Joint Decision Making and Reduced Need for Compulsory Psychiatric Admission

Abstract

The article by de Jong et al1 in this issue of JAMA Psychiatry raises fundamental questions about the practice of psychiatry. In essence, the review finds that advance statements can reduce the occurrence of compulsory admissions by approximately one-quarter, while community treatment orders, medication compliance enhancement, and integrated treatment measures were ineffective in reducing compulsory admissions. Why is this issue important? Writing in On Liberty, John Stuart Mill differentiated between liberty as the freedom to act and liberty as the absence of coercion. Yet, it is clear that inmost countries of theworld (whether codified and regulated by law or not) measures to treat people withmental illness on a basis of compulsory admissions are used and are sometimes commonly used. Within the psychiatric profession, therehasbeenanuneasyelisionbetween theduty tocare forpatientsandtheresponsibilitytoact forsociety,onwhosebehalfphysiciansoftenusecompulsoryadmissions (eg, toprotect the public from risk by peoplewho arementally unwell). Variouswordinghasbeenusedtotry toreconcile theseseparateand oftencontradictory roles, suchas theprovisionof the“least restrictive alternative” formof treatment by the physician. This dual professional role is now subject to a profound challenge from the United Nations Convention on the Rights of PersonsWithDisabilities (CRPD).2 Amongmany other provisions, the CPRDmakes clear that direct decisionmaking by patients and forms of supported decisionmaking are permissibleunder the convention, but that substituteddecisionmaking (which is the essence of compulsory treatment decisions by psychiatrists) is not allowed. Because the CPRD has now been signedby 159 countriesworldwide and ratified (made legally binding) by 151, a vital question arises over whether the traditional practices of psychiatrists’ exercising legally authorizedordefactopowersofcompulsoryadmissions, inbothhospital and community settings, are compatible with the CRPD or not.3 These considerations are complex issues that need to respect the fundamental human rights of all persons, including those with disabilities. They also need to take into account theday-to-dayclinicaldilemmas facedbystaffwho treat and care for people who at timesmay lackmental capacity in specific domains andwho, for example,mayactively threaten toharmthemselvesorothers.Therefore, theresponsible implementationof theCRPD is a pressing international challenge to the mental health sector. Against this background, the article by de Jong et al1 adds important evidence to support these debates on how to reduce compulsory admissions in mental health care. The authors tested the following 4 candidate interventions to reduce compulsoryhospital admissions: community treatment orders (sometimes called involuntary outpatient commitment) (3studies), complianceenhancement techniques (2studies), and augmentation of standard care (which they termed integrated treatment) (4 studies), alongside assessing the effect of advance statements (including advance directives and joint crisisplans [JCPs]) (4 studies).For the first 3options, there was no evidence that they were effective. Admittedly, the samplesize foreachcategorywassmall, andarguably theyeach contained somewhat heterogeneous interventions. For example, integrated treatment included several different types of augmented standard care, namely, crisis resolution teams, integrated treatment in first-episode schizophrenia, and psychoeducation. For the community treatment orders and compliance enhancement interventions, these studies (both individually and when analyzed by group) also demonstrated no evidence of benefit, as shown in the forest plot in the article by de Jong et al.1 Yet, advance statements showed a 23% risk reduction in compulsory admissions. The term advance statements covers a rangeof decision-making interventions,whichvarywith respect to their basis in legislation and the manner in which health professionals are involved in their creation.4 Advance directives lie at one extreme of this range because their content is determined solely by the patient or consumer. In the United States, supporting people to create a psychiatric advance directive is viewed as a component of recoveryoriented treatmentplanning, and indeed thesedirectivesmay have the power of law. Psychiatric advance directives aim to promoteconsumerchoice,prioritize thegoalof autonomy,and improve the working alliance withmental health professionals. However, they have not been shown to have an effect on ratesof involuntaryhospitalization.Themost likely reason for this observation is that they are enactedonlywhen theholder is deemed to have lost capacity tomake treatment decisions, are onlyused at a late stage of a relapse of illness, andmaynot be able to prevent such admissions. Routine treatment or care plans lie at the other, more paternalistic, end of the crisis planning spectrum because they may be produced without any patient or consumer involvement, although by consensus it is not seen as good practice. This formof treatmentplanninghasgenerallyactedas thecontrol in trials of other types of advance statements. In addition to advanced statement and care plans, the third type of such advance statements includes JCPs, which lie toward the cenRelated article page 657 Opinion