Is psychiatry becoming more coercive?BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2904 (Published 22 June 2017) Cite this as: BMJ 2017;357:j2904
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The root cause of coercion in mental health services is the widespread false, unshakable belief, out of keeping with all available evidence, that psychiatrists and other mental health professionals can and should accurately predict and successfully prevent suicides. This results in mental health professionals being held responsible, blamed and victimised when a patient they have seen dies by suicide.
Suicide rates in the UK have fluctuated between 10 and 15 per 100, 000 population per annum. Whether a death is classified as suicide or not depends on the coroner’s verdict. Approximately a third of those who die by suicide have been in contact with the mental health services in the year before their death.
The fallacy of suicide prediction
The idea that risk factors can be identified and used to predict the likelihood of suicide and that these risk factors can be grouped into composite risk tools that can quantify the risk of suicide is very appealing. Such tools are commonly used in clinical practice but have little evidence of efficacy. 1 A systematic review of risk factors for suicide concluded they are not of much practical use because they are comparatively common in clinical populations. Moreover, no scales for predicting suicides have sufficient evidence to support their use. 2
In one study experienced mental health professionals who read the records of 78 psychiatric patients and considered all the risk factors to identify which 39 had committed suicide did no better than chance.3
Suicidal intent is not constant. It waxes and wanes, often suddenly and unexpectedly. 4 Hence, suicide risk needs continuous reassessment. The danger of suicide risk assessments is that clinicians can be lulled into thinking that risk, once assessed, is static. Hence, measures determined by assessment tools are out of date as soon as completed. The false security engendered by ticked boxes and completed forms is like fool’s gold.5 Evidence proves that risk categorization, the use of these scales, or an over-reliance on the identification of risk factors in clinical practice provides false reassurance, confuses clinical thinking and is, therefore, potentially dangerous. 1, 2
The fallacy of suicide prevention
There are large numbers of people who satisfy many of the risk factors. Suicide is rare even in high risk groups i.e. those with many risk factors. 4, 6 Amongst those with mental health problems, the risk of suicide is greater when the patient is becoming ill, is recovering or has recovered, than when severely ill. 4
Amongst survivors of near lethal suicide attempts 51% reported acting after thinking about suicide for 10 minutes or less. Of those who had alcohol problems, 93% had thought about suicide for 10 minutes or less. In 79% the impulse has passed within 12 hours. 7
Using the risk factor method, large numbers of ‘false positives’ are identified i.e. the vast majority of those who are identified as being at high risk of suicide, do not commit suicide. This means large amounts of resources are devoted to the care of individuals who are not going to commit suicide. 6 Even in a high risk group with 100 times higher risk of suicide than general population, i.e. 2/1000/year, to save one life, it would be necessary to provide infallible care, in a form acceptable to them 24 hours a day to 500 people for one year.8
Many believe that hospitalization prevents suicides. However, 9 to 14% of all suicides by people with mental illness occur on in-patient wards. 25% of in-patient suicides occur whilst under special observation and the rest were assessed to be at no or low risk for suicide.9, 10 In 1996, due to budgetary constraints, admissions to psychiatric hospital in Fulton County Georgia, USA were reduced by 56%. Patients with substance use disorders, personality disorders, chronic recidivism and noncompliance were not admitted. The suicide rate of the county fell from 12 during 1994-95 to 10/100, 000 during 1997-98. This suggested that hospitalization does not reduce suicide rate in a population.11
The WHO concluded that most suicide prevention measures have had no systematic evaluation or are yet to be evaluated and suffer from a low-base suicide rate.12 No meta-analysis of randomized controlled trials or systematic review has found any evidence to suggest that any known intervention reduces or prevents suicide. 12, 13, 14, 15, 16 The most challenging concerns in offering suicide prevention programmes is the lack of evidence on their effectiveness. 17
Poor interpersonal relationships increase the risk by 5 times, unemployment by 4 times, and debt and financial difficulties by 2.5 times, while social support reduces suicide ideation by 4 times, healthy lifestyle by 5 times, and reasons for living reduced the risk by 5 times.18 Mental health professionals have little influence in these areas.
Suicide by anyone seen by mental health services result in a Serious Untoward Incident Inquiry (SUII). This is to identify mistakes, learn lessons, reduce risks and reduce suicides. SUIIs almost always blame the professionals for failing to accurately predict and successfully prevent suicide by anyone who has been in contact with the services.
SUII teams often behave as if their credibility depends on the number of flaws they discover and the more scathing and dramatic their reports are. Their findings and recommendations are often so vague and non-evidence based that they are difficult to challenge e.g. ‘the atmosphere in the team is not congenial to promoting a culture of high quality patient care’.
Inquiries often uncover many shortcomings e.g. the patient who consistently reported suicidal thoughts over the previous two months was not asked about suicidal thoughts in the hour before their successful attempt; a change of antidepressant was not considered even though the patient was on their 13th antidepressant; CBT was not offered at the last review even though the patient had always expressed their aversion to psychological treatments; a drug screen was not done on the day of death even though the patient always freely admitted daily drug use and all their previous drug screens were positive. The commonest shortcoming identified is that ‘the patient’s risk profile was not updated in the hours before the suicide even though the patient was repeatedly assessed to be at high risk of suicide throughout the previous month. Giving eye-catching names for research documents e.g. ‘Avoidable deaths’9 perpetuates the blame culture.
The recipients of the reports immediately conclude that the shortcomings identified by the inquiry were the cause of the suicide and that had they been altered, the suicide would have been prevented. 6 They endeavour on a quest to fulfil the recommendations and especially, indulge in a crusade of form filling and box ticking, completely ignoring patient care and clinical judgement, until the next SUI and the following SUII identifies a different set of shortcomings and whole cycle is repeated.
A strategy of total risk avoidance leads to excessively restricted management e.g. detaining anyone who mentions the ‘S’ word and continuous one-to-one observations. The progressive removal of “hazards” in order to prevent suicides, in response to SUIIs inquiries lead to inpatient units becoming stark and oppressive- a ‘Creeping Custodialism.’19
Many of these strategies designed to ‘protect’ patients may be damaging to them and serve to further isolate them and ‘paradoxically make suicide more likely’.6, 19 This contradicts the principles of ‘positive risk taking’ advocated by the Department of Health. 20 Moreover, patients may be reluctant to disclose suicidal thoughts for fear of compulsory admission.
The suggestion that medical interventions could prevent suicide therefore not only has no evidence base, but runs the risk of raising false expectations among the public and of encouraging grieving relatives to blame healthcare professionals inappropriately. 4
Tens of thousands of SUIIs over the years and blaming clinicians have not influenced suicide rates. On the other hand, they have forced clinicians to admit and often detain patients, restrict their freedoms, prescribe unnecessary medication, robotically do risk assessments and tick boxes whilst appreciating the futility these measures, simply to avoid unwarranted blame. They have pressurized clinicians into practising defensively, focussing exclusively on suicide prediction and prevention and channelling resources on suicide prevention whilst rationing services for and abandoning the vast majority of people with mental health problems but who do not have many ‘risk factors’ for suicide.
The way forward
Politicians, media and the public have to accept the fact that there are no tools to predict suicides with more certainty than by chance and that no known intervention prevents all suicides. Suicide is a highly complex issue, with a multitude of causes and mechanisms, most of which are poorly understood, let alone amenable to interventions by mental health services. The UK has had one of the lowest suicide rates in the world even before the blame industry started.
A large number of people at a small risk give rise to more suicides than the small numbers who are at high risk. 21 A reduction in general risk would reduce suicides more than interventions that target only high-risk individuals. Suicide reduction is likely to be achieved using population-based strategies aimed at actively reducing risks among the whole population. 12
If we stop blaming and penalising mental health professionals when individuals seen by them die by suicide, and if we stop coercing them to do things that have no evidence base at all, then they will be able to channel resources to improving mental health of individuals and the population which will improve the health outcomes of the whole population and reduce the suicide rates in the population. Moreover, the mental health services would be able to offer more humane and person-centred care for those with mental health problems without resorting to coercion.
1. Mulder R, Newton-Howes G, Coid JW. The futility of risk prediction in psychiatry. Br J Psychiatry 2016; 209:271-272; DOI: 10.1192/bjp.bp.116.184960
2. Chan MKY, Bhatti H, Meader N et al. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry 2016; 209:277-283; DOI: 10.1192/bjp.bp.115.170050
3. Fahy T, Mannion L, Leonard M, Prescott P. Can suicides be identified from case records? A case control study using blind rating. Arch Suicide Research 2014; 8:263-269.
4. Cavanagh J, Smyth RS. Suicide and self-harm. In: EC Johnstone EC, Cunningham Owens D, Lawrie SM, et al. eds. Companion to Psychiatric Studies 8th edn. Churchill Livingstone, 2010: 693-714
5. Oyebode F. Suicide, national inquiries and professional judgement. Adv Psych Treat 2005; 11: 81-83. http://apt.rcpsych.org/cgi/content/full/11/2/81
6. Pridmore S, Ahmadi J, Evenhuis M. Suicide for scrutinizers. Australasian Psychiatry, 2006; 14: 359-364.
7. Wyder M. Understanding deliberate self-harm: an enquiry into attempted suicide. PhD Thesis, University of Western Sydney 2004.
8. Beck A, Brown G, Steer R. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide Life Threat Behav 1999; 29: 1-9.
9. National Confidential Inquiry into Homicides and Suicides. Avoidable Deaths, 2006. http://www.medicine.manchester.ac.uk/ psychiatry/research/ suicide/prevention/nci/reports/avoidabledeathsfullreport.pdf
10. National Confidential Inquiry into Homicides and Suicides. In-patient suicide under observation, 2015
11. Garlow S, D’Orio B, Purselle D. The relationship of restrictions on state hospitalization and suicides among emergency psychiatric patients. Psychiatric Services 2002; 53:1297-1300. http://psychservices.psychiatryonline.org/cgi/content/full/53/10/1297
12. WHO. Towards Evidence-based Suicide Prevention Programmes 2010. http://www.wpro.who.int/NR/rdonlyres/94606C00-2CAB-404D-A6CF-ECCA2CF26B6...
13. Appleby L, Shaw J, Amos T et al. Suicide within 12 months of contact with mental health services: national clinical survey. BMJ 1999; 318: 1235-1239.
14. Milner AJ, Carter G, Pirkis J, et al. Letters, green cards, telephone calls and postcards: systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide. Br J Psychiatry 2015; 206:184-190; DOI: 10.1192/bjp.bp.114.147819
15. Riblet NBV, Shiner B, Young-Xu Y, Watts BV. Strategies to prevent death by suicide: meta-analysis of randomised controlled trials. Br J Psychiatry 2017; 210: 396-402; DOI: 10.1192/bjp.bp.116.187799.
16. WHO. For which strategies of suicide prevention is there evidence of effectiveness? 2004. http://www.euro.who.int/Document/E83583.pdf
17. Gunnell D, Frankel S. Prevention of suicide: aspirations and evidence. BMJ 1994; 308:1227-1233. http://www.bmj.com/content/308/6938/1227.full?sid=33107941-297d-470d-b85...
18. Centre for Suicide Research and Prevention Research findings into suicide and its prevention - final report. Hong Kong SAR: The University of Hong Kong, 2005.
19. Patfield M. Creeping custodialism. Australasian Psychiatry 2000; 8: 370-372.
20. Department of Health (2007) Independence, Choice and risk: a guide to best practice in supported decision making. Best practice guide, learning and development materials, supported decision making tool, leaflet for people using services. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_074773
21. Rose G. The strategy of preventive medicine. Oxford University Press, 1992
Competing interests: No competing interests
psychiatry could become more coercive if the mental health depts don't work toghether with all subjects which surround the person with psychiatric troubles: i.e. families, GP, social institutions . if mental health depts work only for farmacotherapies, without involving social referents of patients, the care process can only become a control-care. every refusal of patient implies alarm and can become coercion or contention in the acute wards.
there is another coercion form, basing on "support administration" law of 2004, patient can receive a coercion from a tutelary judge through the support administration to get a farmacotreatment or to stay in a long term psychiatric sheltered house, without considering the patient's will. this way is sometime suggested when patients are described "having no compliance" or difficult, but is becoming a way to escape from a full approach to patients and referents, limiting de facto the mental health dept's work to farmaco-supply or allocation in sheltered facilities. my impression is that we are going to have less compulsory hospitalizations in the acute wards, but an increase of corcive admissions to sheltered psychiatric facilities.
the further coercion is the increasing number of patients who undergo long acting treatmnts, limiting the therapeutical process to "injecton" without being involved (if they can) in a personal or familiar psychotherapeutical process, or in a social inclusion (job...) process
as far as I know, at the beginning of word first war, italian psychiatric hospitals had 54.311 patients; in 1978 (Basaglia reform year) patients were 78.538; year 2000 lthe PROGRES study found 1370 sheltered facilities for 15943 patients, of which 58% were never been in psychiatric hospitals or forensic psychiatric hospitals.
the question is the not only coercion but the need of cultural improvement of MHD, quitting the securitary way and building a socioeducational way to help patients and referents in a shared therapeutical process, as far as possible.
if patients and referents can discuss in a cooperative way with MHD the therapeutical needs, there will be less need for coercion and shletered facilities. however a part of patients can become needing facilities, if they lose family support, or house.
my personal experience in Ambito territoriale 24 of Marche Region is that patients needing coercion can be moderated working with patients and referents in a continous relation. during the last 19 years only two patients did become needing sheltered facilities without coercion, and two further patients did get the corcive need to undergo regular therapy but living at own houses. furtermore, during the last six years two sheltered houses are working in Ambito territoriale 24, the first in Force for 13 persons, the second in Comunanza since 2016 for 20 persons, all of them, but the two above cited, are coming from outside the ambito territoriale 24
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In this Greek public psychiatric hospital, patients were systematically tied to their beds, locked, abandoned, even for years!
They even tied up autistic patients!
During a recent fire, 3 of them were burned alive, unable to escape.
Reports show that restraint is still commonly used in Greek psychiatric wards.
Nowhere in Europe and the World such deplorable coercive treatment conditions are allowed, that the UN argues constitute torture.
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Over the 40 years that I have worked as a lawyer, the majority of the clients I have defended have been people subjected to forced psychiatric treatment. I can therefore claim to know the fields of psychiatry, justice and their “judgements” inside out. The conclusion I have come to is that the strongholds of psychiatry have absolutely nothing to do with “care”, the law or justice – instead, they are nothing other than instruments of domination.
Competing interests: No competing interests
I generally agree with all concerns about coercion, apart from the sentence: “In Italy, for example, a new law in 2012 required the development of secure residential facilities for people with mental disorders considered “socially dangerous.” Legislation such as this, disguised as innovation, represents a backwards step.” There are some important issues to be clarified:
1) Italy has now one of the lowest involuntary treatment rates in Europe (17/100.000 in 2015, Minister of Health). This is a result of a substantial reform which started with Law 180 / 1978.
2) The recent reform of forensic hospitals, contrary to what the article implies, has also resulted in significant improvements, such as closure of all 6 forensic hospitals, the decrease in the no. of forensic beds from about 1500 to 604 (of which 567 occupied, Commissario Straordinario of the Italian Parliament, Second Biannual Report 2017), the reconfiguration of forensic facilities in much smaller units linked to community mental health services (from hundreds of beds to a maximum of 20), and the rapid turnover with 457 persons discharged in 18 months. In Trieste and the related region Friuli Venezia Giulia, out of the 10 beds available, only 2 are today occupied, and all these facilities are managed with an open door policy. This has been defined as a “second revolution” after the closure of all psychiatric hospitals in 1999.
Competing interests: No competing interests
Professors Sashidharan and Saraceno raise an important question in their recent editorial (1), “Is psychiatry becoming more coercive?”. In this piece the authors note several striking trends in psychiatric care, namely: increased rates of involuntary hospitalization (specifically in England), greater reliance among clinicians and judicial systems on risk assessment tools, and the proliferation of community treatment orders (CTOs), among other things. Their overall assessment appears to be that: 1) Coercive psychiatric practices are increasing in frequency; that 2) Such coercion is harmful and inconsistent with the professional obligation of caring; and that 3) Psychiatry is (incorrectly) prioritizing risk management over the needs of clients, thus abandoning a patient-centered approach.
While I do not have the space to go into detail on the multitude of issues the topic of coercion brings, I will comment on a few aspects of the author’s piece and the problem generally.
First, the obvious question: “Is psychiatry becoming more coercive?”. As will be clear by the end of this response, the answer is a complicated one; one that I do not think the authors are able to affirmatively answer. To determine whether psychiatry is becoming more coercive, one would need to have a firm baseline for each of the coercive actions in question, and observe the variation in each, over time (and relative to the changing population). For example, one could look at the overall involuntary hospitalization rates for each European country with available statistics and follow it over a 10-year period. If an increase in coercion were found, it may not be ethically problematic (as appears to be the underlying judgment of the authors). Rather, an increase in involuntary treatment may merely reflect changing patterns in diagnostic prevalence (i.e. if a society experienced an increase in the overall prevalence of mental disorders, it would seem reasonable to expect a concurrent increase in treatment; including involuntary treatments) or merely a fixed prevalence rate within a growing population. In this respect, context is key. If we presume that sometimes involuntary treatment is appropriate, a point not without contention (2), increases in its use are not ipso facto misguided. Undoubtedly Sashidharan and Saraceno provide evidence for an increase in coercion, in some places and settings; however, they have not provided a systematic overview for any particular form of coercion, over time, for any specific region, setting, or population. As such, I believe that the authors cannot answer the proposed question.
Secondly, the question is further muddled when considering what counts as coercion. One could argue that the concept exists on a continuum, particularly in the field of psychiatry, where the designation of a financial representative (a common feature of community treatment orders [CTOs]), temporary hospitalization (e.g. in an effort to prevent suicide), and long-term institutionalization are all considered to be coercive acts. Should all such actions be considered equally problematic? Does the increase in less intensive modes of coercion raise the same degree of concern as more invasive forms? Put differently, is increased coercion a bad thing if such coercion is less harmful in toto? Or more importantly, should such seemingly disparate actions even be categorized together? These questions may not have direct bearing on the authors’ primary inquiry, but leave much to be discussed by clinicians, ethicists, and policy-makers alike.
Finally, this editorial brings to mind what might be considered more fundamental conceptual issues. Though the frequency of coercion is clearly an important moral and social topic, psychiatry and associated “helping professions” have not clearly answered the following questions: 1) How much coercion is appropriate in mental healthcare settings?; 2) What justifications are both necessary and sufficient for employing coercion?; 3) With whom can/cannot psychiatric coercion be employed?; 4) What are socially acceptable and morally permissible forms of coercion?; and more broadly 5) What is the role of psychiatry in coercing?/Can psychiatric coercion be clearly delineated from its historical roots, as a form of social control? (3). Before appraisals about trends in coercion can be meaningfully interpreted (and consequent social policy crafted), these fundamental issues must be addressed.
Undoubtedly psychiatric coercion will remain an important research and policy topic. Investigations about the frequency and evidence for its use must continue in a methodical and rigorous fashion. This must be done while pursuing higher-order ethical questions about coercion; as is being done in other parts of psychiatry (e.g. about the nature and meaning of the concept of mental disorder ).
(1) Sashidharan, S. P. & Saraceno, B. (2017). Is psychiatry becoming more coercive? BMJ, 357, j2904.
(2) Gomory, T., Cohen, D., Kirk, S. A. (2013). Coercion: The only constant in psychiatric practice? In M. Dellwing & M. Harbusch (Eds.), Krankheitskonstruktionen und krankheitstreiberei: Die renaissance der soziologischen psychiatriekritik (pp. 289-312), Germany, Springer VS.
(3) Szasz, T. S. (1963). Law, liberty, and psychiatry: An inquiry into the social uses of mental health practices. New York, NY: Syracuse University Press.
(4) Bolton, D. (2013). What is mental illness? In K. W. M. Fulford et al. (Eds.), The Oxford handbook of philosophy and psychiatry (pp. 434-450), New York, NY: Oxford University Press.
Competing interests: No competing interests
It is good to see this important subject being raised in a mainstream journal. I would definitely welcome more research into the increasing frequency of detention. One possible explanation is that ever increasing pressure on psychiatric beds leads to a situation where in order to qualify for inpatient intervention patients must be so unwell that they lose capacity to consent in the process. Also, with initiatives such as intensive home treatment being introduced, many patients who would have previously been admitted are now able to recover in the community. It seems quite plausible that a combination of those two factors results in an increased proportion of inpatients being held in hospital under MHA detention. Trying to address the issue through changes to MHA legislation, without a full understanding of the factors contributing to the current picture, seems premature and possibly even counterproductive.
Competing interests: No competing interests