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Ask the Mental Health Expert Archives 2001-2004

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Medication Against Will

Q. I am a student working on a research project dealing with the ethical issues concerning medication against the client's will and coercive treatment. What is the standard of care? I have noted throughout the research there is much concern voiced by patient advocacy groups. Why can I not find research, or standards of care from the psychiatric community and care providers? It is easy to see, reading bulletin boards from patients, that this happens. Am I looking in the wrong places?

A. You may be having problems because you are not finding the right resources, and because there is no single, monolithic standard of care that governs the use of involuntary medication, restraints, etc., in all U.S. psychiatric facilities. The general standard of psychiatric care vis-à-vis involuntary medication is stated in Dr. Robert Simon's book, Psychiatry & Law for Clinicians (American Psychiatric Press, 1998): "Psychotropic medications, usually neuroleptics, should not be used solely for the purpose of physically immobilizing a patient. Psychotropic medications are indicated for the treatment of a patient's psychiatric disorder that is the cause of behavior requiring emergency control." (p. 118).

In addition, the American Psychiatric Association has a position statement in their "Task Force Report 22" (1985, 1992), which notes, among other things, that "medication, if rationally used, may shorten the length of stay in seclusion by helping the patient to gain mastery and control over aggressive urges. One hazard, however is that the patient is rendered so lethargic and helpless by drugs that he becomes disorganized and combative thus clinicians need to tread a line between under and over medication and document specific target symptoms that respond to psychotropic agents. Some patients in seclusion can be offered medication orally; this may be preferable to the repetitive and demeaning injection of medication to a patient who is in restraint or in seclusion."

The APA is now updating their policies in light of recent regulations proposed by the U.S. Health Care Financing Administration (HCFA) and by Senators Dodd and Lieberman. For more on these developments, see the APA website (www.psych.org/pub_pol_adv/sec_res_rior_test.cfm). Also see www.hcfa.gov/quality/4b1/htm. The Veterans Administration has also published its own patients' rights guidelines (see Federal Register, Dec. 1982). A good recent review article is by RM Wettstein, entitled, "The right to refuse psychiatric treatment", in Psychiatric Clinics of North America, March 1999. Another good source of more patient-oriented information is the National Alliance for the Mentally Ill (http://www.nami.org).

I hope all this gets you started on your project.

March 2001

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