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Pressures to adhere to treatment: observations on ‘leverage’ in English mental healthcare

  • Tony Zigmond (a1)
Summary

Coercion in psychiatric practice appears to be increasing. Is this in patients' best interest? Is it good medical practice?

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References
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1 Department of Health. In-patients Formally Detained in Hospitals under the Mental Health Act 1983 and Patients Subject to Supervised Community Treatment, Annual Figures, England 1987–88. Statistical Bulletin. Department of Health, 1988.
2 The NHS Information Centre for Health and Social Care. In-patients Formally Detained in Hospitals under the Mental Health Act 1983 and Patients Subject to Supervised Community Treatment, Annual Figures, England 2009–10. NHS Information Centre for Health and Social Care, 2010.
3 Mental Health Act Commission. The First Biennial Report of the Mental Health Act Commission. HMSO, 1985.
4 Care Quality Commission. Monitoring the Use of the Mental Health Act in 2009/10. CQC, 2010.
5 Burns, T, Yeeles, K, Molodynski, A, Nightingale, N, Vazquez-Montes, M, Sheehan, K, et al. Pressures to adhere to treatment (‘leverage’) in English mental healthcare. Br J Psychiatry 2011; 199: 145–50.
6 Szmuckler, G, Appelbaum, PS. Treatment pressures, leverage, coercion, and compulsion in mental health care. J Ment Health 2008; 17: 233–44.
7 General Medical Council. Consent: Patients and Doctors Making Decisions Together: 19. GMC, 2008.
8 Department of Health. Mental Health Act Code of Practice. TSO (The Stationery Office), 2008.
9 The Queen on the Application of SH v Mental Health Review Tribunal QBD (Admin) (Holman J) 3/4/2007 3rd April 2007 [2007] EWHC 884 (Admin).
10 National Institute for Health and Clinical Excellence. Medicines Adherence Involving Patients in Decisions about Prescribed Medicines and Supporting Adherence. NICE, 2009.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Pressures to adhere to treatment: observations on ‘leverage’ in English mental healthcare

  • Tony Zigmond (a1)
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Re:Pressures to adhere to treatment: observations on 'leverage' in English mental healthcare

Tony Zigmond, Consultant Psychiatrist
02 November 2011

Thank you to Drs Mela and Scott-Orr for their interest. It seems to me that there are two issues here. First, should the law be discriminatorybetween patients with a physical illness and those with a mental illness? I think not and I'm pleased to say the United Nations Convention on the Rights of Persons with Disabilities (2006), to which the UK is a signatory, supports this view. The convention obligates States to (amongstmany other things) "take all appropriate measures, including legislation, to modify or abolish existing laws, regulations, customs and practices that constitute discrimination against persons with disabilities". To explain this further, the UN High Commissioner for Human Rights said1 "Legislation authorizing the institutionalization of persons with disabilities on the grounds of their disability without their free and informed consent must be abolished. ...... This should not be interpreted to say that persons with disabilities cannot be lawfully subject to detention for care and treatment or to preventive detention, but that the legal grounds upon which restriction of liberty is determined must be de-linked from the disability and neutrally defined so as to apply to all persons on an equal basis".

Secondly, should the law (for everyone) favour patient autonomy, medically determined best interest or a mixture?

In other words, either everyone, with the capacity to make the decision, should be permitted to "die (or rot) with their rights on" or nobody should. Or the authority to overrule capacitous refusal could be based on a neutral factor such as risk to other people. It should not be dependent on the stigma associated with certain terminology (a mental illness diagnosis).

1. Annual report of the United Nations High Commissioner for Human Rights and reports of the office of the high commissioner and the secretary-general A/HRC/10/48 26 January 2009

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Conflict of interest: None declared

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Donald Scott-Orr, VMO Psychiatrist
26 October 2011

Tony Zigmond's article in August BJPsych about 'leverage' in English mental health care, helps to demonstrate the promotion of coercion withoutappeal (as may be even more common in the USA) resulting from an apparent contradiction in local mental health law:

'Even when taking medication is a condition attached to a conditional discharge (from a restriction order, Mental Health Act 1983) or community treatment order, it would be unlawful to recall the individual solely because the individual decided to refuse the medication.'

Presumably at the time of conditional discharge (including the requirement that they continue prescribed medication) the person is well enough to cope with the requirement. They are coerced (by stated conditions), hopefully, because it has been demonstrated that without medication they are highly likely to become unwell again.

So what is different about the situation where the person is out of hospital and stops their medication, that they cannot be legallycoerced to take it? Has the person changed in some way when they face a similar clinical risk?

Is it better to have a legal provision for this coercion outside the hospital, with all the necessary legal safeguards and reviews required (as under the Australian New South Wales Mental Health Act) or toawait decompensation and have caring people desperately trying to forestall such an event, possibly with illegal (and possibly inappropriate) 'leverage' pressures?

The article does not address the often characteristic accompanying distress to the person and their network when a person decompensates into more disorganised psychosis. Perhaps 'he died with his rights on'.

In the NSW Act, intervention requires not only the 'least restrictive' option, but also the 'continuing condition' of a mentally illperson and risk of ANY harm. In other words, if the history indicates a chronic illness and the likelihood of decompensation off medication, this must be considered, even it the person is apparently getting by at the time.

Perhaps failure to initiate sensitive intervention, including coercion as necessary, with legal safeguards and appeal capacity, in such circumstances, is negligence. Such intervention may alsobe regarded as a 'loving act'.

To say that a person has the capacity to make a decision does not determine the quality or appropriateness of that decision.

To say that a person is 'capacitous' because they are capable of apparently understanding their situation (and so 'having the capability of making decisions about their own treatment') and have 'insight', is to leave open much definitional argument, but it is not appropriate as the sole determinant of non intervention in a situation of carefully determined clinical risk to the person and the legitimate distress of others.

In asking the question: 'Who should have the final say?', the article seems to assume that this question is resolved by choosing either the sufferer or the psychiatrist. In matters of coercion it is the law which has the final say and at its best it seeks widely and wisely foran answer - hence Tribunals. Hence also the need for good law.

It may be that the (statistical numbers) rise in coercion in psychiatric practice is necessary, but dealing with doubts about its desirability is not best met by placing difficulties in the way of people getting treatment they need to live their lives most fulfillingly and withothers. Rather the preferred emphasis may be for more careful review, in particular cases, of the necessity of coercion and of prescribing choices.

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Conflict of interest: None declared

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Pressures to adhere to treatment: observations on 'leverage' in English mental healthcare

Mansfield Mela, Psychiatrist
16 September 2011

Coercion, compulsion, adherence, compliance, persuasion and like terms need to be in our clinical consciousness as recently articulated in the editorial by Tony Zigmond in relation to an English study on leverage (1) (2). The suggestion that resolving the practice of leverage/coercion is best left to patient choice assumes that there is a lot of coercion going around, albeit erringly. His assumption that other branches of medicine are devoid of similar practice is flawed and incorrect. Removal of obese children from their parents, denial of driving rights to the epileptic who wants to make the choice to drive and the mandatory revelation of HIV status to partners by reluctant spouses are but few of similar coercion in other branches of medicine. It is worth noting that, in these examples and in the examples of mental illness, focusing only on the patient's choice narrows the implications of those choices as they affect others. It also takes away from physicians the collective role theyplay to the society at large. The following reasons are why, at the time we are trying to allow voluntary participation in treatment decisions, we must guard against amplifying and magnifying 'choice'.1.Choice is shaped and essentially dependent on insight. Correlates of insight are no longer restricted to anosognosia like views or neuropsychological dysfunction based on injuries to frontal, parietal or temporal lobes. Volumetric reductions in several cortical regions evinced by neuroimaging studies are well documented in chronic schizophrenia and first episode psychosis (3, 4). As such, lack of insight, unawareness of illness and the need for treatment can no longer be relegated to the domain of choice. Those involve a network of brain structures affected by the disorder. Even the Law recognises this in assigning the 'but for mental disorder' designate in various medicolegal criteria.2.Medicolegal provisions of treatment are unfortunately driven by public reactions to failures in the mental health system. The Law is then made and takes precedence in determining the acceptable level of risk by which the society should be exposed to. This is known as 'where the public perilbegins' (5). In recognition of the implications of the choices made for and against treatment, the tension between autonomy and beneficence has not stopped being the most contentious of ethical quagmires. A broader perspective is in order beyond choice.3.The rates of coercion cannot categorical be said to be increasing as opined by Tony Zigmond. To modify this perceived alarming statistics he referenced, other relevant factors should be recognised along side the increasing number of formal compulsory hospital admissions (1987 - 2010). The population of the English society has not only increased, over the last three decades, but become diverse with migrants who affect rates of mental disorder as well as potential for coercion. The tolerance for mental illness and societal acceptance is changing. Community support for patients, a by product of economic prosperity has dwindled (6), and contributes to coercive approaches from both family and practitioners. Although litigation of practitioners is lower than the USA, it is none theless relevant in determining physicians' attitude towards voluntariness (7, 8).4.When the treatment of our patients considers the past and the future, progress in reducing stigma necessitates the use of leverage in some situations. The high rates of the use of leverage have been suggested as agood thing. The Americans have experienced a before and after paradigm of reducing leverage. 'Rotting with their rights on' was not only their titleof scientific publications but was the terminology used to describe the repercussions. It is a full circle savoir-faire the United Kingdom doesn'tneed and should avoid as there are tragic and costly consequences on focusing only on choice(9). Despite decades of that experiment in the USA,the opinion to use leverage as a positive tool still exists(10).

1.Zigmond T. Pressures to adhere to treatment: observations on 'leverage' in English mental healthcare. Br J Psychiatry. Aug;199:90-1.2.Burns T, Yeeles K, Molodynski A, Nightingale H, Vazquez-Montes M, Sheehan K, et al. Pressure to adhere to treatment ('leverage') in English mental healthcare. The British Journal of Psyhiatry. 2011;199:6.3.Buchy L, Ad-Dab'bagh Y, Malla A, Lepage C, Bodnar M, Joober R, et al. Cortical thickness is associated with poor insight in first-episode psychosis. J Psychiatr Res. 2011 Jun;45(6):781-7.4.Buchy L, Czechowska Y, Chochol C, Malla A, Joober R, Pruessner J, et al. Toward a model of cognitive insight in first-episode psychosis: verbalmemory and hippocampal structure. Schizophr Bull. 2010 Sep;36(5):1040-9.5.Buchner F, Firestone M. Where the public peril begins: 25 years after Tarasoff. Journal of Legal Medicine. 2000;21(2):25.6.Becker T, Kilian R. Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? Acta Psychiatr Scand Suppl. 2006(429):9-16.7.Glancy DR, Glancy GD. The case that has psychiatrists running scared: Ahmed v. Stefaniu. J Am Acad Psychiatry Law. 2009;37(2):250-6.8.Glancy GD, Chaimowitz G. Tarasoff warnings result in criminal charges. J Am Acad Psychiatry Law. 2003;31(4):524-5.9.Gutheil TG. In search of true freedom: drug refusal, involuntary medication, and "rotting with your rights on". Am J Psychiatry. 1980 Mar;137(3):327-8.10.Kress K. Rotting with their rights on: why the criteria for ending commitment or restraint of liberty need not be the same as the criteria for initiating commitment or restraint of liberty, and how the restraint may sometimes justifiably continue after its prerequisites are no longer satisfied. Behav Sci Law. 2006;24(4):573-98.

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