Some have suggested that patients (consumers) oppose Assisted Outpatient Treatment. The following papers address the issue.

* *

Many Involuntary Patients Later Say They Agree With Intervention

Clinical & Research News
Psychiatric News January 1, 2010
Volume 45 Number 1 Page 18
© American Psychiatric Association
Joan Arehart-Treichel

How do seriously mentally ill patients feel later about treatment that was forced on them? No study appears to have addressed this question—until now.

Would a severely ill psychiatric patient thank you later for forcing medication on him or her? If the patient regained full mental capacity as a result, chances are good that he or she would. But if the patient did not, chances are fair that he or she would not.

These are the implications of a study headed by Gareth Owen, M.D., a Wellcome Trust clinical research fellow at the Institute of Psychiatry at King’s College, London. Results were published in the November 2009 British Journal of Psychiatry.

The aim of the study was to see what psychiatric patients think about their involuntary treatment after the fact.

This appears to be the first study to “have investigated individuals’ views on such treatment decisions after they had regained capacity,” Owen and his colleagues said.

Between February 2006 and June 2007, 350 seriously mentally ill patients living in a deprived inner-city area of London were consecutively admitted to Maudsley Hospital for treatment. Out of the 350 patients, 115 were found to lack capacity to make treatment decisions, as determined by clinical assessment and the MacArthur competence Assessment Tool for Treatment.

A month later, or earlier if they were discharged before a month was up, the 115 patients were again evaluated for mental capacity. Also at this time, they were asked whether they would consent to an interview regarding their views on having been treated involuntarily.

Ninety-four gave their approval, although only 35 had regained full mental capacity according to the standards mentioned above. The remaining 59 had not regained enough capacity to make treatment decisions, yet had regained enough mental clarity to give an opinion about the treatment they had received, Owen told Psychiatric News.

Out of the patients who had regained full mental capacity, 83 percent said that the right treatment decisions had been made on their behalf—even if their initial treatment wishes had been overridden. But out of the 59 who had regained partial mental capacity, only 41 percent said that the right decisions had been made on their behal

f. In brief, patients were significantly more likely to give retrospective approval of the treatment they had received if they had regained full mental capacity than if they had not.

“Most participants who regained capacity agreed with the surrogate decision making that had taken place during their admission to hospital,” wrote the authors. “They may not have much liked the process of admission or the services received … but they indicated approval nonetheless.” This finding “might moderate concerns both about surrogate decision making by psychiatrists and advance decision making by people with mental illness.”

An abstract of “Retrospective Views of Psychiatric In-patients Regaining Mental Capacity” is posted at <http://bjp.rcpsych.org/cgi/content/abstract/195/5/403>.

* * *

The British Journal of Psychiatry (2009) 195: 403-407. doi: 10.1192/bjp.bp.109.065151 Retrospective views of psychiatric in-patients regaining mental capacity

Gareth S. Owen, MRCPsych

Department of Psychological Medicine and Psychiatry, Institute of Psychiatry Anthony S. David, FRCPsych Department of Psychological Medicine and Psychiatry, Institute of Psychiatry Peter Hayward, PhD Department of Psychology, Institute of Psychiatry Genevra Richardson, LLM School of Law, King’s College London George Szmukler, FRCPsych Health Services Research Department, Institute of Psychiatry Matthew Hotopf, PhD, MRCPsych Department of Psychological Medicine and Psychiatry, Institute of Psychiatry, London, UK Correspondence: Gareth S. Owen, Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, Cutcombe Road, London SE5 9RS, UK. Email: g.owen@iop.kcl.ac.uk Declaration of interest None.

Background

An individual’s right to self-determination in treatment decisions is a central principle of modern medical ethics and law, and is upheld except under conditions of mental incapacity. When doctors, particularly psychiatrists, override the treatment wishes of individuals, they risk conflicting with this principle. Few data are available on the views of people regaining capacity who had their treatment wishes overridden.

Aims

To investigate individuals’ views on treatment decisions after they had regained capacity.

Method

One hundred and fifteen people who lacked capacity to make treatment decisions were recruited from a sample of consecutively admitted patients to a large psychiatric hospital. After 1 month of treatment we asked the individuals for their views on the surrogate treatment decisions they received.

Results

Eighty-three per cent (95% CI 66–93) of people who regained capacity gave retrospective approval. Approval was no different between those admitted informally or involuntarily using Mental Health Act powers ( 2 = 1.52, P = 0.47). Individuals were more likely to give retrospective approval if they regained capacity ( 2 = 14.2, P = 0.001).

Conclusions Most people who regain capacity following psychiatric treatment indicate retrospective approval. This is the case even if initial treatment wishes are overridden. These findings moderate concerns both about surrogate decision-making by psychiatrists and advance decision-making by people with mental illness.

* * *

Consumers’ perceptions of assisted treatment

SUMMARY:

The majority of individuals who refuse treatment accept it after being told that they must, and do not have to be forcibly medicated. And the majority of patients who initially object to hospitalization or medication retrospectively agree with the decision to hospitalize or treat them. Finally, contrary to popular belief, legal status is not an accurate measure of perceived coercion.

* * *

Individuals with severe mental illnesses, such as schizophrenia and bipolar disorder, who have a deficit in awareness of their illness often refuse treatment because they do not believe that they are ill. The majority of individuals who refuse medication subsequently agree to take it in oral form when informed that they must. Therefore, forcible injections are used only in a small minority of cases in which an individual refuses treatment.1

Moreover, the majority of patients who initially refuse medication retrospectively agree with the decision to coercively medicate them.1, 2

The majority of patients who are involuntarily treated afterwards report that they will be more likely to voluntarily accept treatment in the future.1 Similarly, a majority of involuntarily hospitalized patients retrospectively agree with the decision to do so.3 Also, the majority of patients who are court ordered to comply with treatment in the community remain treatment compliant after the orders expire.4

Researchers with the New York State Psychiatric Institute and Columbia University conducted face-to-face interviews with 76 assisted outpatient treatment (AOT) recipients to assess their opinions about the program, perceptions of coercion or stigma associated with the court order, and quality of life as a result of AOT. After they received treatment, interviewed recipients overwhelmingly endorsed the effect of the program on their lives:

• • 75 percent reported that AOT helped them gain control over their lives;
• • 81 percent said that AOT helped them to get and stay well; and
• • 90 percent said AOT made them more likely to keep appointments and take medication.
• 87 percent said they were confident in their case manager’s ability to help them
• 88 percent said that they and their case manager agreed on what is important for them to work on.5

Studies show that legal status (voluntary vs. involuntary hospitalization) often does not correlate with patients’ actual perception of coercion.

In a major study on coercion, more than one third of involuntarily hospitalized patients did not perceive that they had been coerced into the hospital and nearly half believed that there were no reasonable alternatives to hospitalization. In contrast, nearly half of voluntarily hospitalized patients indicated that someone else had initiated the process and 25 percent said there were reasonable alternatives to hospitalization.6

Briefing paper: Consumers’ perceptions of assisted treatment (8/2005) page 2

ENDNOTES 1 Greenberg, W.M., et. al. (1996). Patients’ attitudes toward having been forcibly medicated. Bulletin of the American Academy of Psychiatry and the Law, 24, 513–24. 2 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). 3 Gardner, W., et. al. (1999). Patients’ revisions of their beliefs about the need for hospitalization. American Journal of Psychiatry, 156, 1385-91. 4 Van Putten, R.A., et. al. (1988). Involuntary outpatient commitment in Arizona: A retrospective study. Hospital and Community Psychiatry, 39, 953–8. and Rohland, B.M. (1998, May). The role of outpatient commitment in the management of persons with schizophrenia. Iowa Consortium for Mental Health, Services, Training, and Research. 5 N.Y. State Office of Mental Health (March 2005). Kendra’s Law: Final report on the status of assisted outpatient treatment. New York: Office of Mental Health. 6 Treffert, D.A. (1999). The MacArthur coercion studies: A Wisconsin perspective. Marquette Law Review, 82, 759-85.