Coerced medication in psychiatric care

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It is a very long time since I had inside experience of inpatient psychiatric care. Decades ago, as a student nurse, I spent several months on placement in a large psychiatric hospital, part of the time in a 60-bedded locked ward that housed severely disturbed patients. For a young person without previous exposure to people with severe mental illness it was initially a frightening experience, especially when patients were aggressive and, equally, when the nurses used physical force and restraint. I do not recall the term ‘medication coercion’ being used, but coercion it certainly was when patients had refused their medications and persuasion had failed. But I quickly got used to this, presumably accepting that there was no alternative and I understood that medication compliance was a crucial part of treatment.

So why was I shocked, on reading Jarrett et al.’s (2008) literature review in this issue of JAN (pp. 538–548) to discover that ‘coerced medication’ is still practised? I suppose it seems shocking because it goes so much against the grain of the principle of ‘informed voluntary consent’ that now underpins all modernized healthcare systems. And, in all enlightened societies, the use of physical coercion in any circumstance is increasingly regarded as socially unacceptable. At the same time, the experience of mental illness has become better understood and, with more care based in the community, it has become more visible. Except, that is, for inpatient psychiatric care which, on the whole, remains hidden from view. So, yes, I was shocked by Jarrett et al.’s paper – shame that I needed to be – by the reminder that people still succumb to mental illness so severe that they require inpatient psychiatric care. And that medication, although more sophisticated and effective, is still the cornerstone of treatment in severe and emergency psychiatric situations. There has to be some means, therefore, of ensuring medication compliance. If no alternative is available that can only be achieved by coercion, however much we may wish that this should not be used.

Jarrett et al.’s review of the literature relating to coerced medication (CM) did not uncover alternatives. Indeed, there has been ‘a complete absence of investigation of alternatives’ (p. 546), they say; and, further, they propose that this and the overall dearth of research suggests that CM has become a ‘taken-for-granted’ practice. It also needs to be acknowledged, however, that researching CM in a rigorous way and with any significant number of patients is a hugely challenging and complicated task. I am not suggesting, of course, that research should not be attempted: indeed, I hope that Jarrett et al.’s review will prompt an imaginative and robust international programme of research in this area.

A clear list of research recommendations is offered at the end of the paper (p. 547). Probably the most important of these are the recommendations that mental health service users should be involved in exploring definitions of CM and those patients who have experienced CM should share their concerns. Patients who have been involved in previous research have said, in retrospect, that they agreed that CM had been necessary but, at the same time, they had found it a fearful and embarrassing experience (p. 546). How powerful it would be if patients themselves could participate in the development of alternative approaches or, if and when CM is necessary, what measures should be taken to protect their dignity and their rights.

Jarrett et al. also recommend that future research should address staff training and attitudes in relation to coercive care, and so it must. But I hope that this JAN paper will not cause readers to judge or criticize inpatient psychiatric staff who use CM. On the contrary, this paper reminds us of the very difficult and sometimes dangerous job that these staff do, on our behalf, in caring for people who are seriously mentally disturbed.

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