Am J Psychiatry 1997; 154:483-489
Copyright © 1997 by American Psychiatric Association
Prospective study of patients' refusal of antipsychotic medication under a physician discretion review procedure
JA Kasper, SK Hoge, T Feucht-Haviar, J Cortina and B Cohen
Institute of Law, Psychiatry, and Public Policy, University of Virginia School of Law, Charlottesville 22903, USA.
OBJECTIVE: The authors examined the refusal of antipsychotic medications
and associated outcomes prospectively in a group of 348 psychiatric
patients admitted to three acute inpatient units in a state- operated
mental health facility in Virginia where psychiatrists have the
discretionary power to administer treatment over patients' objections.
METHODS: Newly admitted patients were administered both a questionnaire to
ascertain their attitudes toward admission and the Brief Psychiatric Rating
Scale (BPRS). Patients who refused antipsychotic medication were
identified, and data were collected on the length of refusal and whether
the refusal episode was terminated voluntarily or involuntarily. A group of
patients compliant with antipsychotic medication was selected for
comparison on outcome measures, including the rate of seclusion and
restraint and length of hospitalization. RESULTS: Patients who refused
treatment were found to have significantly higher BPRS scores than were
patients who complied with antipsychotic treatment and more negative
attitudes toward hospitalization and past, present, and future treatment.
Refusal episodes were brief, on average 2.8 days, and all patients, who
refused treatment were treated. When compared with the compliant patients,
patients who refused treatment were more likely to be assaultive, were more
likely to require seclusion and restraint, and had longer hospitalizations.
CONCLUSIONS: Psychiatrists exercised their discretion to promptly treat all
patients who refused treatment. Nonetheless, these patients suffered more
morbidity than compliant patients. This study suggests that the negative
sequelae of in-hospital treatment refusal cannot be eliminated by rapid
treatment. The policy implications are discussed.
