Coerced medication used in psychiatric care despite lack of clinical evidence

Researchers are calling for more studies into the practice of forcing psychiatric patients to take medication, after a research review showed that there have been very few rigorous investigations of the procedure.

The review, published in the latest Journal of Advanced Nursing, suggests that patients receiving coerced medication (CM) are more likely to be in their thirties with a diagnosis of schizophrenia, bipolar disorder or another psychotic disorder.

CM is used more often in the UK than in other countries where other forms of restraint are more common.

Most of the patients featured in the studies that were reviewed had been admitted to psychiatric care on an involuntary basis.

"It is clear from our review that there is little clinical evidence on the use of CM and more research is needed to examine all aspects of this contentious practice" says Manuela Jarrett, a registered mental health nurse from the Health Service and Population Research Department at the Institute of Psychiatry in London.

Jarrett, who co-authored the paper with Professor Len Bowers and Dr Alan Simpson from City University London, carried out a detailed analysis of 14 papers from seven countries, published between 1987 and 2004. These studies included interviews with 543 patients and 263 staff and analysis of 1,165 forms and records from the UK, USA, Sweden, Finland, Germany, Canada and Denmark.

"Legislation for involuntary psychiatric treatment exists in all European Union member states and in other western countries, where an increased risk to self and others provides the ethical and legal grounds for detaining and treating psychiatric patients without their consent" she says. "The fact that there is legislation in different countries suggests recognition of the seriousness and ethical uncertainty of such procedures.

"Perceived risk to others emerged as an important factor in the decision by staff to give a patient CM. But although half the researchers interviewed patients about their views on receiving CM, they didn't ask them whether they perceived themselves to be a risk to their self or others at the time when CM was administered.

"The studies showed that patients experienced a range of negative feelings when they received CM, including fear, embarrassment, anger and helplessness. Despite this, many said that they retrospectively agreed with the practice."

Research papers included in the review showed a notable lack of detailed exploration into the events leading up to the CM incidents and a complete absence of investigation into alternatives.

"This may reflect variations in the way conflict is managed in inpatients settings in different countries" suggests Jarrett. "CM is more likely to be used in the UK than in other countries, in which other forms of restraint such as seclusion or physical restraint are employed. Previous research by Professor Bowers showed that in some countries, such as the Netherlands, injecting someone against their will is seen as a serious violation of the body, yet the use of mechanical restraints is acceptable."

Jarrett and colleagues conclude that their review has highlighted a lack of clinical evidence on which to base CM, pointing out that the practice may discourage people from seeking help from, and engaging with, mental health services.

"Earlier and more effective interventions might be useful in minimising the use of CM, while better training in skills such as de-escalation strategies might also be valuable in avoiding coercion" says Jarrett.

The authors also feel that more research is needed into the use of CM.

"While there has been a lot of research into the pharmacological effectiveness of particular medications for quick and effective sedation, the reasons for the compulsory administration of powerful sedative and neuroleptic drugs have not been scrutinised closely or frequently. And there is little evidence that alternatives have been explored.

"The staff views reported in the literature and small number of studies available suggests that CM is a 'taken for granted' practice in inpatient psychiatry. We feel that this is unacceptable and more needs to be done to establish sound clinical evidence and viable alternatives to this contentious approach."

Coerced medication in psychiatric inpatient care: literature review. Jarrett et al. Journal of Advanced Nursing. 64.6, p538-548. (December 2008)

Journal of Advanced Nursing is read by experienced nurses, midwives, health visitors and advanced nursing students in over 80 countries. It informs, educates, explores, debates and challenges the foundations of nursing health care knowledge and practice worldwide. Edited by Professor Alison Tierney, it is published 24 times a year by Blackwell Publishing Ltd, part of the international Blackwell Publishing group. www.journalofadvancednursing.com

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