Abstract
Tom Trauer, Cathy Jones, St Vincent's Mental Health Service, Melbourne, Australia
We report a case of an involuntary psychiatric outpatient who used outcome measure ratings (in part) to show that she no longer required a Community Treatment Order (CTO), an order made out under the State Mental Health Act [1] that provides for compulsory treatment in the community.
Victoria (not her real name) is a 43-year-old woman with schizophrenia. Her 11-year history has been marked by fluctuating insight and periods of noncompliance during which she had problems with substance abuse and became dangerous. She has had three hospital admissions.
At the hearing in which the patient appealed against her CTO, the Mental Health Review Board (MHRB) considered one of the required criteria: Has the patient refused or is she unable to consent to the necessary treatment for the mental illness? The treating doctor indicated that hospital admissions had been averted by the application of the CTO, and that when the CTO was last lifted compliance with medication and appointments had ceased. The case manager told the Board that although she might fall back into a cycle of drinking alcohol after a few days of ceasing medication, Victoria was generally compliant and manages the illness very well. He also said that the 16-item version [2] of the Life Skills Profile [3] had been completed as part of the recent case review and individual service plan. These LSP ratings covered the previous 3 months. On the item: Does this person generally look after and take her or his own prescribed medication (or attend for prescribed injections on time) without reminding? the rating was 1 (slightly unreliable) and on the items: Is this person willing to take psychiatric medication when prescribed by a doctor? and Does this person cooperate with health services (e.g. doctors and/or other health worker)? the ratings were 0 (always). Victoria's legal representative submitted that she was consenting to treatment and drew the Board's attention to previous MHRB decisions in which (a) partial insight did not preclude a sufficient understanding of the consequences of not taking medication, and (b) the need to interpret the Act in a way that least infringes upon civil rights. The Board discharged Victoria from her status as an involuntary patient. Despite subsequent deterioration in her substance abuse problem and an increased frequency of contact with the service, there has been no contact with the crisis team nor any hospitalizations.
This case demonstrates that routinely collected outcome measures can have a direct impact on patient care. Did the measures detract from the clinical autonomy of the health care professionals involved? We think not, since the ratings only represent a formal and systematic record of clinical opinions that could have otherwise been expressed verbally; however, these opinions had not been documented elsewhere in the file.