Encouraging Pursuit of Court-Ordered Treatment in a State Hospital

The relationship between psychiatry and the law is complex and multifaceted. The rules and regulations governing the practice of psychiatry far exceed those applicable to other branches of medicine. However, the law has provided psychiatrists with unique tools such as involuntary hospitalization and court-ordered treatment, which when used appropriately can help achieve the goals of restoring emotional and behavioral stability to patients with severe mental illness.

This paper focuses on one of these tools: court-ordered treatment, including both court-ordered medications and electroconvulsive therapy. We address why and how we encouraged the use of court-ordered treatment at our institution, a state-operated mental health facility with more than 500 beds, and we discuss the results that were achieved.

Treatment refusal and its consequences

Refusal of medication can be addressed in various ways. The choice of a method will depend primarily on the severity of a patient's illness and on the treatment setting. In an outpatient setting, patient education, counseling, or psychotherapy—or a combination of these approaches—may be preferred. However, in an acute care setting with a patient who is at imminent risk of causing harm to self or others, intense efforts to educate and counsel are certainly in order but will not succeed in all cases. Other methods, including involuntary or court-ordered treatment, may be necessary.

Compared with psychotic patients who take medications, unmedicated psychotic patients have longer hospital stays, are more likely to require seclusion or restraint during hospitalization, and have higher rates of actual or threatened assaults (1). Unmedicated depressed patients are more likely than their medicated counterparts to commit suicide (2). Although a recent retrospective study indicated otherwise (3), a study by Loebel and associates (4) supported the proposition that denial or delay of treatment with psychotropic medications in first episodes of schizophrenia results in increased morbidity and chronicity. There is also substantial evidence that denial or delay of treatment with psychotropic medication in subsequent episodes results in more refractory symptoms among patients with schizophrenia and more frequent affective episodes among those with bipolar disorder (5).

Assertive treatment

In 1997 we weighed the risks and benefits for our hospital population of patients with severe and persistent mental illness and determined that the assertive treatment our patients deserve should include the active pursuit of court-ordered medications for those who refuse treatment and who meet the appropriate statutory criteria. Patients who meet the criteria are those who have a serious mental illness resulting in a deterioration of their ability to function, or suffering, or threatening behavior and a lack of capacity to make a reasoned decision about treatment. The term "assertive treatment" became the theme of a hospitalwide effort that ultimately extended to all disciplines and treatment approaches.

There is no doubt that some patients regard involuntary administration of medication as a negative event. However, Greenberg and colleagues (6) found that 60 percent of 30 patients subjected to enforced medication retrospectively agreed with the decision. Frese (7) wrote particularly persuasively of his own experience in this regard: "I sometimes wonder what would have become of me had someone not given me the treatment I so desperately needed but was so opposed to accepting." Judge David Bazelon (8) questioned from an informed legal perspective, "How real is the promise of individual autonomy for a confused person set adrift in a hostile world?"

Getting physicians to court

It is axiomatic that treating physicians do not like to go to court. They are subjected to cross-examination, the purpose of which is to make them appear ignorant or foolish or both. "Losing" is ego-deflating and frustrating. Time is taken away from other duties. If our assertive treatment effort was to succeed, our job as medical administrators had to be not only one of reversing this avoidance mentality but also one of gaining the enthusiastic support of our staff psychiatrists who would most directly bear the burden of the task.

We began our effort in June 1997 as a performance improvement project. We used as benchmarks the number of petitions filed for court-ordered medications in the preceding year and the number of patients who were currently refusing psychotropic medications for one week or more. Although the one-week period may appear arbitrary, there is evidence that the majority of patients who refuse medication decide to accept it within one week of refusal (9).

At the same time, we began an educational campaign, the theme of which was that high-quality care of acutely ill psychiatric patients requires assertive treatment and that one important aspect of such treatment is the use of psychotropic medications early in a patient's hospital stay. As part of the educational process, we focused on instilling the concept that when a petition for medication is denied, the patient—not the physician—is the loser. Over time, our hospital developed training tapes and conducted in-service presentations, including a mock trial and personal coaching in courtroom demeanor.

The third part of the process was to monitor outcomes and provide feedback to our treatment teams. Since the beginning of the project, a one-page monthly report has been sent to all psychiatrists and unit administrators at our hospital. The report lists by unit the numbers of patients who refused medications for one week or more in the preceding month. It also lists the names of the psychiatrists who brought petitions for court-ordered treatment to conclusion in mental health court. The outcomes of the petitions—granted or denied—are reported as hospitalwide totals. We do not identify the individual psychiatrists who "won" or "lost" petitions, but units that continue to have patients who refuse medications and physicians who do not pursue the court option are easily identified. The consistent message is that there is no disgrace in "losing," only in not trying. The only winners or losers are the patients.

Evaluation of the project

The annual number of petitions filed rose from a baseline of 97 for the year preceding the project to 192 for the 12-month period ending on June 30, 2000.

The process was not problem free. Backlogs were encountered in the mental health court. The demands for jury trials increased. However, during this period the number of hours of restraint use per 1,000 patient days decreased by 11 percent. Patients' injuries caused by other patients decreased by 29 percent. The average length of stay on our acute units decreased by 31 percent for civilly committed patients and 37 percent for forensic patients. The number of patients readmitted within 30 days remained constant.

We do not claim that these results are attributable solely to the filing of more petitions for court-ordered medications and electroconvulsive therapy. We do suggest, however, that heightened awareness among our staff psychiatrists about the benefits of assertive treatment contributed to these results.

Discussion and conclusions

A frequently cited study of the outcomes of involuntary administration of medication is that of Cournos and colleagues (10). The study was a retrospective 12-month comparison of 51 chronically and severely mentally ill patients who received court-ordered medication for periods ranging from three months to more than a year and a matched cohort of involuntary patients who accepted medications. The authors concluded that for the majority of patients, involuntary treatment "did not result in rapid return to the community or later compliance with medication," nor did it produce "the insight and cooperation that psychiatrists hope to achieve." The authors acknowledged, however, that they studied "only committed patients whose stays were far longer than the typical state hospital patients." They suggested that "it may be counterproductive to wait to intervene only when refusal is persistent and the patient is chronically ill and that earlier intervention may be more successful."

Our experience supports this hypothesis. We suggest that early intervention with medications and electroconvulsive therapy, court ordered if necessary, is beneficial in ways not necessarily assessed in the study by Cournos and associates, such as reducing patients' suffering, use of restraints, and violent behavior. Further inquiry is clearly indicated. Our experience also demonstrates that with sufficient education and support, clinicians' attitudes and behaviors can change significantly in a manner consistent with improved patient care.

Dr. Patel is clinical assistant professor of psychiatry in the department of psychiatry at Finch University of Health Sciences- Chicago Medical School, 3333 Green Bay Road, North Chicago, Illinois 60064-3095. Dr. Hardy is clinical associate professor of psychiatry at Stritch Medical School at Loyola University in Chicago.