The short-term outcome of inpatient treatment for schizophrenia is not
dependent on whether the patient is undergoing treatment voluntarily or
The finding provides some empirical evidence to ethically justify
involuntary commitment and treatment of patients with schizophrenia from both
a legal and a medical perspective, according to a study in the July
Tillman Steinert, M.D., lead author of the report, told Psychiatric
News that short-term hospitalization and treatment with neuroleptics for
acute symptoms of schizophrenia and delusional disorders is effective"
even if the patient has no positive belief in the treatment and even if
he or she is convinced that the treatment is wrong for him or her."
He added, "We should know as much as possible about the effects of
such treatment and about the effects of withholding treatment."
Steinert is chair of the psychiatric care research department of the
Weissenau Psychiatric Center at the University of Uln in Ravensburg,
The study involved 88 adults patients with schizophrenia and delusions
consecutively admitted to a 320-bed psychiatric hospital in southern Germany
over a three-month period in 2002. They were assessed using two separate
scales at admission and discharge: the Positive and Negative Syndrome Scale
(PANSS) and the Global Assessment of Functioning (GAF). Discharge took place
an average of 36.2 days after admission.
Patients were grouped according to whether their participation was
voluntary or involuntary in each of the five following aspects of inpatient
treatment: admission, hospital stay, medication, discharge, and intention to
continue treatment after discharge.
Results showed that outcome of treatment—defined as the change
between admission and discharge in scores on the PANSS and the GAF, as well as
change in those scores per inpatient day—was not significantly related
to the voluntariness of patients' participation in any aspect of
Under German law, medication can be administered by coercion to patients
with involuntary legal status during the hospital stay, and patients are so
informed by the judge during a commitment hearing.
In the study setting, the classification of a patient's admission, hospital
stay, and medication as voluntary or involuntary reflects the patient's legal
status and may involve coercion for involuntary patients. However, whether a
patient's discharge and intention to continue treatment are classified as
voluntary or involuntary reflects the personal choice of the patient and is
not subject to formal coercion.
The mean total PANSS score for all patients was 94.1 at admission and 55 at
discharge. The mean GAF score for all patients at admission was 34.3.
For all aspects of treatment, no significant difference between the
voluntary and involuntary patients was found in the mean change in PANSS score
from admission to discharge.
"The involuntary patients generally had improvement that was similar
to or even greater than that of the voluntary patients," according to
Similarly, no significant difference was found in the increase in GAF score
from admission to discharge between voluntary or involuntary patients.
Darrel Regier, M.D., M.P.H., director of APA's Office of Research, who
reviewed the report, notes that the sample size in the study was very
small—only 13 of the 88 patients were in the involuntary group—but
said that its value lies in providing a model for how to subject to scientific
scrutiny a subject that arouses considerable passion.
"Opponents of involuntary treatment object on grounds of civil
rights, but also because they claim that it always is harmful to the
patient," Regier said. "This is an attempt to scientifically
address the question of whether there is always harm associated with coercion
when someone is seriously mentally ill."
The study authors noted that there appear to be no other study findings
comparing voluntary and coerced treatment.
"The finding that the outcome of involuntary inpatient treatment is
similar to that of voluntary treatment should not lead to underestimation of
the subjective suffering of patients who experience involuntary
treatment," the authors wrote, "especially patients with serious
disturbances who are repeatedly treated involuntarily."
The study, "Effect of Voluntariness of Participation in
Treatment on Short-Term Outcome of Inpatients With Schizophrenia," is
posted online at<http://ps.psychiatryonline.org/cgi/content/full/55/7/786?>.▪