Mental health: involuntary treatment and its consequences

Andrés Fontalba

"If Mr. McMurphy doesn’t want to take his oral medication [...], I'm sure we can administer it in another way."

The character of nurse Mildred Ratched in One Flew Over the Cuckoo's Nest presents a serious, strict, orderly and authoritative figure, with a lot of self confidence and all her actions are carried out with the firm conviction that they are aimed at the welfare of the patients in her care. If we asked her if she takes into account the patients' point of view she would answer, without a doubt, affirmatively. The clear example appears in a discussion in which she is asked to watch a game of baseball on television where she goes the extra mile in persuading all that everyone's vote is necessary for any change in the usual programming, thus she finally manage to impose her point of view. She would not hesitate at any time to use persuasion, interpersonal influence, or even threat to guarantee the administration of a prescribed treatment.

These behaviours are still coercive measures in mental health, and the most often described are involuntary admission, retention after voluntary admission, mechanical restraint, isolation and forced administration of medication. The use of these measures as a treatment of mental illness has been reported since ancient times, therefore, it’s an old debate not yet concluded between the freedom of the individual and his free choice of treatment if he suffers a mental disorder opposed to the school of thought that states that these measures are unavoidable, so that a patient accepts treatment and doesn’t harm himself or others, alluding to reasons of safety and protection.

These coercive measures are common throughout the world, although there are marked differences even among European countries, with various different legal frameworks, which leave patient's rights at risk and hinder the incorporation of valuable clinical practices. This clinical variability could be explained by different social attitudes towards mental disorder or unjustified clinical habits or routines. It’s striking that, despite the frequent use of these measures in very diverse contexts, there’s a lack of empirical evidence and an absence of correlation between these interventions with the patients’ prognosis and their health outcomes, and that until very recently, there were very few studies on it and even those presented methodological deficiencies.

To answer this question, the EUNOMIA study (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) was designed and launched. This study gathered the data of a large number of patients recruited in ten countries, its main objective was to evaluate the variations between countries in the use of coercive measures, the factors with which they were related and their results. A secondary analysis of the cohort of 2.030 patients admitted involuntarily, to 770 of whom one or more coercive measures were applied, demonstrated that the measure that produced the most impact on resistance to the treatment was the involuntary administration of pharmacological treatment.

If we take the point of view of clinical management, all the coercive measures were associated with patients being hospitalized for longer. Keeping the patient alone and confined in one room was the most significant predictor for having a longer hospital stay, which added twenty-five days on average to the hospital admission, and all this independently of the symptoms presented at the time of admission.

Patients perceive the use of coercive measures as a humiliating situation and generate additional stress. Likewise, prolonging a hospital admission complicates the long-term results, since it supposes a rupture with their vital process and the exclusion of their environment, and an excessive duration of the hospitalization complicates the later reintegration of the person to his environment.

Aware of this problem, the World Health Organization in the Resource Manual on Mental Health, Human Rights and Legislation concludes that people with mental disorders are particularly vulnerable to abuse and violation of their rights. Discrimination due to a mental disorder can have repercussions on access to adequate health care, as well as on other areas of life, such as employment, education and housing. The inability to integrate properly into society as a consequence of these limitations can increase the isolation experienced by a person, which in turn can aggravate the mental disorder.

The most vicious social coercive measure is stigma, so that anything that exacerbates or ignores the stigma associated with mental illness can make this discrimination even more serious. In addition to the obvious suffering due to mental disorders, there’s this hidden burden of stigma and discrimination. Stigma can manifest itself in multiple ways, through stereotypes, fear, shame, anger, rejection or exclusion. Hence, violations of human rights and basic freedoms and the denial of civil, political, economic, social and cultural rights to those suffering from mental disorders are a common occurrence throughout the world, both in institutional settings and in the community.

To avoid stigma, we need to work equally, to prohibit discrimination and inhuman and degrading treatment, to defend the right to privacy and personal autonomy and in the field of health, the obligation to build a less restrictive environment of freedom and rights to information and patient participation.