Are our policies and laws leading to treatment delays for people with schizophrenia?
It seems so, suggests a review of the evidence around involuntary treatment orders, conducted by the Deeble Institute for Health Policy Research and Schizophrenia Research Institute.
Time for a rethink around involuntary treatment for people with schizophrenia
Dr Anne-marie Boxall writes:
Under Australian mental health laws, people with schizophrenia can only be involuntarily committed to a mental health facility if they are assessed and it is determined that their illness is making them dangerous to themselves or others.
To determine whether they are to undergo involuntary treatment, mental health workers must assess people against an ‘Obligatory Dangerousness Criterion’. This criterion is an advance on methods used prior to the mid-1970s, when many countries authorised involuntary commitment to a mental health facility on medical certification alone, without court approval or any proof of an emergency situation.
An Obligatory Dangerousness Criterion is now widely used in Australia, the USA, and some areas of Canada and Europe as the means by which patients are assessed for the appropriateness of involuntary (compulsory) treatment.
There is no doubt the policy underpinning its use was well intentioned; an Obligatory Dangerousness Criterion was originally developed in an attempt to better balance the rights of the mentally ill with the need to protect the public.
However, over time some experts have begun to raise questions about the utility of this criterion, suggesting that it sometimes means patients don’t get access to necessary treatment as quickly as they should.The problem stems from the fact that in order to be classified as being dangerous to themselves or others, people generally need to have a history of violence or self-harm, and most patients in their first episode of psychosis do not have this kind of history.
Up to 80 per cent of patients in their first episode of psychosis require inpatient treatment early in their illness. In many cases, admission to hospital has to be involuntary because few people recognise that their symptoms are due to an illness.
In community-based treatment, patients sometimes do not adhere to the treatment prescribed, and this may lead to consideration of compulsory community treatment orders.
When people with schizophrenia do not adhere to or consent to treatment, their families, friends, mental health professionals and the legal system may have to wait for them to threaten, attempt, or complete acts that could, or do, result in harm, before they can be involuntarily admitted to hospital, or before compulsory community (outpatient) treatment orders are initiated.
In these circumstances, necessary treatment is delayed, and when psychosis is left untreated for lengthy periods, it adversely affects a person’s psychological state and can lead to poorer outcomes (see for example here, here and here).
While many countries continue to use an Obligatory Dangerousness Criterion to determine whether involuntary treatment is justified, some countries have also begun to use other methods: the United Kingdom (UK) and some parts of Canada and Europe, for example.
In these countries involuntary treatment is permissible even if patients have not been assessed as dangerous, but only if they have previously been deemed incapable of giving consent when it comes to matters of their own health and welfare.
As an example, to commit someone with schizophrenia to involuntary treatment in the UK, a formal application must be made by either an approved mental health professional or the patient’s nearest relative. This application is then assessed by two qualified medical practitioners, one of whom must be approved for this purpose under the Act.
With some countries moving away from relying solely on an Obligatory Dangerousness Criterion to determine if involuntary treatment is justified, Australian policymakers should re-examine current mental health laws, along with the evidence underpinning them.
The evidence in this field is not clear cut, but there are some systematic reviews showing that the use of an Obligatory Dangerousness Criterion can have a detrimental effect on patients suffering from schizophrenia because it can delay timely access to treatment (see for example here, here and here).
The criterion has been shown to particularly problematic for patients in their first-episode of psychosis, and over the short to medium term. The impact of an Obligatory Dangerousness Criterion on long-term outcomes for patients is yet to be determined. See the full version of this paper for a more detailed examination of the evidence.
Because it is likely to be some time before there is strong evidence on the long-term impact of an Obligatory Dangerousness Criterion, there needs to be a broader discussion in Australia and other countries about how we should address the challenge of committing people to involuntary treatment when they cannot or will not consent to voluntary treatment.
Australia should first examine the criteria used in other countries. If there are other policy options available that make inpatient psychiatric treatment more accessible, reduce the duration of untreated psychosis, improve treatment outcomes, and reduce dangerous behaviours in people with severe mental illness, they should be considered.
• Dr Anne-marie Boxall is Director of The Deeble Institute for Health Policy Research, and Managing Editor, Australian Health Review