Forced treatment in psychiatry cannot be defended, neither on ethical, legal or scientific grounds. It has never been shown that forced treatment does more good than harm, and it is highly likely that the opposite is true. We need to abolish our laws about this, in accordance with the United Nations Convention on the Rights of Persons with Disabilities, which virtually all countries have ratified.
Forced treatment in psychiatry is not evidence-based medicine, as this builds on reliable research, clinical expertise and the patients’ values and preferences, none of which apply.
First and foremost, the patients’ values and preferences are not being respected, although the fundamental human right to equal recognition before the law applies to everyone, also to people with mental disorders. This is clear from the Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights and the United Nations Convention on the Rights of Persons with Disabilities.1,2
Secondly, clinical expertise is highly misleading in psychiatry. Doctors tend to credit the drugs for any spontaneous improvement and to put the blame for any untoward symptoms on the disease. What makes the practice of psychiatry particularly problematic is that many drugs can create the diseases they were supposed to alleviate, or worse diseases, or they have adverse effects that are similar to the symptoms used to define other psychiatric disorders.2 Therefore, many patients get several psychiatric diagnoses and become in treatment with several drugs.2 Because of the changes in the brain caused by antipsychotics, for example, continued treatment can lead to supersensitivity psychosis, which should be treated by tapering off the drug, but which is usually treated by an increase in dose, or the addition of an additional antipsychotic, which increases the harms.2 When patients try to come off their drugs, they often get abstinence symptoms similar to the disease being treated, and they are therefore usually put back on full dose.2
Thirdly, it has never been shown that forced treatment does more good than harm, and it is highly likely that the opposite is true. A register study of 2,429 suicides showed that the closer the contact with psychiatric staff – which often involves forced treatment – the worse the outcome.3 Compared to people who had not received any psychiatric treatment in the preceding year, the adjusted rate ratio for suicide was 44 (95% confidence interval 36 to 54) for people who had been admitted to a psychiatric hospital. These patients would of course be expected to be at greatest risk of suicide (confounding by indication), but the findings were robust and most of the potential biases in the study favoured the null hypothesis of there being no relationship. An accompanying editorial noted that some of the people who commit suicide during or after an admission to hospital do so because of conditions inherent in that hospitalisation.4
Antipsychotics are the most commonly used drugs in forced treatment and if we wish to find out how deadly they are, we cannot use the placebo controlled randomised trials in patients with schizophrenia, as they seriously underreport deaths. For example, only 19 of 50 deaths on olanzapine described in trial summaries on websites also appeared in journal articles; and for suicides and suicidal events the numbers were one versus nine and four versus 18, respectively.5 Another reason why trials in schizophrenia are unreliable is their cold turkey design. Patients are almost always in treatment with an antipsychotic drug before they are being randomised,2 and when they are abruptly switched to placebo, their mortality risk increases markedly. One in every 145 patients who entered the trials for risperidone, olanzapine, quetiapine and sertindole died, but none of these deaths were mentioned in the scientific literature, and the FDA didn’t require them to be mentioned.6 Many of the patients killed themselves; the suicide rate was two to five times the usual rate for patients with schizophrenia, and a major reason was withdrawal-induced akathisia.6
In trials in dementia, pre-treatment with antipsychotics is less likely, and a meta-analysis of short-term trials of newer antipsychotics showed that for every 100 patients treated, there was one additional death on the drug.7 It could be even worse because deaths are underreported.5
Patients are also being forced to receive electroconvulsive treatment (ECT) although it is one of the most controversial treatments in medicine. Some psychiatrists say they only use it in life-threatening situations but it has never been documented that ECT can save lives whereas we know it can kill. The death rate appears to be around one per 1000.8 The randomised trials are of poor quality and there is no evidence for any long-term benefit beyond the treatment period for either schizophrenia or depression, whereas it is clear that ECT “works” by damaging the brain.8 With a strict definition of memory loss, between 29% and 55% of the patients are affected.9
Two patient stories
Forced treatment inevitably leads to abuse and gross human rights violations.2 Here are two patient stories I know about personally, as I have met with the patient and the father, respectively.
A very moving documentary tells the story of Mette, a young Danish nurse, who, after having been diagnosed with paranoid schizophrenia received vast amounts of medicine and 150 electroshock treatments.10 Mette was seriously harmed, stigmatised and surrounded by prejudice and ended up on disability living allowance. One day, however, she decided to reclaim her own life and escape from psychiatry, which she did successfully and then achieved some of the greatest goals of her life. Mette’s story illustrates that forced treatment is easily abused.2 Even when it so clearly doesn’t work and actually harms people, psychiatrists continue with it out of despair in an endless progression, causing further harm for the patients’ brains and personalities.2
Garth Daniels in Melbourne began smoking marihuana heavily and was admitted to hospital in an acutely psychotic state aged 21. He is now 38 and has spent about 14 years in mental hospitals; has been seen by some 400 psychiatrists and registrars; and has accumulated an estimated 15,000 pages of files. He has had virtually every known psychiatric drug, often in heroic doses, as well as ECT, which he hates. His family has observed that he has had akathisia (which predisposes to violence)2 and that his behaviour deteriorated when he was given large doses of drugs. In contrast, on each of five occasions over the years when his dosage was reduced, his condition improved. Depot injections have been particularly bad and have resulted in visual hallucinations, agitation and violence, leading to restraint, more drugs, more agitation and still more drugs. Garth’s father says that his son is normally a quiet and placid person and that when he was on a moderate dose of amisulpride, he presented as alert, aware and affectively intact to the point of being a warm and interested person.
The hospital has routinely applied for permission to give another 12 ECTs each time they completed the approved course, although this went against Garth’s Advance Directive and his family’s wishes. Garth has been given about 100 ECTs despite the fact that guidelines recommend a maximum of 1211 and that the number of ECTs is the best predictor of long-term brain damage.12
Garth has been seriously abused against official guidelines in other ways, e.g. he has been tied to his bed for 69 days straight and began to give up hope. His father was concerned it could result in suicide if his forced treatment didn’t stop, but the response of the psychiatrist responsible for Garth’s care, Professor Paul Katz, Clinical Director of the Mental Health Program at Eastern Health, was to make an application to a Civil and Administrative Tribunal (VCAT) to revoke the father’s Medical Power of Attorney and to remove the father as guardian. Garth then sued Katz for assault. With a devilish kind of irony, one of the treating psychiatrists has admitted that part of the reason that Garth was incompetent to withhold consent for the ECTs was because his memory was impaired as a result of the ECTs, so they had to keep giving it to him against his will!
Garth was recently examined by an independent psychiatrist, Niall McLaren, who had access to his voluminous files. Garth is regarded by his usual psychiatrists as an incurably dangerous schizophrenic although he does not show any symptoms which could sustain such a diagnosis or a disturbance of contact with reality. Garth has been subjected to two decades of treatment for schizophrenia and has utterly failed to respond. McLaren also noted that Garth’s medication had been reduced very quickly, even abruptly, which is serious professional malpractice, as it markedly increases the risk of suicide and homicide.2
Garth’s family recently moved to another state and took him with them, thus evading the reach of the Victorian Mental Health Act. He is currently being treated as an out-patient on low doses of medication, with no ECT. His family report that his mental state has never been better. Despite the dire claims of his former treating psychiatrists, he has absolutely no signs of psychosis.
The courts don’t respect the evidence or human rights
In 2006, lawyer Jim Gottstein won an Alaska Supreme Court case about forced treatment with olanzapine.2 The court decided that the government cannot drug someone against their will without first proving by clear and convincing evidence that it is in their best interests and there is no less intrusive alternative available. In another case, the court decided that if an alternative is “feasible,” the state has to either provide it or let the person go.
Gottstein has noted that the public’s opinion is that the drugs work, and that if people weren’t crazy, they would know that the drugs are good for them.13 Accordingly, psychiatrists argue at court hearings that no sound person would refuse medically sound treatment, and the courts comply with their wish. It was therefore essential for Gottstein’s success to use scientific data to convince the Supreme Court that this isn’t true. The court ruled that, “Psychotropic medication can have profound and lasting negative effects on a patient’s mind and body” and “are known to cause a number of potentially devastating side effects.”
This was a stunning victory for human rights in psychiatry but there is a long way to go. The lawyers assigned to represent the patients generally fail miserably, and the psychiatric profession has explicitly acknowledged that psychiatrists regularly lie to the courts,2 e.g. by exaggerating the dangerousness of a mentally ill person’s behaviour, or by stating that the treatment works even when this is clearly not the case, or by ignoring its harms.
In one such case I was involved with, I demonstrated to a Norwegian High Court that the psychiatrist’s arguments were scientifically wrong and that the patient’s treating psychiatrists had committed serious malpractice by not responding to dangerous symptoms of intoxication, but the court didn’t care the least and ordered continued treatment with olanzapine although the patient was already objectively damaged by this drug in terms of tardive dyskinesia and had possibly even had malignant neuroleptic syndrome, which carries a high mortality. I find this absolutely disgusting. The lawyer’s appeal to the Supreme Court was rejected with the argument that there was nothing of a principled nature. The Supreme Court didn’t seem to care that some of the key evidence provided by the psychiatrist was objectively wrong. I doubt this is how courts react in murder cases when it is shown that the evidence provided to a lower court was wrong.
Jim Gottstein invited me to Anchorage in June 2016 to give a talk about abolishing forced admission and treatment and to meet with various people. The trip was sponsored by the Law Project for Psychiatric Rights and made possible by a grant from the Alaska Mental Health Trust Authority. Jim arranged for me to be an expert witness in a case of forced drugging and the proceedings could best be characterised as a sham where the outcome was determined beforehand. The lawyer for the patient is not informed that there will be proceedings until the day of the proceedings, which means that there is no possibility for preparing a proper defence.
Furthermore, the petitions I saw for continued confinement and drugging of patients in Alaska were untruthful to the extreme. Although the patients were very different, the arguments were the same for all of them and there was a prefabricated text on the forms (in italics below), e.g.:
Petitioner has reason to believe the patient is incapable of giving or withholding informed consent. The facility wishes to use psychotropic medication in a non-crisis situation. This is a statutory requirement AS 47.30.839(a)(2). So, this is just saying that the criterion has been met, but the petition doesn’t state what the facts are that lead to that conclusion.
The patient’s prognosis with this course of treatment: good.
The patient’s prognosis without these medications: poor.
Of the medications requested, the patient has previously taken the following medications and experienced these results or side effects: Has taken these medications and done well without side effects.
The following less intrusive treatment options/alternatives are available: none.
Firstly, it is highly unlikely that the patients are unable to provide or withhold informed consent. The UN Convention makes it clear that “unsoundedness of mind” and other discriminatory labels are not legitimate reasons for the denial of legal capacity, and that the concept of mental capacity is highly controversial in and of itself:1 “Mental capacity is not, as is commonly presented, an objective, scientific and naturally occurring phenomenon. Mental capacity is contingent on social and political contexts, as are the disciplines, professions and practices which play a dominant role in assessing mental capacity … In most of the State party reports that the Committee has examined so far, the concepts of mental and legal capacity have been conflated so that where a person is considered to have impaired decision-making skills, often because of a cognitive or psychosocial disability, his or her legal capacity to make a particular decision is consequently removed. This is decided simply on the basis of the diagnosis of an impairment (status approach), or where a person makes a decision that is considered to have negative consequences (outcome approach), or where a person’s decision-making skills are considered to be deficient (functional approach). The functional approach attempts to assess mental capacity and deny legal capacity accordingly. It is often based on whether a person can understand the nature and consequences of a decision and/or whether he or she can use or weigh the relevant information. This approach is flawed for two key reasons: (a) it is discriminatorily applied to people with disabilities; and (b) it presumes to be able to accurately assess the inner-workings of the human mind and, when the person does not pass the assessment, it then denies him or her a core human right — the right to equal recognition before the law. In all of those approaches, a person’s disability and/or decisionmaking skills are taken as legitimate grounds for denying his or her legal capacity and lowering his or her status as a person before the law. Article 12 does not permit such discriminatory denial of legal capacity, but, rather, requires that support be provided in the exercise of legal capacity.”
Secondly, there is no sound scientific evidence in support of blanket statements that the patient’s prognosis is good with medications and poor without. The fact that these patients have often received their drug cocktails for a long time actually demonstrates that the prognosis with the drugs is poor, which is also what the science tells us: the prognosis with treatment with antipsychotic drugs is poor.2,6,13 Patients fare better the less these drugs are being used.
Thirdly, it is close to impossible to take antipsychotic drugs or any other psychiatric drugs without side effects. It is therefore almost invariably misleading, and usually flatly untrue, to state that the patient “Has taken these medications and done well without side effects.”
Fourthly, it is misleading in the extreme to suggest that there are no less intrusive treatment options available. There are always less intrusive options available, as the very wide variation in ECT usage shows, and forced drugging is not necessary, as there are no psychiatric drugs that can cure psychiatric disorders whereas all of them can make matters worse.14,15 Compounding the matter, psychiatric trainees are required to pass tests in administering ECT but they are never required to show proficiency in not using ECT or in not using drugs or in tapering them off.
As regards ECT, the patients should be told that many psychiatrists treating similar conditions will hardly ever or never use ECT and that it is wholly a matter of chance or risk which type of psychiatrist the patient sees. Many jurisdictions insist that patients can be forced to have ECT against their will if they “unreasonably refuse” it. However, it is not at all clear what would constitute “reasonable refusal to accept ECT,” and what criteria the hospitals apply in deciding when refusal is unreasonable. In practice, refusal to accept ECT is always taken to be “unreasonable.”
Whom should the judges believe?
When psychiatrists say the treatment is helpful while the patients say it is not, we should let the patients decide, as they know best. Indeed, they are the only ones who can tell how a drug affects them subjectively. Drug trials is psychiatry are biased in many ways, e.g. because the placebo controlled studies have not been adequately blinded.2 The blinding is often broken due to the drug’s side effects and this leads psychiatrists to overestimate the effect,2 sometimes to such an extent that they can see the exact opposite of what is actually true. This was demonstrated in a double-blind placebo controlled trial funded by the US National Institute of Mental Health and reported on in 1964. It was a six-week study of newly admitted patients with schizophrenia in treatment with phenothiazines like chlorpromazine. None of the 270 patients became worse and the drugs were reported to reduce apathy, improve motor movement and to make patients less indifferent – exactly the opposite of what these drugs do to patients, and which the psychiatrists had admitted a decade earlier – and side effects were said to be “mild and infrequent … more a matter of patient comfort than of medical safety.”6,16
Antipsychotics are very poor drugs. Even helped by all the formidable biases in the trials,2 the outcome is poor. The minimal improvement on the Clinical Global Impressions Ratings corresponds to about 15 points on the Positive and Negative Syndrome Scale,17 but what was obtained in recent placebo controlled trials in submissions to the FDA was only 6 points,18 although it is easy for scores to improve quite a bit if someone is knocked down by a tranquilliser and express their abnormal ideas less frequently. Thus, the FDA has approved newer antipsychotic drugs whose effect is far below what is clinically relevant.
Although patients are not often subjected to forced treatment with antidepressants, it is nonetheless telling that the patients themselves, both children and adults, say in double-blind placebo controlled trials that the drugs don’t work for them while their psychiatrist say in the same trials that the drugs work.2 It is also noteworthy that in a large survey from 1995, people thought that antidepressants, antipsychotics, electroshock and admission to a psychiatric ward were more often harmful than beneficial.19
Abolishing laws of forced treatment
Forced treatment cannot be defended, neither on ethical, legal or scientific grounds. We need to abolish our laws about this, in accordance with the United Nations Convention on the Rights of Persons with Disabilities.1 The evidence we have tells us that forced treatment increases the harm done not only to patients but also to others.2,6,14.15 Violence breeds violence, but perhaps the strongest argument against forced drugging and ECT is that, apart from psychiatric patients, only soldiers at war are forced to run risks against their will that might kill them. The difference is that soldiers have usually chosen themselves to become soldiers whereas psychiatric patients have not chosen to become psychiatric patients.
In rare cases force may be needed, e.g. if a patient is dangerous, but restraint without belts, i.e. holding the patient firmly, will suffice. And if that is not enough, the case should be a matter for the police, which it is in Iceland and in Trieste.2
It is a myth that psychiatrists need access to forced treatment. With adequate leadership and training of staff in de-escalation techniques, it is possible to practice psychiatry without using force.2,20,21 In Iceland, belts have not been used since 1932 when a psychiatrist burnt them, and there are psychiatrists all over the world who have dealt with deeply disturbed patients for their entire career without ever having used antipsychotics, ECT or force.2 Peter Breggin never uses such treatments, and Niall McLaren has never used ECT. While he was head of department for a total of eight years at two Australian hospitals, ECT wasn’t used at all (McLaren, personal communication). He didn’t bar it, simply made it more difficult for his staff to use it, as they had to justify it by showing there was no alternative. At the same time, the admission rate to the hospital dropped, the average duration of stay dropped and the bed occupancy rate dropped by as much as half. In both hospitals, some time after his appointments had expired and he had moved, ECT was resumed and the bed occupancy rate quickly rose again.
There are many initiatives to reduce the amount of forced treatment.2 But the necessary culture change will never happen if we don’t make it illegal. Surely, there will be difficult cases where it will be missed, but we will need to live with that, as the benefits of abolishing forced treatment are far greater than the harms.2 Further, there are ways of dealing with the difficult cases without force. For example, we are allowed to prevent a patient with anorexia from dying by feeding her and don’t need psychiatric laws for this; we are entitled to save people’s life if we can.
In many countries, a person considered insane can be admitted to a psychiatric ward on an involuntary basis if the prospect of cure or substantial and significant improvement of the condition would otherwise be significantly impaired. But is this ever the case? Are there any treatments that can cure insane patients, or which can lead to such substantial improvements that the patient’s condition would be significantly impaired if she is not forced to go to hospital immediately? I don’t think so, and, considering the abuse that takes place at psychiatric wards,1,2 this clause should be removed from the law of all nations. There is already a clause that, if patients present an obvious and substantial danger to themselves or others, they can be involuntarily admitted, but we don’t even need this. According to the National Italian Mental Health Law, a reason for involuntary treatment can no longer be that the patient is dangerous. This is a matter for the police.2
In 2015, the UN Committee on the Rights of Persons with Disabilities called on States parties to protect the security and personal integrity of persons with disabilities who are deprived of their liberty by eliminating the use of forced treatment, seclusion and various methods of restraint in medical facilities, including physical, chemical and mechanic restrains.22 The Committee found, like patients do,2 that these practices are not consistent with the prohibition of torture.
If you still accept forced treatment and involuntary detention after having read my article, I hope you will read a heart-breaking book, “Dear Luise,” that describes virtually everything that is wrong with psychiatry.23 Luise had begged and begged not to be treated with antipsychotics, which she didn’t tolerate, and had seen her best friend at the care home being killed by them. Luise was herself killed only six months later, aged 32, by a lethal injection. Both women dropped dead on the floor. The system, however, congratulated itself for its first-class homicide where everyone seems to have been immunised beforehand against being found guilty. Luise’s mother was told that Luise had received the ”highest standard of specialist treatment.” The officially accepted term for deaths such as Luise’s is “natural death.” She had told her mother: “I’ll be next.”
We must stop this, and as the psychiatric profession is not likely to reform itself, real court cases – not sham proceedings – might be a good way forward.
Acknowledgements: I have been inspired by the hundreds of patient stories I have received from patients or their relatives; by the many previous patients who have reclaimed their life and escaped from psychiatry and now call themselves psychiatric survivors; and by my collaboration with lawyer Jim Gottstein and previous Supreme Court lawyer Ketil Lund, psychiatrists Peter Breggin, David Healy, Joanna Moncrieff and Neill McLaren, science journalist Robert Whitaker, psychologist John Read, and Dorrit Cato Christensen, the mother of the young Danish woman killed by antipsychotic drugs who established the organisation “Death in Psychiatry.”
1 United Nations Convention on the Rights of Persons with Disabilities. General comment No. 1 2014 May 19. http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G14/031/20/PDF/G1403120.pdf?OpenElement (accessed 1 April 2015).
2 Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press; 2015.
3 Hjorthøj CR, Madsen T, Agerbo E, et al. Risk of suicide according to level of psychiatric treatment: a nationwide nested case-control study. Soc Psychiatry Psychiatr Epidemiol 2014;49:1357–65.
4 Large MM, Ryan CJ. Disturbing findings about the risk of suicide and psychiatric hospitals. Soc Psychiatry Psychiatr Epidemiol 2014;49:1353–5.
5 Hughes S, Cohen D, Jaggi R. Differences in reporting serious adverse events in industry sponsored clinical trial registries and journal articles on antidepressant and antipsychotic drugs: a cross-sectional study. BMJ Open 2014;4:e005535.
6 Whitaker R. Mad in America. Cambridge: Perseus Books Group; 2002.
7 Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934–43.
8 Read J, Bentall R. The effectiveness of electroconvulsive therapy: a literature review. Epidemiol Psichiatr Soc 2010 Oct-Dec;19:333-47.
9 Rose D, Fleischmann P, Wykes T, et al. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003;326:1363.
10 Mettes Stemme (Mette’s Voice). http://madinamerica.com/mettes-stemme-mettes-voice/ (accessed 9 Dec 2014).
11 Royal College of Psychiatrists. Information about ECT (Electro-convulsive therapy). http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/ect.aspx. July 2015 (accessed 5 Feb 2016).
12 Sackeim HA, Prudic J, Fuller R, et al. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology 2007;32:244-54.
13 Whitaker R. Anatomy of an Epidemic. New York: Broadway Paperbacks; 2010.
14 Breggin P. Brain-disabling treatments in psychiatry: drugs, electroshock and the psychopharmaceutical complex. New York: Springer; 2007.
15. Breggin P. Medication madness: the role of psychiatric drugs in cases of violence, suicide, and crime. New York: St. Martin’s Griffin; 2008.
16 Cole JO. Phenothiazine treatment in acute schizophrenia; effectiveness: the National Institute of Mental Health Psychopharmacology Service Center Collaborative Study Group. Arch Gen Psychiatry 1964;10:246-61.
17Leucht S, Kane JM, Etschel E, et al. Linking the PANSS, BPRS, and CGI: clinical implications. Neuropsychopharmacology 2006;31:2318-25.
18 Khin NA, Chen YF, Yang Y, et al. Exploratory analyses of efficacy data from schizophrenia trials in support of new drug applications submitted to the US Food and Drug Administration. J Clin Psychiatry 2012;73:856–64.
19 Jorm AF, Korten AE, Jacomb PA, et al. ”Mental health literacy”: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aus 1997;166:182-6.
20 Fiorillo A, De Rosa C, Del Vecchio V, et al. How to improve clinical practice on involuntary hospital admissions of psychiatric patients: Suggestions from the EUNOMIA study. Eur Psychiat 2011;26:201-7.
21 Scanlan JN. Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far, a review of the literature. Int J Soc Psychiat 2010;56:412–23.
22 Committee on the Rights of Persons with Disabilities. Guidelines on article 14 of the Convention on the Rights of Persons with Disabilities. The right to liberty and security of persons with disabilities. Adopted during the Committee’s 14th session, held in September 2015.
23 Christensen DC. Dear Luise: a story of power and powerlessness in Denmark’s psychiatric care system. Portland: Jorvik Press; 2012.