1. Community treatment orders (CTO's).
a. Ethical Objections
We believe that CTO's are contrary to the spirit of community psychiatry and community care more generally. The value of civil liberties underscored the original move away from institutional forms of care. Institutions were seen to be stigmatising, brutalising and anti-therapeutic environments. Reformers campaigned against them largely because they failed to respect the human rights of those who were incarcerated. Medical care and social support was to be provided for people with mental health problems in the community so that they could function as ordinary citizens. We believe that CTO's, which would impel patients to take drugs against their wishes, even when well, involve a move away from this respect for human rights. It will mean that a person who has fully recovered from a disabling episode of emotional disorder, but who is now functioning adequately will be forced to receive drugs prescribed by a psychiatrist. The rights of such people will be substantially restricted even though they will not have committed any crime. Thus, CTO's will render psychiatric patients as 'second class' citizens. Their introduction will cast a shadow over all patients who come in contact with mental health services. The proposals are discriminatory, and fly in the face of the government's stated intention to give disabled people more protection from discrimination.
We are making a clear distinction between, on the one hand, medical interventions for the good of the patient, and on the other hand, interventions designed for chemical restraint. While there may be effective physiological or chemical interventions for changing offending conduct, such as castration for rapists, these are not medical interventions. The role of doctor is that of a healer, not an agent of social control.
We believe that CTO's will involve psychiatrists in practices which run contrary to the GMC code of practice, as outlined in Duties of a Doctor. A basic tenet of medical practice is that doctors should not harm their patients. In the normal course of events doctors inform patients about the potential risks of any particular treatment so patients can make informed decisions about whether or not to accept treatment. Sometimes, when a patient is incapacitated, the doctor treats according to her/his judgement of the patient's best interests. The situation in which CTO's will operate is very different. The patient is recovered and capable of making decisions (including decisions such as voting, buying property, travelling abroad). The patient may be willing to tolerate the risk of recurrence, or does not consider him/herself to be disabled in the way understood by psychiatrists. The doctor enforces treatment against the patient's will. All psychiatric drugs have serious unwanted effects. It is widely recognised that the class of drugs most likely to be forced onto patients by CTO's, the neuroleptics, carry risks of long-term irreversible neurological harm, especially tardive dyskinesia (TD). Kane and Smith (1982) reviewed over 70 early studies of TD, and found that on average 20% of people exposed to long-term treatment with major tranquillisers had TD.. Most authorities now accept that chronic exposure to major tranquillisers greatly increases the risk of developing it, and once it has started there is no really successful way of controlling it. Abnormal facial movements usually become worse as the dose of neuroleptic is reduced. The condition constitutes a serious hazard associated with the prolonged use of neuroleptics, and may be associated with memory impairment and brain damage (Famuyiwa et al,1979).
We would also draw the scoping group's attention to the short-term hazards of high dose neuroleptic medication described in the Royal College of Psychiatrists' Consensus Statement on the use of high dose neuroleptic drug (Thompson, 1994). There have been reports of sudden death in young people treated with very high doses of neuroleptic medication, by Simpson et al (1987; quoted in Thompson, 1994), and by Mehtonen et al (1991). In the UK there have been thirteen reports of sudden deaths in patients on pimozide (a neuroleptic) to the Committee on the Safety of Medicines (CSM). In response the CSM (1990) recommended a reduction in the maximum safe dose of this drug. It is thought that these deaths occurred because of the effects that these drugs have on the heart. They can interfere with the conduction of electrical activity responsible for regulating the contraction of heart muscle fibres. They are also known to cause a dramatic fall in blood pressure, as well as depressing activity in the brain centres which regulate breathing. CTO's will exacerbate drug induced problems, placing doctors and patients in an intolerable position. For example, if the patient shows evidence of serious harm from the enforced drugs, should the prescription continue or be withdrawn? CTO's could require psychiatrists not to act in the patient's interests, with the result that patients will suffer.
Since coming to office, the government has rightly stressed the importance it attaches to social inclusion in attempts to help those members of society who have complex social needs. The introduction of CTO's has implications for such people, particularly the values that we hold to be important in the way in which society goes about helping them. CTO's will focus attention on medication, locating the problem within the individual person. This will intensify stigma, increase social exclusion of this group, and divert attention away from the social and environmental causes of distress and breakdown. The end result will be a situation where health and social services staff spend most of their time enforcing CTO's and less time working to provide care and support.
b. Practical Objections
On a practical level, we do not believe that CTO's will achieve the aim of 'protecting the public'. In fact we strongly contest the notion that psychiatric patients in general are a significant danger to the public. It is important to get risks into perspective. A review article in the British Journal of Psychiatry (Taylor & Gunn, 1999) has shown that whilst overall there was a fivefold increase in homicide in the UK from 1957 to 1995, there was a decline of 3% per annum in the contribution to these figures by people with mental illness.
There are many causes of emotional distress. Most episodes of mental breakdown are related to factors in the person's environment: their occupational and housing situation, their family position and the nature of their significant relationships, personal and sometimes racial abuse from neighbours. Such factors are also important when it comes to recovery. There is no doubt that psychotropic drugs have a part to play in helping many people recover in the short-term from breakdown. But in practice they are not a panacea. We have already considered the risks these drugs pose. Although most psychiatrists believe that these drugs favourably influence the long-term outcome of psychoses, the evidence for this is debatable. For example, Kane and Freeman (1994), eminent authorities on the drug management of schizophrenia have reviewed the advantages and drawbacks of neuroleptic treatment. They make the point that a number of authorities have doubted whether neuroleptics have a beneficial effect on outcome.
"...it remains debatable whether or not long-term neuroleptic treatment substantially alters the course and outcome of this disorder..."
(Kane & Freeman, 1994, p.22)
Recent evidence (Thornley & Adams,1998) raises concerns about the validity of drug trial studies which are widely quoted in support of the effectiveness of neuroleptic drugs in the longer term prophylaxis of psychosis. They examined over 2,000 drug trials in schizophrenia over the last 50 years, and concluded that that these studies were of limited quality and limited clincial utility. This consistently poor quality is likely 'to have resulted in an overoptimistic estimations of the effects of (drug) treatment.' Schooler (1991) found that the results of naturalistic long-term follow up studies in schizophrenia show clearly the great diversity of outcomes of the condition. Despite long term medication, some people appear to have a very poor outcome. On the other hand some people do very well with little or no medication. These studies suggest that although neuroleptic medication may be effective in the short term control of psychotic symptoms, their value in preventing relapse or improving outcome in the long-term is much less clear. In addition to this, between 25 to 50% of patients on these drugs continue to experience hallucinations and delusions. The situation is summarised well by another quote from Kane and Freeman (1994):
'Thus, current neuroleptics, despite their great value in controlling schizophrenic symptoms, have a number of major drawbacks. They are far from consistently effective, and a substantial subgroup of patients derive little if any benefit from them. They remain ineffective against negative symptoms. They cause adverse neurological effects which may interfere with psychosocial and vocational rehabilitation and are associated with major problems of drug compliance.'
Our clinical experience indicates that many people have been able to discontinue medication, often against medical advice, and with very positive outcomes. In addition to the irreversible hazards described above, these drugs have many debilitating subjective side effects, such as drowsiness, lethargy, poor motivation, depression, nausea, irritability, insomnia, appetite disturbances and impaired sexual function. One of the major complaints of the user movement is that psychiatrists pay little attention to these negative and distressing effects. CTO's may mean that the quality of life of many more patients will be adversely affected by these unwanted drug effects.
Sadly, the history of psychiatry is not a story of medical enlightenment and progress, but often one of oppression and abuse. Recently, there has been an increasing awareness by management and professional staff of the importance of user perspectives on services and treatment. This has been encouraged by the policy of successive governments over the last 10 years. For example, the Patients' Charter makes it clear that patients have the right to expect treatment to be explained, including the risks and advantages and any alternatives before they consent. A sense of trust is at last begining to emerge between staff, users and carers. There is a sense, from both sides, that a new relationship between medicine and madness can be defined. The current government has put forward a number of progressive ideas about the development of services. However, undoing the damage of the past and building trusting relationships between staff and users will take time. If we have learnt anything about psychiatric services and treatment in the past thirty years it is that there is no such thing as a 'quick fix' solution or a 'magic bullet' with which we can rid ourselves of suffering. Good psychiatric services involve good relationships between staff, users and carers.
The introduction of CTO's has the potential to undermine much of the trust which has been built recently. The government supports the development of 'assertive outreach' teams which work intensively with people over long periods of time in the community. While this could be a positive move, assertive outreach combined with CTO's would result in 'coercive outreach'. This would be a disaster for all concerned, and would lead to a very deep sense of mistrust between many users and psychiatric services. This would be a retrogressive step. Instead of turning to professional staff in times of crises, users will seek to avoid professional services at all costs. The introduction of CTO's could mean that many users 'play down' their difficulties and seek to disengage from services.
2. Reviewable Detention
a. Ethical and Human Rights Objections
In Modernising Mental Health Services the government has proposed the introduction of 'a new form of reviewable detention for those people with a severe personality disorder who are considered to pose a grave risk to the public' (section 4.33). The introduction of any form of preventive, or reviewable, detention is an extremely serious political and human rights issue, and one which has to be debated widely throughout society. It is certainly not appropriate to smuggle such legislation through the backdoor using mental health legislation. In our opinion 'reviewable detention' (or any other version of preventive detention) for 'personality disorders', defined medically under a mental health act, would be equivalent to the social and political abuse of psychiatry witnessed in the former Soviet Union. We do not consider it right that any medical person should be involved with preventive detention. If society wishes to establish controls for people thought to be dangerous this is not a medical matter, but one for the criminal justice system. In summary, our position on this matter is based on the following beliefs:
1. That reviewable detention is a political matter, not a medical one.
2. That psychiatry does not possess a special knowledge which is valid in terms of medical science, and which allows it to predict dangerousness or the risk of reoffence.
3. That there are no effective psychiatric interventions for these offenders.
In judging risks, psychiatrists, like others, refer to information about history and context. There is no evidence that they are better placed than any other group to make predictions about dangerousness. These are strong arguments to distance psychiatrists from powers of preventive detention.
b. Problems with the concept of personality disorder
In setting out the remit of the scoping group, the government has also solicited views about who should be included under the terms of the mental health act. We believe that the category of 'personality disorder' is contentious. It is conceptually weak, has little scientific validity, and little explanatory or predictive power. There is considerable disagreement within psychiatry as to whether the concept is of any use at all. There is no consensus that psychiatric interventions are effective in reducing the risk that these people pose society. In practice the term is often used simply to denote someone who is hostile, dangerous, aggressive or uncooperative, or whose behaviour constitutes a serious sexual threat to the vulnerable. In other words, it is substantially value-laden, even more so than other psychiatric terms. Many psychiatrists believe that there are no grounds for including this category within the scope of mental health legislation.
3. Improving Patients' Control
It is inevitable that there are times when patients are so incapacitated by emotional turmoil and distress, that they neglect themselves or place themselves in need of care. At such times autonomy must be sacrificed and professionals work beneficently. This poses difficulties for many service users who fear that the have no way of stopping professional interventions which run counter to their wishes. MIND has already introduced a 'crisis card' system, but we support fully the proposals of some user groups for advance directives. We believe the new act should include legislation to give advance directives a legal status, which obliges professionals to respect patients' wishes. In addition, new legislation should be introduced to give all detained patients a statutory right to independent patient advocacy.
1. We object strongly to the government's calls for the introduction to CTO's. There are strong ethical arguments and practical difficulties which, in our view, make such legislation unconscionable.
2. The proposal to introduce reviewable detention raises profound human rights issues, and if introduced would turn psychiatrists into jailors. The issues here are of such importance that in our view our society must engage in a very full and thorough debate so that this difficult area can be thought through carefully.
3. The government should use this review of mental health legislation to implement measures, such as advance directives and advocacy, that will place more control in the hands of people who use mental health services.
Those attending the meeting on 8th January, 1999:
Simon Baugh Consultant Psychiatrist, Bradford Community Health Trust
Mike Basher Trainee psychiatrist, The Maudsley Hospital
Pat Bracken Consultant Psychiatrist, Bradford Community Health Trust, and Senior Research Fellow, University of Bradford
Duncan Double Consultant Psychiatrist, Norwich
Claire Henderson Research Psychiatrist, Institute of Psychiatry
Steve Hopker Consultant Psychiatrist, Bradford Community Health Trust
William Hopkins Consultant Psychiatrist & Lead Medical Clinician, Barnett Health Care Trust
Rhodri Huws Consultant Psychiatrist, Sheffield
Joanna Moncrieff Research Psychiatrist, Chelsea & Westminster Hospital
Marcellino Smyth Consultant Psychiatrist, North Birmingham Mental Health Team
Phil Thomas Consultant Psychiatrist, Bradford Community Health Trust, and Senior Research Fellow, University of Bradford
Committee on the Safety of Medicines (1990) Cardiotoxic effects of pimozide. Current Problems, Number 29.
Famuyiwa, O.O., Eccleston, D. & Donaldson, A.A. (1979) Tardive dyskinesia and dementia. British Journal of Psychiatry, 135, 500 - 504.
Kane, J.M. & Freeman, H.L. (1994) Towards more effective antipsychotic treatment. British Journal of Psychiatry. 165 (suppl. 25) 22 - 31.
Kane, J.M. & Smith, J.M. (1982) Tardive dyskinesia - prevalence and risk factors, 1959 to 1979. Archives of General Psychiatry, 473 - 481.
Mehtonen, O.-P., Aranko, K., Malkonen, L. et al (1991) A study of sudden death associated with the use of antipsychotic or antidepressant drugs. Acta Psychiatrica Scandinavica, 84, 58 - 64.
Schooler, N. (1991) Maintenance medication for schizophrenia: strategies for dose reduction. Schizophrenia Bulletin, 17, 311 - 324.
Simpson, G.M., Davis, J., Jefferson, J.W. et al (1987) Sudden deaths in psychiatric patients: the role of neuroleptic drugs. American Psychiatric Association task force report, 27. Washington DC, APA.
Taylor, P. & Gunn, J. (1999) Homicides by people with mental illness: Myth and Reality. British Journal of Psychiatry. 174. 9 - 14.
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