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Joint Decision Making and Reduced Need for Compulsory Psychiatric Admission

Joint Decision Making and Reduced Need for Compulsory Psychiatric Admission 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 in most countries of the world (whether codified and regulated by law or not) measures to treat people with mental illness on a basis of compulsory admissions are used and are sometimes commonly used. Within the psychiatric profession, there has been an uneasy elision between the duty to care for patients and the responsibility to act for society, on whose behalf physicians often use compulsory admissions (eg, to protect the public from risk by people who are mentally unwell). Various wording has been used to try to reconcile these separate and often contradictory roles, such as the provision of the “least restrictive alternative” form of treatment by the physician. This dual professional role is now subject to a profound challenge from the United Nations Convention on the Rights of Persons With Disabilities (CRPD).2 Among many other provisions, the CPRD makes clear that direct decision making by patients and forms of supported decision making are permissible under the convention, but that substituted decision making (which is the essence of compulsory treatment decisions by psychiatrists) is not allowed. Because the CPRD has now been signed by 159 countries worldwide and ratified (made legally binding) by 151, a vital question arises over whether the traditional practices of psychiatrists’ exercising legally authorized or de facto powers of compulsory admissions, in both hospital 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 the day-to-day clinical dilemmas faced by staff who treat and care for people who at times may lack mental capacity in specific domains and who, for example, may actively threaten to harm themselves or others. Therefore, the responsible implementation of the CRPD 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 compulsory hospital admissions: community treatment orders (sometimes called involuntary outpatient commitment) (3 studies), compliance enhancement techniques (2 studies), and augmentation of standard care (which they termed integrated treatment) (4 studies), alongside assessing the effect of advance statements (including advance directives and joint crisis plans [JCPs]) (4 studies). For the first 3 options, there was no evidence that they were effective. Admittedly, the sample size for each category was small, and arguably they each 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 range of decision-making interventions, which vary with 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 recovery-oriented treatment planning, and indeed these directives may have the power of law. Psychiatric advance directives aim to promote consumer choice, prioritize the goal of autonomy, and improve the working alliance with mental health professionals. However, they have not been shown to have an effect on rates of involuntary hospitalization. The most likely reason for this observation is that they are enacted only when the holder is deemed to have lost capacity to make treatment decisions, are only used at a late stage of a relapse of illness, and may not 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 form of treatment planning has generally acted as the control 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 center of this spectrum as a particular application of shared decision making. To achieve this directive, JCPs require an external facilitator, namely, an independent third party, to complete the crisis plan. The facilitator, a mental health professional independent of the treatment team, aims to engage the service user and treating mental health professionals in writing the JCP. Developed after consultation with consumers, this process aims to empower service users or consumers, while facilitating early detection and treatment of relapse. Held by the service user, a JCP contains his or her treatment preferences for any future psychiatric emergency using first-person language. The results of a pilot randomized clinical trial of JCPs for people with psychotic or bipolar illness showed reduced involuntary hospitalization associated with their use,5 and the authors reported positive views of the plans by service users and mental health professionals compared with treatment by the usual types of local community mental health teams that used largely staff-written care plans. The larger CRIMSON (Crisis Plan Impact: Subjective and Objective Coercion and Engagement) multisite trial of JCPs delivered in routine practice found a positive effect on service user–rated therapeutic relationships6 and cost-effectiveness for black patients,7 who are more at risk of involuntary admissions; however there was no reduction in involuntary admissions observed.6 There was clear evidence that the full JCP process had not been fully implemented by many staff members because of attitudinal barriers by health care professionals to sharing clinical decision-making powers with patients. The qualitative elements of the CRIMSON study revealed that many staff, especially psychiatrists, were uncomfortable in sharing clinical decision-making powers with patients.8 Therefore, joint decision making faces challenges both in principle (eg, whether compulsory admission powers should be retained by psychiatrists) and in practice (eg, whether staff will genuinely implement jointly agreed treatment plans with patients as a part of an advance statement). Increasingly, such implementation barriers are being recognized as a critical brake on health care improvement. For example, clinical guidelines are now produced to a high technical standard in many countries worldwide, based on exhaustive reviews of the relevant evidence, yet there are few studies of how far they are implemented in routine clinical practice. Such studies more often identify barriers than facilitators to successful implementation. Therefore, the field now sometimes termed dissemination and implementation science is one of growing significance to translate the findings of clinical trials into routine patient benefit. The review by de Jong et al1 raises the intriguing possibility that hospital admissions using compulsory powers can be substantially reduced by actively including patients (on an equal footing with staff) as partners in planning future treatment and care options. Such an approach, based upon patient choice, would be the antithesis to the paternalistic model of medical care. When fully implemented and evidence based, it will promote liberty. Back to top Article Information Corresponding Author: Graham Thornicroft, PhD, MSc, MBBS, Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, King’s College London, De Crespigny Park, London SE5 8AF, England (graham.thornicroft@kcl.ac.uk). Published Online: June 1, 2016. doi:10.1001/jamapsychiatry.2016.0571. Conflict of Interest Disclosures: None reported. Funding/Support: Dr Thornicroft is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College London Foundation Trust, by the Department of Health via the NIHR Biomedical Research Centre and Dementia Unit awarded to South London and Maudsley National Health Service (NHS) Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust, and by the European Union Seventh Framework Programme (FP7/2007-2013) Emerald Project. Role of the Funder/Sponsor: The funding sources had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The views expressed are the opinions of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health. References 1. de Jong MH, Kamperman AM, Oorschot M, et al. Interventions to reduce compulsory psychiatric admissions: a systematic review and meta-analysis [published online June 1, 2016]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.0501.Google Scholar 2. United Nations. Convention on the Rights of Persons With Disabilities. New York, NY: United Nations; 2006. 3. Freeman MC, Kolappa K, de Almeida JM, et al. Reversing hard won victories in the name of human rights: a critique of the General Comment on Article 12 of the UN Convention on the Rights of Persons With Disabilities. Lancet Psychiatry. 2015;2(9):844-850.PubMedGoogle ScholarCrossref 4. Swanson J, Swartz M, Ferron J, Elbogen E, Van Dorn R. Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates. J Am Acad Psychiatry Law. 2006;34(1):43-57.PubMedGoogle Scholar 5. Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, Szmukler G. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ. 2004;329(7458):136.PubMedGoogle ScholarCrossref 6. Thornicroft G, Farrelly S, Szmukler G, et al. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet. 2013;381(9878):1634-1641.PubMedGoogle ScholarCrossref 7. Barrett B, Waheed W, Farrelly S, et al. Randomised controlled trial of joint crisis plans to reduce compulsory treatment for people with psychosis: economic outcomes. PLoS One. 2013;8(11):e74210. doi:10.1371/journal.pone.0074210.PubMedGoogle ScholarCrossref 8. Farrelly S, Lester H, Rose D, et al. Improving therapeutic relationships: joint crisis planning for individuals with psychotic disorders. Qual Health Res. 2015;25(12):1637-1647.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Psychiatry American Medical Association

Joint Decision Making and Reduced Need for Compulsory Psychiatric Admission

JAMA Psychiatry , Volume 73 (7) – Jul 1, 2016

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American Medical Association
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Copyright © 2016 American Medical Association. All Rights Reserved.
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2168-622X
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2168-6238
DOI
10.1001/jamapsychiatry.2016.0571
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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 in most countries of the world (whether codified and regulated by law or not) measures to treat people with mental illness on a basis of compulsory admissions are used and are sometimes commonly used. Within the psychiatric profession, there has been an uneasy elision between the duty to care for patients and the responsibility to act for society, on whose behalf physicians often use compulsory admissions (eg, to protect the public from risk by people who are mentally unwell). Various wording has been used to try to reconcile these separate and often contradictory roles, such as the provision of the “least restrictive alternative” form of treatment by the physician. This dual professional role is now subject to a profound challenge from the United Nations Convention on the Rights of Persons With Disabilities (CRPD).2 Among many other provisions, the CPRD makes clear that direct decision making by patients and forms of supported decision making are permissible under the convention, but that substituted decision making (which is the essence of compulsory treatment decisions by psychiatrists) is not allowed. Because the CPRD has now been signed by 159 countries worldwide and ratified (made legally binding) by 151, a vital question arises over whether the traditional practices of psychiatrists’ exercising legally authorized or de facto powers of compulsory admissions, in both hospital 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 the day-to-day clinical dilemmas faced by staff who treat and care for people who at times may lack mental capacity in specific domains and who, for example, may actively threaten to harm themselves or others. Therefore, the responsible implementation of the CRPD 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 compulsory hospital admissions: community treatment orders (sometimes called involuntary outpatient commitment) (3 studies), compliance enhancement techniques (2 studies), and augmentation of standard care (which they termed integrated treatment) (4 studies), alongside assessing the effect of advance statements (including advance directives and joint crisis plans [JCPs]) (4 studies). For the first 3 options, there was no evidence that they were effective. Admittedly, the sample size for each category was small, and arguably they each 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 range of decision-making interventions, which vary with 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 recovery-oriented treatment planning, and indeed these directives may have the power of law. Psychiatric advance directives aim to promote consumer choice, prioritize the goal of autonomy, and improve the working alliance with mental health professionals. However, they have not been shown to have an effect on rates of involuntary hospitalization. The most likely reason for this observation is that they are enacted only when the holder is deemed to have lost capacity to make treatment decisions, are only used at a late stage of a relapse of illness, and may not 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 form of treatment planning has generally acted as the control 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 center of this spectrum as a particular application of shared decision making. To achieve this directive, JCPs require an external facilitator, namely, an independent third party, to complete the crisis plan. The facilitator, a mental health professional independent of the treatment team, aims to engage the service user and treating mental health professionals in writing the JCP. Developed after consultation with consumers, this process aims to empower service users or consumers, while facilitating early detection and treatment of relapse. Held by the service user, a JCP contains his or her treatment preferences for any future psychiatric emergency using first-person language. The results of a pilot randomized clinical trial of JCPs for people with psychotic or bipolar illness showed reduced involuntary hospitalization associated with their use,5 and the authors reported positive views of the plans by service users and mental health professionals compared with treatment by the usual types of local community mental health teams that used largely staff-written care plans. The larger CRIMSON (Crisis Plan Impact: Subjective and Objective Coercion and Engagement) multisite trial of JCPs delivered in routine practice found a positive effect on service user–rated therapeutic relationships6 and cost-effectiveness for black patients,7 who are more at risk of involuntary admissions; however there was no reduction in involuntary admissions observed.6 There was clear evidence that the full JCP process had not been fully implemented by many staff members because of attitudinal barriers by health care professionals to sharing clinical decision-making powers with patients. The qualitative elements of the CRIMSON study revealed that many staff, especially psychiatrists, were uncomfortable in sharing clinical decision-making powers with patients.8 Therefore, joint decision making faces challenges both in principle (eg, whether compulsory admission powers should be retained by psychiatrists) and in practice (eg, whether staff will genuinely implement jointly agreed treatment plans with patients as a part of an advance statement). Increasingly, such implementation barriers are being recognized as a critical brake on health care improvement. For example, clinical guidelines are now produced to a high technical standard in many countries worldwide, based on exhaustive reviews of the relevant evidence, yet there are few studies of how far they are implemented in routine clinical practice. Such studies more often identify barriers than facilitators to successful implementation. Therefore, the field now sometimes termed dissemination and implementation science is one of growing significance to translate the findings of clinical trials into routine patient benefit. The review by de Jong et al1 raises the intriguing possibility that hospital admissions using compulsory powers can be substantially reduced by actively including patients (on an equal footing with staff) as partners in planning future treatment and care options. Such an approach, based upon patient choice, would be the antithesis to the paternalistic model of medical care. When fully implemented and evidence based, it will promote liberty. Back to top Article Information Corresponding Author: Graham Thornicroft, PhD, MSc, MBBS, Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, King’s College London, De Crespigny Park, London SE5 8AF, England (graham.thornicroft@kcl.ac.uk). Published Online: June 1, 2016. doi:10.1001/jamapsychiatry.2016.0571. Conflict of Interest Disclosures: None reported. Funding/Support: Dr Thornicroft is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College London Foundation Trust, by the Department of Health via the NIHR Biomedical Research Centre and Dementia Unit awarded to South London and Maudsley National Health Service (NHS) Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust, and by the European Union Seventh Framework Programme (FP7/2007-2013) Emerald Project. Role of the Funder/Sponsor: The funding sources had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The views expressed are the opinions of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health. References 1. de Jong MH, Kamperman AM, Oorschot M, et al. Interventions to reduce compulsory psychiatric admissions: a systematic review and meta-analysis [published online June 1, 2016]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.0501.Google Scholar 2. United Nations. Convention on the Rights of Persons With Disabilities. New York, NY: United Nations; 2006. 3. Freeman MC, Kolappa K, de Almeida JM, et al. Reversing hard won victories in the name of human rights: a critique of the General Comment on Article 12 of the UN Convention on the Rights of Persons With Disabilities. Lancet Psychiatry. 2015;2(9):844-850.PubMedGoogle ScholarCrossref 4. Swanson J, Swartz M, Ferron J, Elbogen E, Van Dorn R. Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates. J Am Acad Psychiatry Law. 2006;34(1):43-57.PubMedGoogle Scholar 5. Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, Szmukler G. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ. 2004;329(7458):136.PubMedGoogle ScholarCrossref 6. Thornicroft G, Farrelly S, Szmukler G, et al. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet. 2013;381(9878):1634-1641.PubMedGoogle ScholarCrossref 7. Barrett B, Waheed W, Farrelly S, et al. Randomised controlled trial of joint crisis plans to reduce compulsory treatment for people with psychosis: economic outcomes. PLoS One. 2013;8(11):e74210. doi:10.1371/journal.pone.0074210.PubMedGoogle ScholarCrossref 8. Farrelly S, Lester H, Rose D, et al. Improving therapeutic relationships: joint crisis planning for individuals with psychotic disorders. Qual Health Res. 2015;25(12):1637-1647.PubMedGoogle ScholarCrossref

Journal

JAMA PsychiatryAmerican Medical Association

Published: Jul 1, 2016

Keywords: advance directives,decision making,ethics, medical,human rights,paternalism,patient admission,psychiatry,psychiatric emergencies,involuntary commitment,hospital admission

References