When chlorpromazine was first introduced, doctors prescribed and patients took what they were given. The prescription of a medicine now, however, is much more likely to be based on the assumption that a patient should understand the condition for which the prescription is given, the nature of any treatment, its duration, its chances of success and the risks of side effects. Patients should be free to ask for any information they want from the prescriber, who will respond genuinely.
Clearly, respect for the autonomy of the patient has to be balanced against a respect for the autonomy of others. Uniquely in psychiatric practice it is necessary on occasion to give treatment without consent, but society has put mechanisms in place to compensate for a patient’s loss of autonomy in such situations, 12 and 13 although it is rarely noticed that, despite these arrangements, patients detained within mental health settings often have fewer rights than prisoners. The argument outlined below does not apply to these emergency situations or to the small number of situations facing all practitioners that amount de facto to a community treatment order, where clinicians may be operating with partial or grudging consent from patients. The argument is aimed at situations, particularly with antipsychotics, where a paternalistic approach to patients may involve an insidious loss of autonomy that may be countertherapeutic and ethically dubious.
THE PROBLEM
Consider the following. Many patients, when first admitted to hospital, will be started on medication regimens that they will not know exceed local or national formulary limits and greatly exceed the regimens that have been shown by research to be optimally effective. They are unlikely to know that there is rarely a pharmacological justification for the co-prescription of two different oral antipsychotics or for a combination of both an oral and depot antipsychotic, or for cocktails of anticonvulsants and antipsychotics. If given an anticholinergic agent they may not know that this has been given as an antidote to the side effects of the primary medication. If they do know this, they are unlikely to know that, quite commonly, it would be possible to avoid the need for an anticholinergic agent. If they are on a combination of antidepressants and antipsychotics, they almost certainly will not know that their ‘depression’ may be a consequence of treatment with antipsychotics and, if so, will not be responsive to antidepressant medication.
On a broader front, the worry is that patients admitted to hospital will have their treatment discontinued abruptly with a new treatment started immediately with little or no consideration being given to the possibility of withdrawal from the earlier treatment. In practice, antidepressants and antipsychotics are treated as though switching from one to another involved no more than switching between vitamins. This, however, is not the case. Putting patients on psychotropic drugs is better regarded as giving people a pharmacological life event.
Doubts have been expressed as to how often, in practice, patients validly consent to many prescribed regimens, and growing concerns have prompted a working party of the Royal College of Psychiatrists to issue guidelines covering some aspects of prescribing. 14 Against this background, it seems certain that in clinical practice betrayals of trust occur, and that situations may arise that are ‘abusive’. Let us consider therefore to what extent dynamics that are familiar from the sexual abuse arena might also apply in this domain.
THE DYNAMICS OF ABUSE
As in other forms of abuse, a ‘victim’ of ‘abusive prescribing’ may be dependent on the ‘abuser’. 15 This dependence may be brought about by virtue of an unavailability of psychiatric services in the victim’s area other than through the prescriber, and by virtue of the unavailability of psychotropic compounds other than by prescription. The victim, therefore, may have to maintain an interaction with the perpetrator and may in the process have to cope with the fact that the perpetrator at some level may be or may be regarded as showing concern for them. A common response to this point is that there is a difference between the intent to take advantage of children found in child abuse and the worst that clinicians can be accused of, which is adherence to out-of-date treatment practices: doctors do not casually or deliberately ‘violate’ their patients. This probably overestimates the degree of conscious intent to harm in many cases of child abuse and sexual harassment and underestimates the harm that can be done by clinicians ‘who know best’.
As with other forms of abuse, there will necessarily be a low incidence of disclosure to others, for a number of reasons. First, it is necessary to disclose the illness in order to disclose the abuse, and victims may understandably be reluctant to do this. Second, there may be a legitimate fear of reprisals should complaints be made, which many suspect might take the form of an increase in the dose of the treatment being complained about. Third, in addition to being seen as ill, just as any other victim of abuse, a victim of abusive prescribing risks further stigmatisation as a ‘loser’. Fourth, there are difficulties in ventilating concerns in this area as complaining about nervousness and other problems as a consequence of treatment leaves the subject open to the perception that all that has been demonstrated is the problem that led to the initial prescription.
Indeed, a further problem is that many individuals may not explicitly make the connection between their treatment regimens and the way they are feeling. 16 and 17 It may only be when they are evaluated by someone else that they become consciously aware of a connection between their treatment and symptoms such as anxiety, depression, demotivation, fatigue, a variety of psychosomatic symptoms, nervousness, impulsiveness, irritability, weight gain, sexual disturbances, suicidality, emotional blunting and other problems.
Finally, if a patient complains, there will often be a lack of support from significant others. This, as in other forms of abuse, may be important in its own right. Indeed, there may be considerable external pressure on the individual – from relatives and friends as well as from mental health professionals – to accommodate to the situation and to internalise blame. This will lead to a sense of defectiveness on the patient’s part or denial of the difficulties that are being experienced. This is compounded by blanket company denials that treatment could cause problems and indeed company suppression of the data indicating that there can be problems.
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