Psychiatrists' opinion about involuntary outpatient reatment.

INTRODUCTION: Involuntary outpatient treatment (IOT) is a kind of compulsory outpatient treatment, whose aim is to improve the adherence to the treatment in people with severe mental illness and with no awareness of disease. In these cases, therapeutic abandonment involves a high risk of relapse, with appearance of disruptive and/or self-aggressive or hetero-aggressive behavior, repeated hospitalizations and frequent emergencies. The application of IOT is not an issue without contention. Therefore, the need of legislative regulation in Spain has been a controversial subject for several years, and there are both advocates and opponents.
OBJECTIVE: The objective of this study is to bring together the opinion of clinical psychiatrists and resident doctors in psychiatry on the involuntary outpatient treatment and its legislative regulation. MATERIAL AND
METHOD: This study is descriptive in nature. The study population consists of 42 clinical professionals in mental health (32 psychiatrists and 10 resident doctors in psychiatry). At the beginning of this study (March 2018), some of these professionals were working in the Psychiatry Department's facilities of the University Hospital Complex of Huelva. A personal survey in paper form consisting of ten questions about IOT was carried out to each member of this study.
RESULTS: 85.7% of clinicians know the current initiative that tries to carry out the legislative regulation of IOT, and 92.8% of them agree to such regulation. In this sense, 83.3% of them are against the fact that more coercive measures for the psychiatric patients such as the involuntary commitment or the civil incapacitation are regulated and IOT is not. On the one hand, 78.6% of the professionals in mental health believe that IOT is beneficial for the patients. Moreover, 95.2% of them think that is beneficial for their relatives, too. On the other hand, 78.6% of clinicians do not consider that the application of IOT to mentallyill patients is stigmatizing.
CONCLUSION: The vast majority of clinicians think that the legislative regulation of involuntary outpatient treatment is necessary in Spain, and they think this treatment is beneficial not only for the patient but also for their family.

INTRODUCTION

Involuntary outpatient treatment- (IOT) is a type of mandatory treatment for outpatients applied in the community, which sets out to guarantee treatment compliance amongst persons who present a severe mental illness, especially patients who are unaware that they are ill and those for whom abandoning treatment would involve a high risk of relapse, with disruptive and/or auto-agressive or hetero-aggressive behaviour, repeated hospitalisation and frequent visits to A&E.

The application of IOT is a controversial issue. Therefore, the need or not for its legislative regulation in Spain has been a controversial subject for a number of years, and its use has both advocates and opponents.

On an international level, IOT is now regulated by legislation in many EU countries (France, Holland, Italy, Portugal, etc.) and in the UK, along with many developed countries (USA, Canada, Australia, New Zeeland), and in some less developed ones (Israel) in other continents.

In the USA, the approval of Kendra’s Law in New York State (1999) and Laura’s Law in the State of California (2002) are relevant to this issue. These laws have been used to regulate the application of IOT in both states. Most of the states that form the USA now have laws that permit IOT.

In Canada there are currently 12 mental health acts that regulate IOT. For its part, New Zeeland regulates the matter via articles 28 and 29 of the Mental Health 1992; while Australia has had IOT for over 20 years, although the nineties were the years when the reforms of the Community Treatment Order (CTO) proliferated. IOT is regulated in Israel via the Treatment of the Mentally Ill Law, 1991.

The IOT programmes of these countries have some differences (reasons leading to implementation, existing modalities, etc.) and similarities (all cases involve persons with severe mental illnesses, with scarce treatment adherence and who present frequent relapses and admissions).

In Spain, IOT has engendered considerable debate in recent years, at both legal and medical levels. Although the controversy is a long-standing one, it has become more open since 2004, when the political party Convergencia i Unió proposed a Bill to the Spanish Parliament, which set out to modify article 763 of the Civil Proceedings Act 1/2000, in order to regulate IOT. The debates included assessments of the opinions a different psychiatric associations, and there were a number of differences of opinion. The Spanish Psychiatry Society (Sociedad Española de Psiquiatría (SEP)) took a posture that was frankly in favour of regulating IOT; the Spanish Society of Legal Psychiatry (Sociedad Española de Psiquiatría Legal (SEPL)) was in favour, but with some reservations; while the Spanish Neuropsychiatric Association (Asociación Española de Neuropsiquiatría (AEN)) was completely opposed to the idea, arguing that it is a “discriminatory and stigmatising measure, with no scientific evidence to prove its efficacy” for the mentally ill. This confrontation, combined with other political motives, led to the bill not being accepted.

The debate reached the Ombudsman who, after hearing both sides, prepared a report in 2005 that followed the line adopted by the AEN, and was against the need for regulation of IOT, arguing that article 6 of the Oviedo Convention and article 9 of Law 31/2002 provided enough legislative guarantees to deal with such situations.

However, in 2006 the Cabinet of the Socialist Government approved a Voluntary Jurisdiction Bill to regulate IOT, which was also rejected when it began to be debated in the Senate.

Since then the situation in Spain regarding IOT has not changed. It is applied to some persons with severe mental illness under court sentence, although there is not explicit legislation regulating it, unlike many surrounding countries, where it is in fact regulated.

In this setting, in early 2018, the Aragonese Society of Legal Psychiatry and Forensic Sciences took up the issue once again, presenting a new proposal propuest for regulation of IOT to the Legislative Branch, in which a series of technical criteria and an established protocol are provided. Its aim is to guarantee that patients with severe mental illness and who, by definition are unaware that they are ill, can be treated.

Thus, at present-, and with no knowledge as yet of the outcome of the regulation proposal submitted by the above-mentioned association, the application of IOT in Spain continues to depend on the discretion of the courts, and is regarded as a controversial issue, with its proponents and opponents in both the medical and legal communities, whose arguments can be seen in summarised form in Table 1.

Table 1

Arguments in favour and against involuntary outpatient treatment (IOT)

A favor del TAI	En contra del TAI
La falta de conciencia de enfermedad es un síntoma en sí mismo.	No se ha demostrado que sea suficientemente efectivo.
No se ha demostrado que tenga efectos perjudiciales.	Convierte el tratamiento comunitario en custodial.
Frente al ingreso: favorece el tratamiento en un entorno menos restrictivo.	Destruye la relación terapéutica.
Responsabiliza al clínico de la evolución del paciente.	Es discriminativo y supone un riesgo de estigmatización de pacientes y profesionales.
Permite que se puedan evitar recaídas y reingresos.	Interfiere el derecho a rechazar el tratamiento.
Mejora la calidad de vida del paciente.	Hace énfasis en el control más que en la asistencia.
Ayuda a evitar que pacientes con alteración grave de su libertad y, por tanto, de su voluntad, abandonen el tratamiento y las consecuencias secundarias.	Se desvalorizan las razones competentes para no aceptar ser tratado.
Prioriza la atención a los casos más graves. Acerca los servicios a los pacientes más necesitados.	Intimida a los pacientes.
Puede favorecer la potenciación de servicios comunitarios	Conlleva dificultades prácticas: implementación de medidas complementarias judiciales y policiales difíciles de aplicar.
	Al imponer, reduce la posibilidad de negociar/consensuar con el paciente

In the legal sector, there are judges who apply it using the now classic argument of “he who can do more, can do less”, which means that if it is possible to authorise an involuntary admission that is always more restrictive than outpatient treatment, then it is only logical to be able to authorise the latter as well. On the other hand, there are judges who do not apply it, since they consider that there is not clear legal coverage to do so. The Public Prosecutors’ Office also has experts who are in favour or against its application.

As regards the opinion of other people involved in IOT, scientific publications contain qualitative studies carried out in Spain and abroad. Borum et al. studied the opinion about IOT held by 306 patients waiting for this method to be applied to them, and they found that over 75% considered it to be of benefit to them.

Swartz et al.- studied opinions about IOT amongst patients, family members, clinicians and the general public, in which results showed that the four groups approved the use of IOT for patients with schizophrenia.

On the other hand, Crawford et al. interviewed 109 patients with severe mental illness, and asked them about the preferred location for receiving obligatory treatment. 48% would prefer to be treated at home, 40% in hospital and 13% at a community centre. The most common reason given for preferring obligatory treatment at home was avoiding the tense and sometimes hostile environment of hospital admission units.

In Spain, there is an outstanding study by Hernández-Viadel et al., which collected the opinions of patients, family members and psychiatrists about the application of IOT, in which between 80% and 90% of psychiatrists and family members and 54% patients felt that IOT was a beneficial measure.

The aim of this article is to gather more detailed opinions of mental health professionals (clinical psychiatrists and resident medical interns in psychiatry) about involuntary outpatient treatment and the legislation that regulates it.

MATERIAL AND METHOD

This is a descriptive study. The population studied was made up of 42 mental health professionals (32 psychiatrists and 10 resident medical interns in psychiatry), who at the time of commencing the study (March 2018) were working at one of the units that make up the Psychiatric Service of the University Hospital Complex of Huelva.

The inclusion criteria consisted of clinical psychiatrists and resident medical interns in psychiatry in the second, third and fourth year of specialisation who, at the time the study commenced, were working at one of the mental health units that make up the University Hospital Complex of Huelva. All the professionals who met the inclusion criteria participated in the study, not one them declined the invitation.

The exclusion criteria consisted of resident medical interns in psychiatry undergoing their first year of residence, since it was felt that they did not yet have enough knowledge to offer a well-developed opinion on the issue.

A personal survey in paper format (Figure 1), was used to ask the mental health professionals face to face about their opinion on involuntary outpatient treatment (IOT) and legislative regulation. The survey consisted of the following ten questions:

Figure 1

Survey on involuntary outpatient treatment.

There have been efforts to regulate involuntary outpatient treatment (IOT). Were you aware of these initiatives?

Do you agree with the regulation of IOT being put into effect in Spain?

Is it acceptable, in the 21st century, to depend on a judge’s discretion to apply IOT?

Did you know that IOT is regulated in the legislation of most nearby countries (France, Portugal, UK, Italy...)?

Do you consider IOT to be beneficial for the patient?

Do you think that IOT is of benefit to the patient’s family?

Would you agree with IOT being used on a member of our family if he/she needed it?

Do you feel that applying IOT to the severely mentally ill is stigmatising?

Do you feel it is sufficient for more coercive measures for the mentally ill to be regulated, such as involuntary internment or legal incapacity, while IOT is not?

Would you be in favour of applying IOT instead of other security measures for certain patients who have committed a crime while their cognitive and volitional capacities were altered?

The possible answers to the questions were: “yes”, “no”, “don’t know/no answer”. The clinicians’ opinions about this type of treatment were also collected in an unstructured manner.

RESULTS

A population was obtained of 42 mental health professionals, 32 of whom were psychiatrists and 10 of whom were resident medical interns in psychiatry. The results of the survey were as follows (Table 2).

Table 2

Results of the survey on involuntary outpatient treatment (IOT)

	Sí	No	NS/NC
1. El tratamiento ambulatorio involuntario (TAI) está intentando regularse. ¿Conocías esta iniciativa?	85,7%	14,3%	0%
	(n=36)	(n=6)	(n=0)
2. ¿Estás de acuerdo con llevar a cabo la regulación sobre el TAI en nuestro país?	92,8%	2,4%	4,8%
	(n=39)	(n=1)	(n=2)
3. ¿Es aceptable, en pleno siglo XXI, depender de la discrecionalidad de un magistrado para poder aplicar el TAI?	28,6%	45,2%	26,2%
	(n=12)	(n=19)	(n=11)
4. ¿Sabías que el TAI está regulado en la legislación de la mayoría de los países de nuestro entorno (Francia, Portugal, Reino Unido, Italia...)?	52,4%	45,2%	2,4%
	(n=22)	(n=19)	(n=1)
5. ¿Consideras que es beneficioso el TAI para el paciente?	78,6%	2,4%	19%
	(n=33)	(n=1)	(n=8)
6. ¿Crees que es beneficioso el TAI para la familia del paciente?	95,2%	0%	4,8%
	(n=40)	(n=0)	(n=2)
7. ¿Estarías de acuerdo con que se le aplicara el TAI a un familiar tuyo si lo necesitara?	83,3%	4,8%	11,9%
	(n=35)	(n=2)	(n=5)
8. ¿Consideras estigmatizante aplicar el TAI a los enfermos mentales graves?	19%	78,6%	2,4%
	(n=8)	(n=33)	(n=1)
9. ¿Te parece adecuado que estén reguladas medidas más coercitivas para el enfermo mental, como el internamiento involuntario o la incapacitación civil, y no lo esté el TAI?	4,8%	83,3%	11,9%
	(n=2)	(n=35)	(n=5)
10. ¿Estarías a favor de la aplicación del TAI en lugar de una medida de seguridad en ciertos pacientes que han cometido alguna conducta delictiva con su capacidad cognitiva y volitiva alterada?	66,7%	23,8%	9,5%
	(n=28)	(n=10)	(n=4)

Nota. NS/NC: no sé/no contesto.

In answer to the question if they were aware of the initiative to regulate IOT, the interviewees gave an affirmative answer in 85.7% of the cases (n=36), while 14.3% (n=6) were unaware of it.

The answer to the question as to if they agreed with regulating IOT gave a result of 92.8% (n=39) in favour, while 2.4% (n=1) opposed the regulation and 4.8% (n=2) abstained from answering.

As regards the acceptability or not of depending on a judge’s discretion to apply IOT in the present day, 28.6% (n=12) thought that it was, while 45.2% (n=19) were opposed to it, and 26.2% (n=11) opted to not give one opinion or the other.

As to whether they knew about the existence of legislative regulation of IOT in most of the surrounding countries, 52.4% (n=22) said they knew, compared to 45.2% (n=19) who answered that they did not. 2.4% (n=1) did not give any answer.

78.6% (n=33) of the mental health professionals considered IOT to benefit the patient, while 2.4% (n=1) thought that it did not. 19% (n=8) of the professionals gave no opinion.

In answer to the question whether it is of benefit to the patient’s family, 95.2% (n=40) thought that it was. 4.8% (n=2) gave no opinion on the issue.

The interviewees’ opinions regarding the application of IOT to a member of their family showed 83.3% (n=35) would be in favour, while 4.8% (n=2) would oppose it, and 11.9% (n=5) gave no answer to this question.

The interviewees’ opinion about whether the application of IOT to patients with severe mental illness is stigmatising, 19% (n=8) considered it to be stigmatising, while 78.6% (n=33) felt that it was not. 2.4% (n=1) gave no opinion.

The question asking if the clinicians felt that it was enough for more coercive methods to be applied to mental patients, such as involuntary internment or legal incapacity, and for IOT to not be used, 4.8% (n=2) felt that it was sufficient, while 83.3% (n=35) thought that it was illogical, and 11.9% (n=5) abstained from answering the question.

Finally, in response to the question about applying IOT instead of security measures to certain patients who have committed a crime while their cognitive and volitional capacities were affected, 66.7% (n=28) showed themselves to be in favour of application, compared to 23.8% (n=10) who were against the idea. 9.5% (n=4) abstained from answering.

DISCUSSION

The application of IOT is a controversial medical/legal issue and therefore the debate about the need for legislative regulation of IOT has its defendants and opponents. Defenders of regulation consider that it is a way to ensure the therapeutic compliance of patients with severe mental illness, while opponents regard it as an infringement on a person’s fundamental rights and an act of discrimination against psychiatric patients.

The patients’ own opinions about the benefits of applying IOT have been collected in a number of studies, - in recent years. All the studies show that most patients consider the measure to be a beneficial one, although the size of this majority varies considerably from one study to another. There are articles, such as the one by Borum et al., where the percentage reaches 75%, while others, such as the one by Hernández-Viadel et al., show that only just over half of patients surveyed (54%) are in favour of this form of treatment. The main argument put forward by patients in favour of IOT is the fact that it is accompanied by fewer hospital admissions and less days in hospital, which most of them prefer to avoid. As regards the opinion of mental health professionals about the application of involuntary outpatient treatment, there is little information in the existing bibliography, although there are outstanding foreign studies by Swartz et al., and others carried out in Spain by Hernández-Viadel et al., in which the opinions of family members and physicians are collected alongside those of the patients. In both cases, the vast majority of family members and medical doctors feel that the application of IOT benefits a patient with severe mental illness. On the other hand, there is a notable absence in the main data bases of scientific articles with the opinions of medical doctors on the need to provide legislative regulation of IOT in Spain.

This aim of the study was to know more about the opinion of clinicians about the different issues surrounding IOT and if legislative regulation is appropriate or not. Some data merits further discussion after conducting the survey and assessing the results.

Most clinicians (85.7%) state that they are aware of the proposal for legislative regulation of IOT proposed in early 2018 by the Aragonese Society of Legal Psychiatry and Forensic Sciences to the Legislative Branch, which is a striking percentage, given the low level of feedback regarding this issue in the media, and its reduced importance in training events (apart from those specifically for legal psychiatry and forensic sciences) of the congresses and symposia for specialists in psychiatry held every year in Spain.

There is less awareness of the presence of regulation of IOT in many developed countries (USA, France, UK…). Even so, there is a slight majority (52.4%) who state they do know of its existence, but an almost equally large percentage (45.2%) is unaware of this situation. This could be explained by the above comment about the low impact of the issue in the media and on training events for psychiatrists.

Another striking figure is the large majority (92.8%) of mental health professionals who are in favour of regulating IOT in Spain. Only one of the 42 surveyed (2.4%) opposed regulation. This large differences is worlds apart from the supposed disparity of opinions that seemed to exist in the medical sector in a number of forums and between the main psychiatric associations that took up positions on the issue (AEN, SEP, SEPL).

One of the issues that created the widest disparities of criteria is the one about the acceptability in this day and age of depending on the judge’s discretion when applying IOT. What came to light is that there are more (45.2%) against such powers of discretion than there are in favour (28.6%), while a sizeable percentage (26.2%) have no opinion on the matter.

As is the case in the studies by Swartz et al. and Hernández-Viadel et al., most of the mental health professionals (78.6%) think that IOT is of benefit for the patient, while an even larger percentage (95,2%) thinks that it is also good for the patient’s family. It is worth noting that no interviewee thought that the application of IOT would be harmful for the patient’s family.

The firm conviction held by most of the interviewees that application of involuntary outpatient treatment is really beneficial for the patient can be seen in the data where 83.3% would be in favour of it being applied to a member of their family if he/she needed it.

The likelihood of IOT increasing stigmatisation of mentally ill patients is one of the points most hotly debated by professionals when discussing this type of treatment. A large majority of the interviewees (78.6%) considered that IOT is not stigmatising for patients with severe mental illness. A telling point in this regard is the comment made by a clinical psychiatrist in the sample who was a clear defender of IOT: “what actually increases the stigma for our patients are the situations we often live through when they arrive completely unbalanced at the accident and emergency unit, brought there by the police, agitated and shouting”.

On the other hand, a large majority (83.3%) see no sense in the fact that in Spain there are measures that more severely limit patients’ freedom, such as involuntary internment or incapacity, while IOT is not available. Some interviewees argue, for example, that “it makes no sense for a more restrictive measure like involuntary admission to be regulated while IOT isn’t”. Only two of the interviewees (4.8%) regarded it as logical, and a notable percentage (11.9%) had no answer on the issue.

As regards the suitability of replacing a security measure with IOT for certain patients who at some time have committed a crime with their cognitive and volitional capacities affected, the existing bibliography and clinical evidence create doubts about the possible benefits of internment in a centre, such as a an oligophrenic patient in a prison psychiatric hospital, most interviewees (66.7%) felt that it is more appropriate to apply IOT than to subject a patient to security measures, although a sizeable percentage (23.8%) were of the opinion that security measures were the best option in such cases.

To sum up, these results back up the ones obtained by Swartz et al. and Hernández-Viadel et al. regarding the opinion of mental health professionals about the benefits of IOT for patients and their families, and also show the ideological inclination of the majority of the medical community towards the need for regulation of involuntary outpatient treatment to bring Spanish legislation into line with most of the countries surrounding it, to enable there to be a complete legal measure that covers the physician and the patient, as already exists with other measures, such as involuntary internment or legal incapacity, and that does not depend on the discretionary powers of judges, as is the case right now.

As a closing point, it should be emphasised that the small size of the sample used for the study and the local nature of the survey, with the inevitable influence that this has on the orientation of one particular service regarding this issue, means that the results cannot be used to draw more general conclusions, and that more studies on this issue are required.