THE BIG IDEA
Forced medication is inhumane

Should the mentally ill be allowed to refuse to take their medication?

By Roger Whitaker, 6/9/2002

Thirty-five years ago, we began emptying state mental hospitals in this country, amid promises that we would build a comprehensive system of community care. As a society, we reneged on that promise, and we all know the sorry result. Many people with severe mental illness have no access to decent housing or to any sort of humane care, and so of course we now see disturbed people on our streets. What should we do about this?

One proposed solution, a step which 41 states have taken, is to pass an involuntary outpatient commitment law. Massachusetts has no such law, but it is being urged to join the pack. We need to be very clear about what is at stake here. States have always had legal methods for committing disturbed people to psychiatric facilities and a process for forced drug treatment in that environment. By passing involuntary commitment legislation, states are asserting the right to demand that people living in the community take ''antipsychotic'' drugs, which represents a profound expansion of state control over the mentally ill.

Here are a few critical facts that we need to know in order to assess the ethical and practical merits of such legislation - facts that involuntary commitment proponents never tell the public.

First, we have made antipsychotic drugs the cornerstone of our care for the past 50 years, and the long-term results have been dismal. The World Health Organization has twice found that outcomes for schizophrenia patients in the United States and other rich countries are much worse than in poor countries like India and Nigeria, where only one in six patients were regularly maintained on these medicines. In a similar vein, Harvard Medical School researchers announced in 1994 that outcomes for US schizophrenia patients had worsened during the past 20 years and were now no better than they were at the start of the 20th century.

Second, we are often told that the mentally ill do not take their ''meds'' because they don't know they are sick. In some instances, that may be so. But patients may also have very rational reasons for not wanting to take these drugs. The older agents like Thorazine and Haldol, which are still in use, regularly induce Parkinsonian symptoms and an extremely painful agitation known as akathisia (which has been linked to homicide and suicide.)

As for the newer generation of antipsychotics like Zyprexa and Risperdal, they are proving to be problematic as well, even if their side effects are of a different sort. With Zyprexa, for instance, extreme weight gain and drug-induced diabetes are evident risks. Nor are physical side effects the extent of the problem. Many patients complain that they are spiritually deadening. They say that the drugs rob them of any sense of joy, of their willpower, and of their sense of being.

Third, consumer groups - the voice of those who would be so treated - are adamantly against commitment laws. They believe that such laws are a gross violation of their civil rights and argue that they are counterproductive, in that forced treatment drives people away from medical care.

Fourth, there is good evidence that assertive outreach programs can be just as effective as involuntary commitment provisions in getting the mentally ill to voluntarily take their medications. The Bazelon Center for Mental Health Law, a Washington, D.C.-based advocacy group that reviewed the research literature on this issue, concluded that if patients are provided with access to services on a voluntary basis, then society can ''accomplish the same ends without coercion, without the trauma of a court appearance, and without violating the individual's right to make decisions about his or her own health care.''

Finally, the public has a greatly exaggerated sense of the dangerousness of the mentally ill. Studies have found that the risk of violence associated with major mental illness is ''small'' in comparison with the risk associated with substance abuse. In other words, we have more to worry about from people who are drunk or stoned on some street drug. Involuntary commitment proponents who hold up high-profile murders are simply using scare tactics, and that is never the stuff of good public policy.

Once these facts are considered, the rationale for involuntary commitment legislation disappears. We can use assertive voluntary programs to achieve the stated goals of the laws. By going this route, we also avoid the very real ethical problem of forcing people to take drugs that regularly induce physical illness of some kind (Parkinson's, obesity, diabetes, etc.), and which many find emotionally deadening. Indeed, it is noteworthy that during the 1970s the Soviet Union used antipsychotics to punish dissidents, who bitterly protested that such drugging was a form of torture.

Involuntary outpatient commitment calls up all the sins of the past, of forced lobotomies and forced electroshock. What we need to do today is focus on creating a more humane future, one that involves listening to consumer groups and providing the mentally ill with good housing, vocational help, and other forms of social support. Many people so treated will welcome antipsychotic medications, and take them readily. And for those who don't want to take such drugs, then the obvious challenge for our society is to provide alternative methods to help them cope with their delusions and voices.

Robert Whitaker is author of ''Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.''

This story ran on page E8 of the Boston Globe on 6/9/2002.
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