CLINICAL HANDBOOK OF SCHIZOPHRENIA

POLICY AND SOCIAL IMPLICATIONSEvidence for and Justification of IOCAn important and controversial policy issue in many jurisdictions has been the extent towhich involuntary treatment should be extended into the community.Two randomized controlled studies have compared the effectiveness of IOC in reducinghospital admission. The first, carried out in New York, randomly assigned 78 peopledischarged from Bellevue Hospital to compulsory community treatment and comparedthem with 64 people treated voluntarily by the same intensive treatment team (Steadmanet al., 2001). Over the following 11 months, no difference was observed in the rate of admission,symptoms, or quality of life, and no patient in either group was charged with aviolent offense.The second study, in North Carolina, randomly assigned 129 people to compulsorytreatment and 135 to voluntary treatment of varying intensity and by four different teams(Swartz et al., 2001). In this study, the compulsorily treated group had 57% fewer admissionsand spent 20 days more in the community over the 1-year follow-up. However, thereduction in admissions occurred only when compulsory orders were associated withmore intensive treatment. It may be that it is the availability of intensive treatment thatmatters, and if this is available to everyone, as in New York, compulsion adds nothing. A2000 review published by the RAND Corporation also concluded that the evidence gatheredacross the United States did not support the use of IOC, and a database study inAustralia had similar negative conclusions (Kisely, Xiao, & Preston, 2004). Although researchevidence is only one of a number of factors that should be taken into account informulating policy, it has had very little impact on the spread of IOC legislation introducedin many jurisdictions in recent decades. However, the question of whether IOC“works” remains an important one for future research.Ethical Basis of Detention49. Involuntary Commitment 521As described earlier, legislation usually requires that commitment be justified on thegrounds that failure to accept psychiatric treatment involve risks to the health or safety ofthe patient or of others, though these risks are often rather poorly defined and rarelyquantifiable. Deciding what level of treatment pressure is commensurate with the risk isnot straightforward, but it may be helpful to try to apply an ethical framework commonlyused to assist decision making in general medicine. This requires consideration ofthe person’s capacity to take treatment decisions that are in his or her best interests. Capacityis usually defined as the ability to understand and retain information about theproposed treatment, and to weigh in the balance the consequences of alternative decisionsabout it. People with capacity can determine what treatment is in their own best interests,even where their views are not in accord with those of clinicians, and minimal pressure,perhaps limited to persuasion, is all that can be justified. If capacity is lacking, the treatmentthat is in the person’s best interest may need to be determined by clinicians, thoughtaking account, if possible, of the past and present wishes of the patient, and the views ofsignificant others. Advance statements about treatment preferences, made with capacityin anticipation of a future loss of capacity, such as might occur in psychotic relapse, carriesweight in the assessment of what is in someone’s best interests. Once the treatmentthat is in the best interests of the patient is established, the minimal level of pressure necessaryto achieve the objectives of this treatment can then be exerted.Although the application of this framework is helpful in clarifying the decision to bemade, mental health professionals are often faced with situations in which a simple judgmentof capacity is not easy to make. A client may, apparently through choice, live in