SUMMARY: Patients with psychiatric disorders refuse medications for a variety of reasons, including experience with, or fear of, side effects. In other cases, the refusal is based on lack of awareness of illness or on delusional beliefs. Many such patients must ultimately be medicated involuntarily. Studies suggest that the long-term effects of involuntary medication on individuals with schizophrenia and manic-depressive illness (bipolar disorder) are more positive than is commonly thought. In most studies, the majority of patients retrospectively agreed that involuntary medication had been in their best interest. Anecdotal claims by opponents of involuntary medication that involuntary treatment has widespread, devastating, and lasting effects are not supported by these studies.

  • Nine patients, seven with schizophrenia and two with bipolar disorder, refused medication when admitted to a psychiatric unit. All nine were given a single injection of long-acting fluphenazine decanoate. At the end of two weeks, their symptoms were markedly improved (BPRS improved from 10.4 to 4.1), and all were accepting medication voluntarily. Keisling R. Characteristics and outcome of patients who refuse medication. Hospital and Community Psychiatry 34:847–848 , 1983.
  • Twelve patients refused medication when admitted to a psychiatric unit. Three-quarters of them were diagnosed with schizophrenia or bipolar disorder. Compared to a control group that accepted medication, the refusers had less insight into their illness, were more psychotic, had higher mood elevation, and were more grandiose. After two weeks of medication, six of the patients (50 percent) no longer wished to refuse medication. “They were more likely to view medications as important for their illness and were less likely to believe in alternative treatments.” The other six patients “still preferred to refuse treatment despite considerable improvement in their clinical condition.” Marder SR et al. A study of medication refusal by involuntary psychiatric patients. Hospital and Community Psychiatry 35:724–726, 1984.
  • Twenty-four patients who had been involuntarily medicated with antipsychotic medication were interviewed at the time of discharge from the hospital. Sixteen (67 percent) were diagnosed with schizophrenia or bipolar disorder, and 5 more (21 percent) with atypical psychosis. Thirty-three percent of the patients said they had refused medication because they believed they had no need for it, 29 percent said they had refused medication because of “severe confusion or psychotic ideation,” and 17 percent “stated that they did not know why they [had] refused medication.” At discharge, 17 patients (71 percent) agreed that the decision to involuntarily medicate them had been correct and agreed with the statement: “If I become ill again and require medication, I believe it should be given to me even if I don’t want it at the time.” The 7 patients (29 percent) who disagreed scored high on measures of grandiosity, hostility, and suspiciousness; 6 of them had a diagnosis of bipolar disorder. The authors concluded that “it is impossible to avoid the conclusion that the treatment refusal of every patient in our sample was influenced by psychosis.” Schwartz HI et al. Autonomy and the right to refuse treatment: patients’ attitudes after involuntary medication. Hospital and Community Psychiatry 39:1049–1054, 1988.
  • Eleven patients who had been forcibly medicated during their psychiatric hospitalization were retrospectively interviewed. Seven strongly agreed and two somewhat agreed (thus 82 percent total) that their involuntary treatment had been useful. Seide M et al. The reluctant psychiatric patient: ethics and efficacy around the issue of forced medication (Session 2219). American Public Health Association 117th Annual Meeting, Chicago, October 24, 1989.
  • Seventy-nine patients who had been placed under guardianship, 75 (95 percent) of whom had been involuntarily medicated, were asked to retrospectively fill out a questionnaire. Eighty-seven percent of the patients had been diagnosed with schizophrenia or bipolar disorder. The results were as follows:Do you have a mental illness?
        • definitely/probably not – 47%
        • don’t know – 9%
      • definitely/probably do – 44%

    How helpful was your guardianship?

        • very/fairly helpful – 45%
        • neutral – 21%
      • very/fairly unhelpful – 34%

There was a high correlation between patients who believed they had a mental illness and those who found the guardianship helpful (p < .01). The authors concluded that “although a majority of the patients were against enforced treatment in principle, often because they thought it conflicted with their civil rights, most found the actual experience, including medication, to be helpful.”
Adams NHS and Hafner RJ. Attitudes of psychiatric patients and their relatives to involuntary treatment. Australian and New Zealand Journal of Psychiatry 25:231–237, 1991.

  • Fifty-one state hospital involuntary inpatients who refused to accept medication and were therefore involuntarily medicated were compared with 51 matched involuntary inpatients who were similar except that they voluntarily accepted medications. Seventy-nine percent of the study group and 66 percent of the matched controls had diagnoses of schizophrenia or affective disorder. The patients who were involuntarily mediated had improved symptoms and were discharged more quickly than the matched controls, suggesting that their refusal to take medication had prolonged their hospital stay. At one year follow-up, there was no difference between the two groups in their rate of rehospitalization or compliance with follow-up outpatient medication, which was relatively poor for both groups. This is not surprising since both study patients and controls had been involuntarily hospitalized and had been assigned to long-stay wards for chronic patients. In addition, none of the patients were placed on outpatient commitment or other form of assisted treatment at discharge. The authors conclude that “those in need of continued care could be considered for an expanded use of outpatient commitment.” Cournos F et al. Outcome of involuntary medication in a state hospital system. American Journal of Psychiatry 148:489–494, 1991.
  • In a forensic psychiatric hospital in which 97 percent of all patients were in involuntary treatment, an anonymous questionnaire was used to assess the attitudes of 203 patients to various forms of treatment. Two-thirds of the patients felt that medication was helpful, and only 10 percent considered medication to be harmful. Vartiainen H et al. The patients’ opinions about curative factors in involuntary treatment. Acta Psychiatrica Scandinavica 91:163–166, 1995.
  • Twenty-eight outpatients who “had felt pressured or forced to take psychiatric medications within the past year” were administered a questionnaire by their peers. Diagnostically, they were part of a larger group of users of psychosocial rehabilitation centers in which 52 percent of those with known diagnoses had schizophrenia or bipolar disorder. Only 2 of the 28 had actually been physically forced to take medication. In reply to questions about how they felt about having been pressured to take medications, 9 (32 percent) were positive, 9 (32 percent) expressed mixed views, 6 (21 percent) reported no effect, and 3 (11 percent) reported a negative effect. In addition, 12 patients (43 percent) said that “the experience gave them a sense that people were looking out for their best interest.” The authors also noted that “only a few respondents said that past experiences of pressured or forced medication had had any effect on their subsequent willingness to take medication.” Lucksted A and Coursey RD. Consumer perceptions of pressure and force in psychiatric treatments. Psychiatric Services 46:146–152, 1995.
  • Thirty patients who had been forcibly medicated during their psychiatric hospitalization were interviewed by telephone one to two weeks later by individuals who had not been involved in their treatment. Eighty-seven percent of the patients had been diagnosed with schizophrenia or bipolar disorder. Among the refusers, 30 percent recalled having refused the medication because they had believed there was nothing wrong with them, and 20 percent said they had refused because they had believed the medication was poison.

Retrospectively, 18 patients (60 percent) said that having medication forced was a good idea, 9 (30 percent) disagreed, and 3 (10 percent) were unsure. Most of those who disagreed had either paranoid schizophrenia or bipolar disorder with grandiosity. The authors concluded that “forced medication frequently restores the capacity to make competent decisions and often results in a more rapid return of freedom to be discharged from involuntary hospitalization.” Greenberg WM et al. Patients’ attitudes toward having been forcibly medicated. Bulletin of the American Academy of Psychiatry and the Law 24:513–524, 1996.