A new study based on a survey of 30 forcibly treated, discharged psychiatric patients found that 60 percent retrospectively favored having been treated against their will.

The study by William Greenberg, M.D., acting medical director of the division of psychiatry at Bergen Pines County Hospital in New Jersey, and colleagues touched on an area rarely explored by psychiatrists.

"This is a study that was started in the throes of the changes we were going through in the early 1980's," Greenberg told Psychiatric News. "Very few people have looked at the issue." Yet it is true that many involuntary patients remain hostile to the mental health profession after treatment, he said.

The balance between autonomy and care is perhaps the most difficult treatment issue facing psychiatry, observed Greenberg. "I think this is an area where caring and concerned clinicians really struggle among themselves." Most clinicians have seen circumstances in which mentally incompetent individuals have made decisions harmful to themselves or others, he added.

"[Forcible medication is] not dehumanizing people or blindly robbing them of their autonomy for your convenience. It's a felt necessity that we have when we see people destroying their lives," Greenberg said. He likened the situation to that of a parent seeing a child engaged in self-destructive behavior.

A series of decisions, starting with Rogers v. Commissioner (Okin) in 1979 and Rennie v. Klein in 1983, tended to "cast all psychiatrists as careless in the use of medication and relatively disrespectful of patients' autonomy. They also included a view of the medications being used as extremely dangerous," Greenberg explained. In particular, many judges reflected deep fear of drug-induced tardive dyskinesia.

"Many of us were concerned because we knew many patients' refusal was not based only on trying to avoid unpleasant reactions," but instead on delusional thinking, said Greenberg. Clinicians are concerned that the image of "a poor, victimized, screaming patient being unreasonably forced to take dangerous medications doesn't do justice to the clinical realities we deal with on a day-to-day basis," he said.

The study identified 65 discharged patients for the survey but obtained responses from only 30, of which 60 percent thought they should have been forcibly medicated, about a third thought they should not, with the rest unsure.

The small percentage of respondents may limit the findings and is one of the problems of a post-discharge survey, Greenberg noted. An earlier survey by Harold Schwartz, M.D., now director of the Institute of Living in Hartford, Conn., looked at 24 patients just prior to discharge. Seventeen of the 24 patients surveyed by Schwartz said that in retrospect they should have been medicated, and if they suffered a recurrence in which they were dangerous to themselves or others, should be medicated again. That study was criticized as possibly reflecting patients' fears that a candid response might jeopardize their discharge, said Greenberg.

Schwartz noted that despite that weakness, his study included a complete assessment of the mental state of his 24 respondents, while the Greenberg study did not.

Schwartz said that some of those who do not agree retrospectively with having been medicated may be delusional despite having been helped by medication. Others may be nonresponders who know from experience that they will not be helped by medication, while a very small percentage may be people who should never have been forcibly medicated.

Greenberg echoed Schwartz, noting that of nine interviewed patients who clearly retrospectively still disagreed with having been forcibly medicated, three were diagnosed with bipolar mania and four with paranoid schizophrenia. Such disorders are characterized by delusional thinking, he observed.

Although Schwartz and Greenberg agreed that forcible medication is more often than not in the patient's interest, it does not mean that forcible treatment is always the right thing, Schwartz commented.

"I would never presume that everybody who is medicated against [his] will is medicated to good effect or that it is the right choice for each person."

A theoretical solution to the problem is the so-called "Ulysses contract," a psychiatric advance directive. It is named after Homer's voyager in The Odyssey who bade his crew strap him to the mast of his ship so he could hear the seductive song of the sirens without drowning himself in a state of transient madness, explained Greenberg. The concept is that of an advance directive by a currently lucid person stating what should be done if he or she requires forcible psychiatric treatment in the future. In theory, it protects caregivers from arbitrary court rulings denying them the right to treat patients, and protects patients strongly opposed to a particular treatment modality. While Minnesota state law provides for such a directive, the concept has not caught on, Schwartz commented.

Unlike other advance directives, which presume that a patient decides what should be done if he or she lapses into unconsciousness during a future illness, a Ulysses contract is problematic because it implies a situation in which a conscious but irrational person could strongly protest his or her own prior directive, said Schwartz. (Psychiatric News, February 7, 1997)