Ethics of treating fixed delusions

[F0nzie]

I have had a number of patients over the years with fixed delusions and absence of other symptoms of Schizophrenia who get repeatedly placed on court order. Antipsychotics don't work for many of these patients and all forced treatment does is agitate them. Sure a stressor or they use meth or cocaine nudges them out of isolation and into the public eye where they get into trouble and the police are called. But they are not a threat to themselves or others. I have been told by other psychiatrists that treatment should be forced because we are ultimately responsible for any adverse events while they are under our care. But what about putting someone on medications that clearly shows no improvement whatsoever? Can't people just be allowed to be delusional and left alone if treatment doesn't help anyways? These people are not depressed, they're not manic, they're not suicidal, they're not homicidal, they get ss benefits or family support and can take care of basic needs. But yet we receive legal threats and threats from family to force medication? I think part of the problem is there are no defined boundaries on what our speciality does and does not do within the scope of mental illness other than maybe the diagnosis of malingering. How can this be resolved?


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[splik]

The purpose of using antipsychotics in these kinds of cases is not to treat delusions (as antipsychotics do not typically treat delusions once they have formed), but to reduce psychotic acting-out. despite the woeful lack of evidence supporting the use of long-term neuroleptics and increasing evidence that they cause cerebral volume loss and worsen functional outcomes in people with psychosis, there is evidence to support these drugs reducing violent behavior in patients with psychosis. Delusions cause people to act in ways that they would not ordinarily because of the conviction in their believe, and in some patients neuroleptics do seem to reduce psychotic acting-out. But clearly there are some people who do not respond to neuroleptics. In fact, it is a sizeable minority. In these cases, if there is no evidence that neuroleptics will help, then you shouldn't use them. In psychiatric matters, the courts almost always defer to the expertise of the psychiatrist (which is kind of why civil commitment hearings and forced medication hearings tend to be kangaroo courts), so there is actually nothing stopping you from saying that you do not believe that neuroleptics are appropriate in this case, that the risks of treatment outweight the benefits, and here is the evidence that multiple trials of these drugs have not had any effect on recidivism. If they are using substances then court-ordered treatment for this is still going to be an important part of reducing risk, and engagement in mental health services (which may be primarily case-management driven) is likely to also be appropriate.

But I hear you, I find the coercive aspects of psychiatry extremely uncomfortable and I think it is unethical to continue to forcibly drug people with toxic substances that have not been shown to work in that person.

 

[nitemagi]

I tend to think about antipsychotics treating an other positive psychotic symptom (paranoia, hallucinations). And often those things feed the downstream delusion. By reducing the underlying paranoia, hallucination or disconnect, the delusion slowly breaks down over time, presuming they have some reality contact. I've seen a good number of cases where the other psychotic symptoms besides the delusion are not clear for quite a while. Overall I'm a fan of the extended evaluation, and I do agree with Fonz and Splik that the mandated medicating when there's been no evidence of benefit weighs heavy. I'm not a fan.

Interestingly, almost as a side note, I have seen some people where they develop an apparent delusion or even paranoia that is actually psychological in origin, and that after failing medication after medication, therapy is what snaps them back to reality.

 

[twright]

I have had a number of patients over the years with fixed delusions and absence of other symptoms of Schizophrenia who get repeatedly placed on court order. Antipsychotics don't work for many of these patients and all forced treatment does is agitate them. Sure a stressor or they use meth or cocaine nudges them out of isolation and into the public eye where they get into trouble and the police are called. But they are not a threat to themselves or others. I have been told by other psychiatrists that treatment should be forced because we are ultimately responsible for any adverse events while they are under our care. But what about putting someone on medications that clearly shows no improvement whatsoever? Can't people just be allowed to be delusional and left alone if treatment doesn't help anyways? These people are not depressed, they're not manic, they're not suicidal, they're not homicidal, they get ss benefits or family support and can take care of basic needs. But yet we receive legal threats and threats from family to force medication? I think part of the problem is there are no defined boundaries on what our speciality does and does not do within the scope of mental illness other than maybe the diagnosis of malingering. How can this be resolved?


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How do they get put on forced treatment? With no homicidality, suicidality, or grave disability, what are the typical grounds given?

 

[clausewitz2]

The purpose of using antipsychotics in these kinds of cases is not to treat delusions (as antipsychotics do not typically treat delusions once they have formed), but to reduce psychotic acting-out. despite the woeful lack of evidence supporting the use of long-term neuroleptics and increasing evidence that they cause cerebral volume loss and worsen functional outcomes in people with psychosis, there is evidence to support these drugs reducing violent behavior in patients with psychosis. Delusions cause people to act in ways that they would not ordinarily because of the conviction in their believe, and in some patients neuroleptics do seem to reduce psychotic acting-out. But clearly there are some people who do not respond to neuroleptics. In fact, it is a sizeable minority. In these cases, if there is no evidence that neuroleptics will help, then you shouldn't use them. In psychiatric matters, the courts almost always defer to the expertise of the psychiatrist (which is kind of why civil commitment hearings and forced medication hearings tend to be kangaroo courts), so there is actually nothing stopping you from saying that you do not believe that neuroleptics are appropriate in this case, that the risks of treatment outweight the benefits, and here is the evidence that multiple trials of these drugs have not had any effect on recidivism. If they are using substances then court-ordered treatment for this is still going to be an important part of reducing risk, and engagement in mental health services (which may be primarily case-management driven) is likely to also be appropriate.

But I hear you, I find the coercive aspects of psychiatry extremely uncomfortable and I think it is unethical to continue to forcibly drug people with toxic substances that have not been shown to work in that person.

Yeah, to the extent I have had friction with anyone in my program so far, it has been because I am very leery of summoning Leviathan when dealing with patients. As a result, I have become a stickler for applying the actual legal standard in my state for involuntary commitment rather than the, um, looser interpretations of that standard that still do manage to convince hearing officers a distressingly large percentage of the time.

 

[Merovinge]

But yet we receive legal threats and threats from family to force medication?

If someone is getting forced treatment and the family is threatening you to put them on medications it seems like a bit more is going on then a delusional disorder?

 

[SeniorWrangler]

People with jealous and erotomanic delusions can be dangerous to others.
Also, all the studies I've read of dangerousness in psychotic disorders suggest that the most risky patients are those using drugs of abuse, but not getting any psychiatric medications.