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Balancing Patient Freedom With Safety And Well Being

The rationale for court mandated outpatient treatment

I have always hated involuntary psychiatric treatment. It is demeaning to human dignity, subject to abuse, and extremely unpleasant both to experience and to recommend. But there are rare times when pressuring someone into treatment becomes the lesser evil, preferable to the risks of suicide, violence, jail or homelessness.

My first experiences in psychiatry occurred fifty years ago, at a time when 650,000 patients were warehoused in psychiatric hospitals, accurately described as 'snake pits'. I very much admired Tom Szasz for calling this out and fighting to free patients from their bondage. Some of my own earliest writings were directed against psychiatric paternalism- emphasizing instead the great value of eliciting patient preferences and of negotiating, rather than dictating, their treatment plans. And, in many years of emergency room work, my instinct was almost always on the side of taking reasonable risks- letting most people go when they insisted, rather than playing it safe by forcing them into a hospital stay.

But there are exceptions- people with severe and chronic mental illness who are an ongoing, clear, and present danger to self, family, and/or the public, but who lack the insight or volition to get the help needed to reduce what is otherwise an unacceptable risk.

How do we achieve an equitable balance between the sometimes competing values of freedom and safety?

Involuntary commitment to inpatient psychiatric hospitals has become very uncommon in the US because almost all psychiatric hospitals have been closed (90%, comprising 600,000 beds in the last 50 years). Completely not coincidentally, the concomitant failure to provide adequate community treatment and housing has resulted in an equivalent 600,000 people with severe mental illness being housed in jails or left homeless on the street. This neglect has made the United States for many people the worst place in the world to have a severe mental illness.

Forty-six states have adopted Assisted Outpatient Treatment (AOT) statutes in an attempt both to improve the lives of the severely ill and also to reduce risk among those who are at highest risk if their severe mental illness goes untreated. Court-ordered treatment is applied only rarely and only for people who meet strict legal criteria of risk and lack of insight.

I write about this issue now in response to a recent paper by Barnes and Badre: 'Is the Evidence Strong Enough to Warrant Long-Term Antipsychotic Use in Compulsory Outpatient Treatment?'

These authors argue against the use of involuntary medication in AOT programs, because the existing literature is insufficient to prove longterm efficacy beyond one year. Drs Barnes and Badre have confused two non-related issues: the risk/benefit of long-term antipsychotic use with its use in short term AOT programs.

The duration of court mandated outpatient treatment is generally brief. In 22 states, initial AOT orders are limited to 90 days or less; in 15 others, they are limited to 180 days or less; and even with renewals, 35 states allow orders of up to no more than one year. In the state of New York, 45% of orders are not renewed at the end of 6 months. Only 39% remain in the program for more than one year and only 25% for more than 30 months.

Most people in AOT convert successfully to voluntary treatment within a year. Many who were unhappy when originally ordered into outpatient care, later feel grateful once they have been helped by it. Studies show that AOT improves symptoms and functioning and reduces hospitalizations, arrests, and violence.

The Barnes/Badre argument about the lack of literature supporting long term antipsychotic treatment doesn't apply to most people who are in AOT only on a short term basis. It has more relevence to the 25% or so of cases in which court mandated outpatient treatment is extended for a longer period of time. Because it is impossible to extend placebo controlled studies for indefinite periods, we will probably never have conclusive evidence on long term risks vs benefits of antipsychotic meds. But shorter term, randomized clinical trials show unequivocally that antipsychotic medicine dramatically reduces relapse rates during the first year after an episode.

For people with a history of severe, persistent, and dangerous relapses, the real risks of antipsychotic medicine are often outweighed by the substantial benefit. Protecting individual freedom is a great social good. But protecting personal and public safety is an equally compelling social good. It is no gift to a psychotic individual to protect his freedom to refuse much needed treatment if the immediate consequence is his harming himself or others, or winding up in jail for a nuissance crime, or being left derilict and homeless. Court mandated treatment is usually short, its benefits are often long.

AOT laws provide legal recognition and protection of the patient's right to refuse treatment, but stipulate that this right is not absolute. Mandated treatment is permitted for specified, usually brief, periods only when the patients judgment is severely and manifestly impaired and when his refusing treatment will lead to terrible consequences. The risks of illness must be very great and must clearly exceed the very considerable risks posed by antipsychotic meds.

Unfortunately, enforced treatment has become a polarizing issue that is often discussed in ideological terms, as if there is a universal right answer. In my experience, people who seem to differ in theory agree much more in practice when discussing the specifics of any given situation.

Eleanor Longden of Hearing Voices and I have had very different experiences of psychiatry, but agree completely on a common sense approach that places the highest value on free decision making, except in the very most extreme circumstances when such freedom may lead to disaster.