Treating Mental Illness

Akhil Parashar

Being diagnosed with, and coming to terms with mental illnesses is a trying time in an individual’s life. Things often get more challenging when it comes time for treatment, as a lot of the medications tend to have nasty side-effects. This essay will explore the appropriate treatments for those suffering from serious mental illnesses, the ethical and human rights issues surrounding the various treatments, and the concerns around consent for treatment.

II   Appropriate treatment types

The nature of psychiatric treatment does not always allow the mitigation of discomfort and distress to be a paramount concern.[1] The question of what is appropriate is a normative one, as it begs the question of what actually is appropriate. One would think the ideal treatment for serious mental illnesses would be the one that helps the sufferer fight the illness and restore their competency to the fullest extent possible, in the timeliest manner. The unfortunate truth of antipsychotic and psychotropic medications is that they often carry severe side-effects.[2] Psychiatrists have a responsibility to strike a balance between prescribing medication on the basis of its effectiveness and sufferable side-effects.

Therapeutic treatment is claimed to be one that is apt for the patient’s condition. This means that treatment can be discontinued if the threshold of appropriateness is breached i.e. the negative consequences of taking medication outweigh the benefits. In Mental Health Law in New Zealand, Sylvia Bell and Warren Brookbanks suggest appropriate treatment is one that is in the patients’ best interests, therapeutically appropriate and the least intrusive.[3] For treatment to be in best interest of a patient, it needs to mitigate the mental disorder in question, whist taking the side-effects into account.[4] Therapeutically appropriate treatment ought to either mitigate, or prevent further decline in a patient’s condition, or both.[5] Finally, the least intrusive option is one that maintains and/or promotes a patient’s self-governance. Unfortunately, there is no one-size-fits-all approach applicable to psychiatric treatment, as all patients react differently to medications. The appropriateness of a treatment could be brought into question when the medication prescribed elevates the risk of diabetes, or along with slowing down the “firing” in the brain, it also slows down every other brain function and hinders communication or daily tasks. Such treatments require a crucial balance to be struck between restoring the patient to a position whether they can function like the rest without posing a risk to themselves or others around them, and ensuring that treatment is not too taxing on them both physically and psychologically.

III  Types of treatments and ethical and human rights issues

A     Psychotropic medication

Psychotropic medications are designed to target the symptoms of the disorders, rather than the disorders themselves, and there is recommendation from the World Health Organisation to administer medication alongside psychosocial treatments.[6] One of the reasons for this is non-compliance being a factor when administering medication, when dealing with such patients. Given their potency, these are heavily regulated to avoid abuse and harm.[7]

B     Electroconvulsive therapy

Electroconvulsive therapy, or ECT, does not have a good reputation, given its history.[8] However, for many individuals whose bouts of antidepressants have been unsuccessful and suicidality is a risk, ECT has proven to be effective.[9] ECT’s contentious history and intrusive nature mean that several psychiatrists suggest that it should be used as a last resort. Furthermore, any administration of ECT needs to comply with the statutory requirements around disclosure of treatment and the consequences associated with it.[10] Although a patient is entitled to decline treatment, it can still be administered if a Tribunal-appointed psychiatrist approves it.[11]

C    Psychosurgery

Source: https://www.ibiweb.org/what-behavioral-health-means-for-employers/

The risks involved with psychosurgery mean that in order for it to be administered, the patient needs to give informed consent in order to be subjected to it. The statute sets out strict criteria as to the circumstances under which the treatment can be administered.[12] This, along with ECT, are often seen as last resort treatments as although they might be in the patient’s best interest, it is not unlikely for them to be non-invasive – an important component for judging a treatment’s appropriateness.[13]

D    Ethical and Human Rights Issues

Non-compliance by patients tends to result in seclusion and/or restraint to maximise the chances of successful treatment administration. Mental illnesses often take a person’s free-will and ability to reason away from them, and clinicians often need to resort to such methods to minimise deterioration of a patient’s condition. The methods employed today are by no means perfect, but the alternative, to let the patients suffer and to have themselves and others around them being put in jeopardy is a risk a reasonable practitioner would not want to take. There are cultural considerations that need to be accounted for when exercising seclusion and/or restraint, such as the touching of certain body parts. Bell and Brookbanks argue for seclusion and restraint to be the last resort as they too breach the criteria of being non-intrusive.[14]

Although technically patients can withdraw previously-given consent under the Mental Health (Compulsory Assessment and Treatment) Act 1992, clinicians can continue with the treatment.[15] The paternalistic approaches discussed could be viewed as problematic and in violation of basic human rights. This appears brutal, but it is important to note that effective alternatives to treatments such as ECT and psychosurgery are either non-existent, difficult to administer or have unknown side-effects and effectivity. To put a patient through the distress of being administered ECT or psychosurgery is not usually an easy decision to make for a psychiatrist. A utilitarian approach is often used to justify the momentary suffering of one over the detriment of many, including of the patient themselves.[16]

IV  The state’s powers and consent

It has been suggested in recent times that those suffering from disorders are capable of forming their own decisions, and do withhold the capacity to consent. This has been extended to argue that consent is not a foreign concept to those suffering, and with certain amendments, capacity to give consent can be extended to them too. Such discussions are important to have, because it is not unjust to assert that we do not know everything as far as science is concerned. The contention comes about when those suffering from serious mental illnesses assert that they are able to comprehend their actions and environment given the dominating nature of various mental illnesses. A schizophrenic who has previously declared that the government poisons the minds of the populace ought not be given the authority to consent to treatment, or otherwise.[17]

We have an ethical duty as a society to treat the vulnerable in a humane, civilised manner that would assist in their betterment. There are always trade-offs when making decisions, and to mitigate the risk posed to society as a whole is often the only suitable solution. One could also argue in favour of invasive treatments by suggesting that in the absence of obligatory medical intervention, the quality of life of the sufferer is compromised. When the risk of self-harm or violence are considered, the Benthamite approach, however authoritarian, seems more alluring. The right to consent to treatment is essential for those who are have the capacity to consent.[18] The argument for maintaining a sufferer’s dignity, self-regulation and autonomy are refuted by the suggestion that they were not there to begin with, and it is acceptable to treat them to the best of our ability to provide the dignity, power to self-regulate and autonomy each individual is entitled to. The status-quo is imperfect and needs to be challenged in order to bring forth better, more humane treatments to allow the sufferers to live a life of dignity and comfort, whilst preserving the safety of society.

Treatments for sufferers of serious mental illnesses are rarely uniform, and require modifications to be made to be suitable for the sufferer in question. The treatments available currently are high risk, but in the absence of suitable alternatives, overruling the sufferer’s autonomy to achieve a better outcome for them and society as a whole is essential.

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Featured image source: https://www.wsj.com/articles/why-our-mental-health-takes-a-village-1516640136

[1] Anselm Eldergill Mental Health Review Tribunals: Law and Practice (Sweet and Maxwell, London, 1997) at 1130.

[2] NIH “Mental Health Medications” (October 2016) National Institute of Mental Health <https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml>.

[3] Sylvia Bell and Warren Brookbanks Mental Health Law in New Zealand (3rd ed, Thomson Reuters New Zealand Ltd, Wellington, 2016) at [152-153].

[4] At 154.

[5] R (on the application of Wilkinson) v Responsible Medical Officer Broadmoor Hospital [2001] EWCA Civ 1545, [2002] 1 WLR 419 at [70].

[6] World Health Organisation Mental Health Policy and Service Guidance Package: Improving Access and Use of Psychotropic Medicines (Singapore, 2004).

[7] Bell and Brookbanks, above n 3, at 159.

[8] New South Wales Royal Commission into Deep Sleep Therapy Report of the Royal Commission Into Deep Sleep Therapy (Sydney, 1990).

[9] Bell and Brookbanks, above n 3, at 160.

[10] Mental Health (Compulsory Assessment and Treatment) Act 1992, s 58 – s 60; s 60(a); s 67.

[11] Section 60(b).

[12] Section 61.

[13] Bell and Brookbanks, above n 3, at 164.

[14] At 170.

[15] Section 63; Section 58(2)(b).

[16] Bell and Brookbanks, above n 3, at 168.

[17] At 179.

[18] At 178.