercive treatment, there is limited understanding of how various factors—such as involuntary versus voluntary admissions, the use of restraints, and the potential for racial or ethnic disparities—interact to affect patient outcomes. Existing literature often fails to differentiate between trauma resulting from hospitalization itself and pre-existing trauma conditions [6], leaving important gaps in our understanding of the full range of factors that contribute to hospital-induced trauma [7].

This study aims to fill these gaps by examining the iatrogenic effects of psychiatric hospitalization from a Canadian perspective. By considering a range of factors—including voluntary and involuntary admissions, the length of hospitalization, the use of control measures like seclusion and restraints, and potential racial/ethnic disparities—this research will offer valuable insights into the broader landscape of trauma experienced by patients in psychiatric care. The findings aim to inform the development of trauma-informed care policies, ensuring that psychiatric hospitals provide more compassionate and effective treatment for patients, families, healthcare staff, and the broader community.

We hypothesize that the frequency of occurrence of reported stress and trauma symptoms will be higher in patients who receive involuntary treatment compared with those whose admission and treatment were on a voluntary basis. We also expect that length of hospitalization will positively correlate with experiences of control measures (e.g., seclusion, high observation, physical and chemical restraint) and reports of patient abuse (physical, emotional, verbal, and sexual), which will each be positively related to stress and trauma symptoms. Finally, we expect that racial/ethnic disparities may exist in the acute psychiatric hospital admission process, which could predispose certain populations to being more vulnerable to stress and trauma [8].

Methods

Setting

The organization operates four hospitals within a single region, each with two units dedicated to admitting adults requiring urgent psychiatric treatment. Admissions are centralized through Emergency Departments, with patients assigned to the next available bed across the city. Although each hospital site and psychiatric admission unit maintains distinct characteristics, the zonal administration has made consistent efforts to harmonize care processes, therapeutic approaches, and overall patient experience across sites.

Study Design

This study employed an observational, cross-sectional survey design with convenience sampling. All adult patients admitted to acute psychiatric units over a 4-month study period were invited to participate. Exclusion criteria included declining consent, lack of capacity to consent, or illness-related restrictions. No initial chart review was required. Research assistants consulted care teams to evaluate consent and capacity. Patients deemed incapable of making treatment decisions remained eligible if their legally authorized Decision Maker consented and guided participation. Eligible participants completed an anonymous online survey via tablet. The survey contained three validated scales and basic demographic and clinical history questions. No personal identifiers were collected (see Measures).

Outcome Measures

The primary outcome measure was the incidence of stress and trauma symptoms arising in relation to the experience of acute psychiatric hospitalizations in {removed for anonymity} hospitals. The secondary outcome measure examined demographic effects on stress and trauma symptoms in acute psychiatric settings, particularly regarding voluntary vs involuntary treatment in hospital..

Participants

The sample included 157 participants; however, some did not complete all survey items. Analyses used the available data without case omission or missing-value replacement. In total, 139 participants completed demographic questions. The mean age was 40.7 years (SD = 15.1; range 18–70). For detailed sample characteristics, see Tables 1 and 2 in Appendix A.

Measures

Demographics: Eight items assessed background information, including age, gender, marital status, educational background, employment status, country of birth, most commonly used language, and annual income. Open-ended responses were permitted where applicable.

Clinical history/status: Eleven items assessed psychiatric history, clinical status, and experiences during the current admission. These included previous diagnoses, legal status at admission and currently, involvement of police/security, previous admissions (voluntary vs. involuntary), admission length, experiences of control measures (e.g., seclusion, restraint), exposure to abuse types, witnessing aggression or harassment, and restrictions on passes/privileges. Most were answered “Yes,” “No,” or “Prefer not to answer.”

Stress: The Perceived Stress Scale (PSS-10) [9] measured psychological responses to external stressors. Participants rated frequency of stressful thoughts/feelings during admission (0 = never to 4 = very often). Example: “How often have you felt nervous and stressed during this hospital admission?” Item analysis indicated six poorly performing items; removing them improved reliability to α = .82. Analyses used the 4-item scale, with higher scores reflecting higher perceived stress.

Trauma: The Impact of Events Scale (IES-6) [10] measured trauma-related distress (intrusion, avoidance). Participants rated distress (0 = not at all to 4 = extremely) in relation to their current admission over the past 7 days. Example items: “I tried not to think about it”; “I felt watchful on guard.” Reliability was excellent (α = .90). Higher scores reflected greater trauma symptoms.

Satisfaction: The Verona Service Satisfaction Scale (VSSS) [11] assessed satisfaction with care, environment, and provider relationships (1 = very dissatisfied to 5 = very satisfied). Adapted for this study, two poorly performing items were removed, improving reliability to α = .92. Analyses used the 4-item version, with higher scores indicating greater satisfaction with healthcare..

Data Analysis

REDCap and SPSS were used for survey and statistical analyses. Data were checked for outliers, and none were found. Descriptive statistics and Cronbach’s alpha values were calculated for demographic and study variables (perceived stress, trauma, and satisfaction). Variables were standardized, and normality and linearity were confirmed using histograms. Multicollinearity was assessed with Variance Inflation Factor (VIF) and tolerance values. Associations between variables were analyzed using point-biserial correlations for dichotomous and continuous variables, ANOVA for categorical and continuous variables, and ANCOVA to assess categorical effects on continuous outcomes, controlling for covariates. Levene’s test for homogeneity of variance was checked for between-group comparisons, with Tukey’s post hoc tests for pairwise comparisons.

For between-group comparisons, some variables (e.g., education, income, marital status, ethnicity) were re-coded into fewer categories to increase statistical power. Similarly, diagnoses with small sample sizes (e.g., anxiety disorder) were grouped into broader categories (e.g., mood disorder). Variables with “Yes,” “No,” and “Unsure” options (e.g., voluntary/involuntary admission) were assessed with ANOVA, provided group sizes were sufficient. If response categories (e.g., “unsure” or “prefer not to answer”) had too few responses, they were excluded, and point-biserial correlations were used instead. Tables 1 and 2 in Appendix A provide the original categories and recoding details.

Notes: Admission length, duration of admission in days; Phys Restraint, physical restraint; Chem Restraint, chemical restraint; Pass Denial, denial of privileges/passes or time off unit; High Observe, high observation; 1:1 Nursing, one on one nursing care; Phys Aggress, experiencing physical aggression; Verb Aggress, experiencing verbal aggression; Sex Harass, experiencing sexual harassment; Emot Abuse, experiencing emotional abuse or neglect; Witness Abuse, witnessing physical, emotional, verbal, or sexual abuse towards others; Stress, perceived stress; Trauma, trauma symptoms; Satisfaction, level of satisfaction with healthcare. * p < .05 and ** p < .01 level (two tailed)

Table 1: Intercorrelations between the study variables.

Table 2: Descriptive Statistics for Stress by Demographic.

Results

Descriptives

In total, there were 137 participants that completed the PSS, 133 that completed the IES, and 140 that completed the VSS.

Stress: The mean score for perceived stress during psychiatric hospital admission was M=2.09 (SD=.99) with scores ranging from 0 (“never”) to the maximum of 4 (“very often”). This corresponds to a total mean score of 8.37 (SD=3.96), which according to the PSS represents a relatively low degree of stress.

Trauma: The mean score for trauma symptoms during psychiatric hospital admission was M=1.81 (SD=1.13), with scores ranging from 0 (no symptoms) to 4 (the maximum amount). This average suggests that, overall, there was a moderate degree of trauma symptoms within the sample. With respect to incidence of trauma symptoms, the literature recommends a 1.75 cutoff score [12], which 71/133 participants met. Thus, the incidence of trauma in the sample was 53.4%.

Satisfaction: The mean score for satisfaction with the care/service patients received was M=3.79 (SD=.1.04) with a range score of 1 (the minimum; very dissatisfied) to 5 (the maximum; very satisfied). In the literature, patients are considered dissatisfied when their mean score falls below 3.5 [13]. The average in our study thus suggests that, overall, the level of satisfaction with the psychiatric healthcare team was relatively high.

Variable relationships

As seen in Table 1, length of admission positively correlated with physical and chemical restraint and experiencing physical aggression as well as negatively correlated with healthcare satisfaction. Meanwhile, most of the control measures that patients reported experiencing (seclusion, physical and chemical restraint, denial of privileges, high observation, and 1:1 nursing) positively correlated with one another, and with stress and trauma symptoms, and negatively correlated with healthcare satisfaction. Similarly, both experiencing and witnessing different kinds of abuse (physical, verbal, sexual, emotional) positively correlated with stress and trauma, and the various control measures experienced on the psychiatric unit and negatively correlated with healthcare satisfaction. As would be expected, self-reported stress and trauma symptoms positively correlated, and each negatively correlated with patients’ healthcare satisfaction.

Demographic group differences in admission-related stress and trauma

To compare reports of stress and trauma across demographic groups, including baseline diagnosis/disorder, age, gender, education, marital status, employment status, income, country of origin, and ethnicity, we used ANOVA and Tukey’s post hoc tests. Means (M) and Standard Deviations (SD) for stress and trauma for each group are reported in Tables 2 and 3 below.

Table 3: Descriptive Statistics for Trauma by Demographic.

Demographic and Clinical Effects on Stress and Trauma

Age: Age had a marginally significant effect on stress, F (2, 108)=2.60, p=.079, with the oldest group (55-70 years) reporting the lowest stress. However, post hoc tests were not statistically significant. Age had a significant effect on trauma symptoms, F (2, 105)=5.89, p=.004, with younger patients reporting significantly higher trauma scores than older patients, MD=.89, SE=.27, p=.003, 95% CI, .26 to 1.52.

Gender: Gender had no significant effect on stress, F (1, 130)=1.87, p=.174, or trauma symptoms, F (1, 126)=.07, p=.79.

Education: Education did not have a significant effect on stress, F (2, 130)=.12, p=.885, or trauma symptoms, F (2, 126)=.02, p=.98.

Marital status: Marital status had a marginally significant effect on stress, F (2, 127)=2.95, p=.056, with married patients reporting lower stress than separated patients, MD=2.99, SE=1.26, p=.051, 95% CI, -.01 to 5.98. A similar trend was found for trauma symptoms, F (2,123)=2.92, p=.058, with married patients reporting lower trauma symptoms compared to separated patients, MD=.81, SE=.32, p=.071, 95% CI, -.1.69 to .06.

Employment status: Employment status had no significant effect on stress, F (2,127)=.41, p=.67, but had a marginally significant effect on trauma symptoms, F (2, 123)=2.75, p=.068. Retired patients reported the lowest trauma scores compared to employed patients, MD=.69, SE=.29, p=.054, 95% CI, -.01 to 1.38.

Annual income: Annual income had no significant effect on stress, F (2,110)=.38, p=.69, or trauma symptoms, F (2, 109)=.15, p=.86.

Country of origin: Country of origin had no significant effect on stress, F (1,133)=.05, p=.83, but did affect trauma symptoms, F (1,129)=2.95, p=.04, with Canadian-born patients reporting higher trauma scores compared to non-Canadian-born patients, MD=.39, SE=.22, p=.04, 95% CI, -.05 to .83.

Ethnicity: Ethnicity had a marginally significant effect on stress, F (4,126)=2.35, p=.058, with Indigenous patients reporting higher stress than Caucasian patients, though the difference was not statistically significant, MD=3.02, SE=1.17, p=.08, 95% CI, -.21 to 6.27. When assessed as “white” vs “non-white,” ethnicity had a significant effect on stress, F (1,117)=8.46, p=.004, with non-white patients reporting higher stress, MD=2.07, SE=.711, 95% CI, -3.47 to -.66. Ethnicity did not significantly affect trauma symptoms, F (4,122)=.245, p=.91, or when assessed as “white” vs “non-white,” F (1,113)=.778, p=.380.

Baseline diagnosis/disorder: Baseline diagnosis did not significantly affect stress, F (4,133)=1.86, p=.12, but did affect trauma symptoms, F (4,129)=5.10, p<.001. Post hoc tests showed patients with mood disorders had lower trauma scores than those with psychotic disorders (MD=.74, SE=.21, p=.005, 95% CI, .16 to 1.32) and those in the “Other” category, who had the highest trauma scores (MD=1.10, SE=.33, p=.010, 95% CI, -2.00 to -.18).

Current legal status: Current legal status had no significant effect on stress, F (2,135)=.15, p=.86, or trauma symptoms, F (2,132)=.96, p=.39.

Police/security involvement: Police/security involvement during initial admission did not significantly affect stress, F (2,131)=.29, p=.75, or trauma symptoms, F (2,131)=.29, p=.75.

Discussion

This study aimed to investigate the incidence of stress and trauma symptoms associated with acute psychiatric hospital admission. We explored how various factors related to the hospital experience (e.g., length of stay, reason for admission, legal status, exposure to control measures) impacted healthcare satisfaction, stress, and trauma symptoms, and whether these effects varied by sociodemographic factors. Despite relatively low perceived stress and moderate to high healthcare satisfaction, we found that over half of the sample met the criteria for iatrogenic trauma related to the hospital admission process. Additionally, certain admission characteristics were strongly linked with higher stress and trauma symptoms, while some demographic groups experienced these effects more acutely.

Notably, the finding that more than 50% of participants met criteria for trauma, despite relatively low perceived stress and satisfactory healthcare experiences, is concerning. It suggests that while hospital processes may focus on reducing stress and ensuring satisfaction, they may not adequately address trauma, which could have significant implications for recovery. Providers should recognize that trauma and stress symptoms, though related, may be distinct, and a more nuanced understanding of these experiences could improve care and clinical outcomes. If trauma is not properly identified and managed during admission, it may inadvertently contribute to iatrogenic harm, counteracting efforts to support healing. Thus, clearer definitions and recognition of trauma are essential for improving the care process.

Our findings also revealed significant relationships between hospital experiences (such as the length of stay, the use of restraints, and exposure to aggressive behaviors) and higher stress and trauma symptoms, alongside lower healthcare satisfaction. These results align with previous research highlighting that trauma in psychiatric settings is not just confined to the admission process but extends throughout hospitalization [2,3,4]. Lengthier stays, especially those involving restraints or physical aggression, likely signal more severe illness, which can increase the risk of trauma and diminish satisfaction with care. The use of control measures such as physical restraints or witnessing abuse also correlated with higher trauma symptoms, reinforcing the need to reassess these practices to minimize harm.

Demographic findings

We found notable demographic differences in trauma and stress experiences. Older patients (50+ years) and those who were married reported lower levels of stress and trauma compared to younger patients (18-34 years) and those who were single. These results likely reflect greater resilience in older and married individuals, who may have better coping strategies and stronger social support. Younger individuals, particularly those employed or single, may face more social stressors, such as job demands or mental health stigma, which could amplify the negative effects of psychiatric hospitalization [14]. This mirrors findings from the COVID-19 pandemic, where older individuals demonstrated more resilience compared to younger cohorts [20,21]. Additionally, younger individuals may experience higher levels of stigma regarding mental illness, exacerbating the emotional toll of hospitalization.

Interestingly, non-Canadian-born patients reported fewer hospital-related trauma symptoms compared to Canadian-born patients. This could reflect differences in prior healthcare experiences, as individuals from countries with poorer mental healthcare systems might be more accustomed to hardship in healthcare settings, thereby perceiving traumatic experiences in Canadian hospitals differently. Alternatively, Canadian-born patients may have higher expectations of their healthcare system, amplifying any negative experiences they encounter [15-21].

Ethnicity and Diagnosis

Ethnicity also played a role, with “white” patients reporting fewer stress and trauma symptoms compared to “non-white” patients. Although ethnicity alone did not emerge as a significant predictor within specific subgroups, the overall findings point to ongoing racial disparities in mental healthcare. This underscores the need for further research to explore how systemic biases may influence patient experiences and outcomes.

For diagnosis, psychotic disorders and the “other” diagnostic category exhibited higher trauma symptoms compared to mood disorders. This is consistent with previous research showing that involuntary admissions, physical/chemical restraints, and the presence of security often accompany psychotic disorders, all of which are traumatic experiences. The “other” category’s higher trauma scores may reflect the unique challenges faced by patients with conditions like ADHD, personality disorders, or gambling, which could present distinct types of trauma.

Contrary to expectations, legal status and the presence of police/security on admission did not significantly affect stress or trauma symptoms. This may be due to the study’s design, where patients may have been reflecting on their overall hospital experience versus the initial admission phase. It could also be influenced by the sample size. However, the relationships between voluntary status, diagnosis, and exposure to control measures suggest that voluntary admissions may still play a role in shaping trauma and stress outcomes, warranting further exploration.

Strengths and Limitations

The study’s strengths include its diverse sample across multiple hospital sites, the use of reliable and widely accepted scales, and its focus on specific hospital admission experiences. However, the cross-sectional design, reliance on self-report data, and small sample size limit the ability to draw causal conclusions or generalize findings. Additionally, the quantitative approach does not offer insight into the underlying reasons for the observed patterns. Future research should include qualitative and longitudinal designs to better understand the nuanced factors contributing to stress and trauma in psychiatric settings.

Conclusion

In conclusion, findings from this study highlight the potential importance of teasing out admission-related stress versus trauma symptoms, and what kinds of psychiatric inpatient experiences might
predict these outcomes, as well as healthcare satisfaction. Further research is warranted to further explore how demographics and legal status play a role in shaping patient stress and trauma symptoms both during the initiation of hospital admission, and while on the unit.

Ethics approval

This study has been approved by the University of {removed for anonymity} Conjoint Health Research Ethics Board (REB21-1458).

References

1. Goldberg RW, Green-Paden LD, Lehman AF, Gold JM (2001) Correlates of insight in serious mental illness. J Nerv Ment Dis 189(3):137–145.
2. Owusu E, Oluwasina F, Nkire N, Lawal MA, Agyapong VIO (2022) Readmission of patients to acute psychiatric hospitals: Influential factors and interventions to reduce psychiatric readmission rates. Healthcare 10(9):1808.
3. Jani A, Ravishankar S, Kumar N, Vimitha J, Shah S, et al. (2021) Factors influencing care-seeking behavior for mental illness in India; a situational analysis in Tamil Nadu. J Public Health (Oxf) 43(Suppl 2):10–16.
4. Kashani JH, Hodges KK, Simonds JF, Hilderbrand E (1981) Life events and hospitalization in children: Comparison with a general population. Br J Psychiatry 139(3):221–225.
5. Dressing H, Salize HJ (2004) Compulsory admission of mentally ill patients in European Union Member States. Soc Psychiatry Psychiatr Epidemiol 39:797–803.
6. Guzman-Parra J, Aguilera-Serano C, Garcia-Sanchez JA, Garcia Spinola E, Torres-Campos D (2018) Experience coercion, post-traumatic stress and satisfaction with treatment associated with different coercive measures during psychiatric admission. Int J Ment Health Nurs 28(2):448–456.
7. Mueser K, Goodman LA, Trumbetta SL, Law D, Rosenberg SD, et al. (1998) Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol 66:493–499.
8. Switzer GE, Dew MA, Thompson K, Goycoolea JM, Derricott T, et al. (1999) Posttraumatic stress disorder and service utilization among urban mental health centre clients. J Trauma Stress 12:25–39.
9. Meyer H, Taiminen T, Vuori T, Aijala A, Helenius H (1999) Posttraumatic stress disorder symptoms related to psychosis and acute involuntary hospitalization in schizophrenic and delusional patients. J Nerv Ment Dis 187:343–352.
10. Cusack KJ, Frueh BC, Hiers T, Suffoletta-Maierle S, Bennett S (2003) Trauma within the psychiatric setting: A preliminary empiric report. Adm Policy Ment Health 30(5):453–460.
11. Frueh BC, Dalton ME, Johnson MR, Hiers TG, Gold PB, et al. (2000) Trauma within the psychiatric setting: Conceptual framework, research directions, and policy implications. Adm Policy Ment Health 28:147–154.
12. Lees-Haley PR, Price R, Williams CW, Betz BP (2001) Use of the Impact of Events Scale in the assessment of emotional distress and PTSD may produce misleading results. J Forensic Neuropsychol 2(2):45–52.
13. Horowitz M, Wilner N, Alvarez W (1979) Impact of event scale: A measure of subjective stress. Psychosom Med 41:209–218.
14. Vanaken L, Scheveneels S, Belmans E, Hermans D (2020) Validation of the Impact of Events Scale with modifications for COVID-19 (IES-COVID19). Front Psychiatry 11:78.
15. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 24(4):385.
16. Taylor JM (2015) Psychometric analysis of the ten-item perceived stress scale. Psychol Assess 27(1):90.
17. Lazarus RS (1966) Psychological stress and the coping process. New York: McGraw-Hill.
18. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM (1993) The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Annu Conv Int Soc Trauma Stress Stud San Antonio TX 462.
19. Vasterling JJ, Proctor SP, Amoroso P, Kane R, Heeren T, et al. (2006) Neuropsychological outcomes of army personnel following deployment to the Iraq War. JAMA 296:519–529.
20. Nwachukwu I, Nkire N, Shalaby R, Hrabok M, Vuong W, et al. (2020) COVID-19 pandemic: Age-related differences in measures of stress, anxiety and depression in Canada. Int J Environ Res Public Health 17(17):3666.
21. Nwachukwu I, Nkire N, Shalaby R, Hrabok M, Vuong W, et al. (2022) COVID-19 pandemic: Influence of relationship status on stress, anxiety, and depression in Canada. Ir J Psychol Med 39(4):351–362.