Robert Whitaker: Medical Science Argues Against Forced Treatment Too

The argument that is usually made against involuntary commitment and forced treatment is that these actions, under the authority of a state, violate a person’s basic civil rights. They deprive a person of liberty and personal autonomy, and do so in the absence of a criminal charge. The United Nations Convention on the Rights of Persons With Disabilities upholds that position by prohibiting discrimination in relation to these rights. That is a morally powerful argument, and it should stand at the center of any protest against forced treatment.

However, there is another argument, one of adjunctive value, that can be made against involuntary commitment and forced treatment. Medical science argues against forced treatment too.

The “state,” in order to justify involuntary commitment and forced treatment, will argue that such coercion is necessary to provide “medical treatment” to individuals who, because of their impaired state of mind, won’t give their consent to such treatment. The implication is that if the “psychotic” individual were of sound mind, he or she would want this treatment, and thus the state is serving as a helpful guardian. But this “medical” argument falls apart upon close examination.

First, there is evidence that psychiatric hospitalization itself—whether voluntary or involuntary– leads to an increased risk of suicide. In a 2014 study, researchers at the University of Copenhagen looked at the psychiatric care received by 2,429 individuals in the year before they committed suicide, and after matching this group of completed suicides to a control group of 50,323 people in the general population, and after making adjustments for risk factors, they concluded that the risk of dying from suicide rose as people received increasing levels of psychiatric care. Taking psychiatric medications was associated with a six-fold increased likelihood that people would kill themselves; contact with a psychiatric outpatient clinic with an eight-fold increase; visiting a psychiatric emergency room with a 28-fold increase; and admission to a psychiatric hospital a 44-fold increase.[1]

In an editorial that accompanied the article, which was published in the Journal of Social Psychiatry and Psychiatric Epidemiology, the writers—all experts in suicide research—observed that these were robust findings. The Danish study, they wrote, “demonstrated a statistically strong and dose-dependent relationship between the extent of psychiatric treatment and the probability of suicide. This relationship is stepwise, with significant increases in suicide risk occurring with increasing levels of psychiatric treatment.” This link was so strong, they concluded, that “it would seem sensible, for example, all things being equal, to regard a non-depressed person undergoing psychiatric review in the emergency department as at far greater risk [of suicide] than a person with depression, who has only ever been treated in the community.”

These researchers concluded that it is “entirely plausible that the stigma and trauma inherent in (particularly involuntary) psychiatric treatment might, in already vulnerable individuals, contribute to some suicides. We believe that it is likely that a proportion of people who suicide during or after an admission to hospital do so because of factors inherent in that hospitalization.”[2]

Second, from a medical point of view, the “therapeutic relationship” between “patient” and “doctor” is understood to be an important factor to a “good outcome,” and forced treatment regularly leads to a breakdown in that relationship. The personal accounts of people who have been forcibly treated regularly compare it to torture, rape, and so forth. Moreover, these accounts cannot be dismissed as the writings of people who are “impaired” in their thinking, either at the time or later; such personal accounts often reveal an extraordinary level of detail and clarity.

Third, forced treatment regularly involves injections of an antipsychotic, and such initial treatment is regularly a precursor to long-term treatment with such drugs (and often in a coercive manner). However, there is now substantial evidence that such drug treatment over the long term does harm. For instance:

  • There is evidence that the drugs shrink brain volumes, with this shrinkage associated with an increase in negative symptoms, functional impairment, and cognitive decline.[3]
  • The drugs induce tardive dyskinesia in a significant percentage of patients, which reflects permanent damage having been done to the basal ganglia.
  • Martin Harrow, in his longitudinal study of psychotic patients, found that medicated patients fared worse over the long-term on every domain of functioning. The medicated patients were eight times less likely to be in recovery at the end of 15 years than those off the medication.[4]

This is simply a quick review of the medical case that can be made against forced treatment. But even this cursory review tells of treatment that increases the risk of suicide, can prove devastating to the “therapeutic relationship,” and may set a person onto a long-term course of medication use that has been found to be associated with a variety of harms and poor outcomes. As such, the argument that involuntary commitment and forced treatment are in the best “medical” interest of the “impaired” person falls apart when viewed through this scientific lens, and once it does, involuntary commitment and forced treatment can be clearly seen for what they are.

They are not a means for providing necessary “medical help” to an individual. They are an assertion of state authority and power over an individual, and that assertion of authority violates the person’s fundamental civil rights. Any societal discussion of involuntary commitment and forced treatment needs to focus on that issue, and not be distracted by the “medically helpful” claim.

 

[1] C. Hjorthøj, Risk of suicide according to level of psychiatric treatment—a nationwide nested case control study. Soc Psychiatry Psychiatr Epidemiol (2014) 49: 1357-65.

[2] M. Large. Disturbing findings about the risk of suicide and psychiatric hospitals. Soc Psychiatry Psychiatry Epidemiol (2014) 49:1353-55.

[3] J. Radua, “Multimodal meta-analysis of structural and functional changes in first 
episode psychosis and the effects of antipsychotic medications,” Neuroscience and Biobehavioral Review 36 (2012): 2325–33.

[4] M. Harrow. “Factors involved in outcome and recovery in schizophrenia patients not on antipsychotics medications.” J Nerv Ment Dis (2007) 195: 407-414.

 

 

Peter Gøtzsche – FORCED ADMISSION AND FORCED TREATMENT IN PSYCHIATRY CAUSES MORE HARM THAN GOOD

http://www.deadlymedicines.dk/forced-admission-and-forced-treatment-in-psychiatry-causes-more-harm-than-good/

By Peter C. Gøtzsche, Professor, MD, DrMedSci, MSc

8 March 2016

Forced treatment in psychiatry as we currently know it cannot be defended, neither on ethical, legal or scientific grounds. Ethically, the patients’ values and preferences are not being respected, although the fundamental human right to equal recognition before the law applies to everyone, also to people with mental disorders.1,2 This is clear from the United Nations Convention on the Rights of Persons with Disabilities,2 which virtually all countries have ratified. However, we ignore the convention and continue to discriminate against people with mental problems.

Please consider this. Doctors cannot give patients insulin without their permission, not even if the lack of insulin might kill them, and they cannot give adult Jehova’s witnesses blood transfusions without their permission, even if the lack of blood might kill them. The only drugs that can be given without permission are also some of the most dangerous ones. Psychiatric drugs are the third major killer after heart disease and cancer, with an estimated 539,000 deaths in the United States and European Union combined.1,3 Only soldiers at war and psychiatric patients are forced to run risks against their will that might kill or cripple them. But there is an important, ethically relevant difference: soldiers have chosen to become soldiers; psychiatric patients have not chosen to become psychiatric patients.

In many countries, a person considered insane, or in a similar condition, can be admitted to a psychiatric ward on an involuntary basis if the prospect of cure or substantial and significant improvement of the condition would otherwise be significantly impaired. After having studied the science carefully over many years, I have come to doubt that this is ever the case.1

Forced treatment most commonly involves the use of antipsychotics, but they are very poor drugs. The placebo controlled trials are seriously flawed because they have not been adequately blinded.1 Antipsychotics have many and conspicuous side effects, so most doctors and patients can guess whether an active drug or a placebo is given, which exaggerates the measured effect markedly.1 Furthermore, almost all patients in these trials were already in treatment with an antipsychotic drug before they were randomised after a short wash-out period. This cold turkey design means that abstinence symptoms – which may include psychosis – are being inflicted on patients who get placebo. Even helped by these formidable biases in the trials, the outcome is poor. The minimal improvement on the Clinical Global Impressions Ratings corresponds to about 15 points on the Positive and Negative Syndrome Scale,4 but what was obtained in recent placebo controlled trials in submissions to the FDA for newer antipsychotics was only 6 points,5 although it is easy for scores to improve quite a bit if people are knocked down by a tranquilliser and express their abnormal ideas less frequently. Thus, the FDA has approved newer antipsychotic drugs whose effect is far below what is clinically relevant. Old drugs are similarly ineffective.1

Whereas the benefits of antipsychotics are doubtful, the harms are certain, and the cold turkey design is lethal. One in every 145 patients who entered the trials for risperidone, olanzapine, quetiapine and sertindole died, but none of these deaths were mentioned in the scientific literature.6 Therefore, if we want to find out how lethal these drugs are, we should look at trials in dementia, as such patients are not so likely to have received antipsychotics before randomisation. Randomised trials in dementia shows that for every 100 patients treated for a few weeks, one is killed by an antipsychotic, compared to those treated with placebo.7 It could even be worse than this because deaths are seriously underreported in published trials. For example, a review found that only 19 of 50 deaths and 1 of 9 suicides on olanzapine described in trial summaries on websites also appeared in journal articles.8

There is no evidence that mechanical restraint in belts or seclusion has any benefits, but these treatments can also be lethal. Violence breeds violence and when psychotic patients become violent, it is very often because of the inhumane treatment they receive. It may also be because they get abstinence symptoms when they drop a few doses of an antipsychotic because they are very unpleasant to take, which can include akathisia – an extreme form of restlessness that predisposes to both suicide and homicide.1

Electroshock is also forced on people although it doesn’t seem to work for schizophrenia and although the effect on depression is temporary, which often results in a series of shocks.1 About half of the patients get memory loss1 and the more treatments they get, the more severe is the memory loss.9 Some psychiatrists claim that electroshock can be lifesaving but this has never been documented whereas we know that electroshock may kill people: about 1 in 1000 patients die.10

Another reason for using force is if patients present an obvious and substantial danger to themselves or others, in which case they can be involuntarily admitted. However, this is not necessary. The National Italian Mental Health Law specifies that a reason for involuntary treatment cannot be that the patient is dangerous. This is a matter for the police, as it also is in Iceland, and patients in Italy can decide that they want treatment elsewhere.1

Forced treatment does more harm than good and it kills many people, not only because of the direct harms of the drugs but also because of suicide. A register study of 2,429 suicides showed that the closer the contact with psychiatric staff – which often involves forced treatment – the worse the outcome.11 Compared to people who had not received any psychiatric treatment in the preceding year, the adjusted rate ratio for suicide was 44 (95% confidence interval 36 to 54) for people who had been admitted to a psychiatric hospital. These patients would be expected to be at greater risk of suicide than other patients (confounding by indication), but most of the potential biases in the study favoured the null hypothesis of there being no relationship. An accompanying editorial noted that some of the people who commit suicide during or after an admission to hospital do so because of conditions inherent in that hospitalisation.12

I fully admit that some patients are very difficult to treat optimally without using force. But it seems that, with adequate leadership and training of staff in de-escalation techniques, it is possible to practice psychiatry without using force.1,13,14 In Iceland, belts have not been used since 1932, and there are psychiatrists all over the world who have dealt with deeply disturbed patients for their entire career without ever having used antipsychotics, ECT or force.1

I believe we have to abolish laws of forced admission and treatment, in accordance with the United Nations Convention on the Rights of Persons with Disabilities.2 Abandoning using force will be harmful to some patients but it will benefit vastly many more. We will need to work out how we may best deal with those patients who would have benefited from forced treatment in a future where force is no longer allowed.

Peter C Gøtzsche graduated as a Master of Science in biology and chemistry in 1974 and as a physician 1984. He is a specialist in internal medicine. Co-founded the Cochrane Collaboration in 1993 and established The Nordic Cochrane Centre the same year. He became professor of Clinical Research Design and Analysis in 2010 at the University of Copenhagen.

References

1 Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press; 2015.

2 United Nations Convention on the Rights of Persons with Disabilities. General comment No. 1 2014 May 19. http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G14/031/20/PDF/G1403120.pdf?OpenElement (accessed 1 April 2015).

3 Gøtzsche PC. Does long term use of psychiatric drugs cause more harm than good? BMJ 2015;350:h2435.

4 Leucht S, Kane JM, Etschel E, et al. Linking the PANSS, BPRS, and CGI: clinical implications. Neuropsychopharmacology 2006;31:2318-25.

5 Khin NA, Chen YF, Yang Y, et al. Exploratory analyses of efficacy data from schizophrenia trials in support of new drug applications submitted to the US Food and Drug Administration. J Clin Psychiatry 2012;73:856–64.

6 Whitaker R. Mad in America. Cambridge: Perseus Books Group; 2002.
7 Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-

analysis of randomized placebo-controlled trials. JAMA 2005;294:1934–43.

8 Hughes S, Cohen D, Jaggi R. Differences in reporting serious adverse events in industry sponsored clinical trial registries and journal articles on antidepressant and antipsychotic drugs: a cross-sectional study. BMJ Open 2014;4:e005535.

9 Sackeim HA, Prudic J, Fuller R, et al. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology 2007;32:244-54.

10 Read J, Bentall R. The effectiveness of electroconvulsive therapy: a literature review. Epidemiol Psichiatr Soc 2010 Oct-Dec;19:333-47.

11 Hjorthøj CR, Madsen T, Agerbo E, et al. Risk of suicide according to level of psychiatric treatment: a nationwide nested case-control study. Soc Psychiatry Psychiatr Epidemiol 2014;49:1357–65.

12 Large MM, Ryan CJ. Disturbing findings about the risk of suicide and psychiatric hospitals. Soc Psychiatry Psychiatr Epidemiol 2014;49:1353–5.

13 Fiorillo A, De Rosa C, Del Vecchio V, et al. How to improve clinical practice on involuntary hospital admissions of psychiatric patients: Suggestions from the EUNOMIA study. Eur Psychiat 2011;26:201-7.

14 Scanlan JN. Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far, a review of the literature. Int J Soc Psychiat 2010;56:412–23.