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Critical appraisal of the Schizophrenia Commission's report

  • Sohom Das (a1)
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Abstract
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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1 Schizophrenia Commission. The Abandoned Illness: A Report by the Schizophrenia Commission. Rethink Mental Illness, 2012.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
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Critical appraisal of the Schizophrenia Commission's report

  • Sohom Das (a1)
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eLetters

Commissions, Coercion and Choice

Robert A. McCutcheon, CT1 in Psychiatry
12 March 2013

The recent letter by Das (1) was a succinct and clear appraisal of much of the Schizophrenia Commission's report. Das takes issue withthe report’s point that "shared decision making on medication choices is essential", commenting that this cannot refer to the "chronic schizophrenic that refuses all medication" and that it is "obvious to any psychiatrist that the report is not referring to this type of patient".

I do not think the issue is as cut and dried within psychiatry as Dassuggests. A recent editorial in the British Journal of Psychiatry (2), which proposed that patient choice should indeed be extended to patients with psychotic disorders, was met with nothing but nodding heads and commendations. However, the reality of journal pages and that of NHS psychiatry is often as distinct as that of the psychiatrist and the psychotic patient. The way decisions concerning antipsychotic medication are made is frequently quite straightforward - if you have a chronic psychotic illness and refuse treatment then coercion will be used to ensure you are receiving medication.

If two parties have diametrically opposed views and are unable to compromise thenshared decision-making will be limited. We feel ethically justified in coercive treatment because we have decided that the patient does not have the capacity to decide on his treatment and therefore we are acting in hisbest interests. This highlights the two issues that are at the heart of the debate - 'capacity' and 'best interests'.

In practice, the judgment of capacity is often treated as a relatively simple matter where if a patient is refusing medication they are seen as lacking the ability to weigh the information necessary to make this decision.

The question of best interests is also frequently treated as uncomplicated - that it is in a patient's best interests to ensure they receive antipsychotic medication. But can we say we know what the best interests are for a patient who has spent the majority of their life trying to avoid contact with psychiatry and has personally felt no benefitfrom antipsychotic medication? Are we justified in saying, as Das does, thatthey were "saved from their itinerant salubrious lifestyle". I do not think it is an impossible notion that an individual might prefer to live awithdrawn or chaotic life rather than one imposed on them externally. Putting yourself in an individual's shoes to determine their best interests means understanding their wishes and motivations, not those of the medical profession or the rest of society. When a psychiatrist judges the best interests of a patient, the decision is formed from within a system that is extremely risk averse and often appears to be built on the premise of avoiding psychosis to the exception of all else. The scales we use to weigh various eventualities (for example, psychosis; stability; side effects; risk to others) may be quite different to those that individuals would choose for themselves in their pre-morbid state. Best interests for an individual will vary tremendously depending on the attitude that individual has to life.

Antipsychotics can be tremendously beneficial medications but there will be a subset of patients who receive little benefit from them. Recent research on treatment trajectories (3) supports the idea that the benefit of antipsychotic medication may primarily be in 'dramatic responders', with patients who show a more modest response being difficult to distinguish from those treated with placebo. Furthermore, as in all of medicine, there will be patients whose long term outcome would have been superior without treatment. Despite best intentions, our interventions may sometimes harm patients and recognising this is the onlyway we can make progress in minimizing this unpalatable truth.

The problems we have to deal with are not easy to solve. Terms such as 'patient choice' are meaningless and obscure the issues at heart. We need to talk about specifics. Many of the decisions we deal with as psychiatrists are made on the basis of limited evidence and cannot be madeobjectively. It aids both us and our patients to realise that while psychiatric training and experience opens one's eyes to many of the complexities of mental illness, it can just as easily narrow one's view asto how a life can be lived.

References

1. Das S. Critical appraisal of the Schizophrenia Commission's report(letter). Psychiatrist 2013; 37:72-73

2. Morrison AP, Hutton P, Shiers D, Turkington D. Antipsychotics: is it time to introduce patient choice? Br J Psychiatry 2012; 201: 83-84

3. Marques TR, Arenovich T, Agid O, Sajeev G, Muthen B, Chen L, Kinon BJ, Kapur S.The different trajectories of antipsychotic response: antipsychotics versus placebo. Psychol Med 2011; 41: 1481-1488

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Conflict of interest: None declared

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