What is the effect of involuntary medication on individuals with serious mental illness? - Backgrounder

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March 2014


SUMMARY: A small number of individuals with serious mental illness have to be treated involuntarily. This is because such individuals have little or no awareness of their illness, i.e., they have anosognosia, and when they are not being treated with medication, they become dangerous to themselves or others. Several studies have followed-up individuals who were treated involuntarily to ascertain the effect of such treatment. As would be expected, some of them were unhappy with such treatment, but a surprising number of others retrospectively said that the involuntary treatment was justified. It is sometimes claimed that the existence of involuntary treatment “scares people with mental illness away from treatment,” but in fact there is no evidence to support that claim.

The following are some of the published studies on this issue:

    • 2010: A Norwegian study compared the outcome between patients admitted to psychiatric hospitals for their first episode of psychosis. 91 were admitted voluntarily and 126 involuntarily. At the end of 2 years following discharge there was no difference between the two groups on their adherence to medication.
    • 2009: In England, 94 individuals “who lacked capacity to make treatment decisions” were admitted to a psychiatric hospital, and then assessed one month later or at discharge, if that came sooner. Among the 35 who regained the capacity to make treatment decisions, 29 (83%) answered yes to the question: “Were the right [treatment] decisions taken on your behalf?” Among the 49 who did not regain the capacity to make treatment decisions after one month, 20 (41%) answered yes to that question. Although almost two-thirds of the patients had been admitted involuntarily, “there were no clear differences in the views expressed about surrogate decision-making between those who were treated involuntarily under the Mental Health Act on admission compared with those who were treated informally.”
    • 2006: In New Zealand, 69 patients who had been on involuntary outpatient treatment (“Community Treatment Orders”) for less than one year were queried about the effects of involuntary treatment. Among the 69 patients, 46 (67 percent) agreed that people on involuntary outpatient treatment “are more likely to take medication” and 47 (68 percent) agreed that they “are more likely to stay out of the hospital.”
    • 2005: In New York, researchers 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
      • 90 percent said AOT made them more likely to keep appointments and take medication
    • 2004: In North Carolina, interviews were conducted with 104 individuals with schizophrenia and related disorders regarding their feelings about involuntary (assisted outpatient) treatment. Such mandated treatment was regarded as being effective by 62 percent and as being fair by 55 percent of these individuals. Those who had awareness of their own illness (insight) were much more likely to regard mandated treatment as fair.
    • 2003: In New York, 117 individuals with severe mental illness were followed up for 11 months after discharge from a psychiatric hospital. Those who perceived themselves as being forced to take medication (“high perceived coercion”) were compared with those who did not perceive themselves as being forced to take medication. At the end of 11 months, there were no differences between the two groups in their adherence to medication.
    • 1999: In North Carolina, 331 individuals, 97 percent of whom had schizophrenia, bipolar disorder, or other psychotic disorders, were queried about the perceived effects of involuntary outpatient commitment. Among them, 83 percent said that “people under outpatient commitment are more likely to take their medication” and 77 percent said that they were “more likely to stay out of the hospital.”
    • 1996: In New Jersey, 30 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."
    • 1995: In Maryland, 28 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."
    • 1991: In Australia, 79 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 < 0.01). 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."

  • 1988: In New York, 24 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."
  • 1989: The “Well-Being Project.” In California, 331 individuals with a mental illness diagnosis, the majority of whom had been previously hospitalized, volunteered to fill out a questionnaire. The project was organized by the California Network of Mental Health Clients (CNMHC), an organization explicitly dedicated to opposing involuntary treatment, and 320 of the 331 participants were CNMHC members. This highly-select group of individuals were then asked to respond to the following question as part of a larger survey: Do mental health clients avoid treatment due to fear of involuntary commitment? The respondents could only answer “yes” or “no,” although answers to other questions were scaled 1 to 5 with intermediate possibilities, such as “occasionally.” The result of the survey was that 47 percent of the individuals answered “no” and 53 answered “yes.” It is remarkable that only 53 percent of the respondents answered “yes,” given the fact that 97 percent of them were thought to oppose involuntary treatment.

This project has been frequently cited by individuals opposed to involuntary treatment as having proven that involuntary treatment “scares people with mental illness away from treatment.” The survey, of course, does no such thing and, because of its highly biased sample, is scientifically worthless.



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