Treatment Delays for Involuntary Psychiatric Patients Associated With Reviews of Treatment Capacity

JD Vanderkooy, BSc1, Sidney H Kennedy, MD, FRCPC2,4, R Michael Bagby, PhD, CPsych3,4

Objective: To determine the duration of delays in treatment initiation when involuntary patients apply for a review of a finding of treatment incapacity and to estimate the cost of keeping patients hospitalized without treatment in these circumstances.

Method: Using a computerized database and written records, we identified all patients at 2 psychiatric hospitals in Ontario who applied for a review of a finding of treatment incapacity during a 10-year period. We recorded clinical and demographic variables, dates of stopping and starting medication, and dates of review board hearings and outcomes. We also noted all cases in which a patient appealed a decision from the review board to the court.

Results: Two hundred and thirty-seven patients made 334 applications to the review board. The board overturned the physician’s finding of incapacity in only 5 (1.5%) applications; 15 appealed the review board’s finding to the courts. None of these appeals were successful. In the absence of an appeal to the courts, the average delay in initiating treatment was 25 days. For patients appealing to the court, the average delay was 253 days. The cost of hospitalizing untreated patients while their capacity was under legal review was estimated at $3 867 000, of which $1 333 000 could have been saved if treatment had started immediately after the review board confirmed incapacity.

Conclusion: We have identified extensive delays in initiating psychiatric treatment for a number of patients. These delays are associated with legal review of treatment capacity. There are serious clinical risks and substantial costs associated with delay in treating patients with acute psychiatric illness. Where jurisdictions review treatment capacity, we recommend that treatment not be impeded once a review board has confirmed a clinical finding of incapacity.

(Can J Psychiatry 2002;47:181–185)

Clinical Implications

Mental health legislation in some Canadian jurisdictions results in unacceptable delays in initiating standard psychiatric treatment.
There is a significant financial cost and poor use of scarce psychiatric beds, in addition to previously reported adverse clinical outcomes.
Legislators need to consider clinical outcomes and costs when drafting mental health legislation.

Limitations

The study only looked at patients who appealed treatment incapacity.
The study methods did not allow for a systematic evaluation of clinical outcomes associated with treatment delay.

Key Words: mental health legislation, treatment capacity, treatment incapacity, treatment competency, treatment delay

Résumé : Délais de traitement des patients psychiatriques en cure obligatoire, associés aux évaluations de l’aptitude au traitement

In most Canadian jurisdictions, a physician determines whether a patient is capable of consenting to psychiatric treatment; in some jurisdictions, treatment refusal is not permitted (1). In those jurisdictions that allow treatment refusal, patients can challenge a finding of incapacity by applying to a quasi-judicial review board, and the decisions of the review board can be further appealed to the courts. If an application to a review board is initiated and treatment has not already commenced, it cannot begin until the matter is resolved. As a result of this legal requirement, patients are sometimes detained without treatment for extended periods.

Delayed psychiatric treatment of detained patients has been linked to several serious harms. These include prolonged individual suffering, increased self-destructive behaviour, increased use of seclusion and restraint, poorer long-term prognosis, deterioration of the therapeutic alliance, increased assaults by the patient, creation of a nontherapeutic ward milieu, demoralization and ethical dilemmas for health professionals, the blocking of inpatient beds, redirection of limited clinical resources to nontherapeutic activities and, paradoxically, the deprivation of liberty rights that results from withholding the treatment necessary to effect release from involuntary detention.

Detailed evidence for these detrimental effects of treatment delay has been reviewed elsewhere (1,2).

In the US, several studies have examined the amount of time elapsing between the onset of treatment refusal and the disposition of the matter by the courts (3–6). Delays in initiating treatment measured in this way range from a low of 24 days (4) to a high of 135 days (3). In Canada, there are single case reports of a man with active schizophrenia and a history of good clinical response to antipsychotic medication who was detained untreated for nearly 2 years (7), and of another man with an active psychotic illness who was kept, untreated and in seclusion, for over 404 days (8).

We are unaware of any systematic research on the duration of treatment delays carried out in a Canadian jurisdiction. Thus, our objective in this study was to determine the duration of delays in initiating treatment for patients found to be incapable of consenting to psychiatric treatment at 2 Ontario psychiatric hospitals. We also calculated the resulting financial cost. While we noted some negative outcomes associated with prolonged delays in initiating treatment, we were unable to systematically examine clinical outcomes in this study.