IJLP-01078; No of Pages 3 International Journal of Law and Psychiatry xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Law and Psychiatry
Involuntary outpatient treatment (IOT) in Spain M. Hernández-Viadel a, C. Cañete-Nicolás a, C. Bellido-Rodriguez b, P. Asensio-Pascual a, G. Lera-Calatayud c,⁎, R. Calabuig-Crespo d, C. Leal-Cercós a a
Psychiatry Department, Hospital Clínico Universitario, Valencia, Spain Psychiatry Department, Medical-Legal Institute of Valencia, Spain Psychiatry Department, Hospital De La Ribera, Alzira, Valencia, Spain d Psychiatry Department, Hospital Clínico Universitario Doctor Peset, Valencia, Spain b c
a r t i c l e
i n f o
Available online xxxx Keywords: Involuntary outpatient treatment Serious mental disease
a b s t r a c t In recent decades there have been significant legislative changes in Spain. Society develops faster than laws, however, and new challenges have emerged. In 2004, the Spanish Association of Relatives of the Mentally Ill (FEAFES) proposed amending the existing legislation to allow for the implementation of involuntary outpatient treatment (IOT) for patients with severe mental illness. Currently, and after having made several attempts at change, there is no specific legislation governing the application of this measure. Although IOT may be implemented in local programmes, we consider legal regulation to be needed in this matter. © 2015 Elsevier Ltd. All rights reserved.
1. Background on Spanish mental health legislation, its use and why it is a problem in Spain A number of important events have taken place in psychiatry since the mid-twentieth century: the development of psychopharmacology, new forms of psychosocial intervention, the human rights movement, the promotion of patient rights, equating the rights of the mentally ill to those of other patients, and the integration of mental health care into the general health care system. These developments have allowed developed countries to minimise custodial forms of intervention and to progress in the area of the individual and social freedoms of citizens with mental disorders (Ferreirós-Marcos, 2006). In Spain, the restoration of democracy and the Constitution of 1978 ushered in significant institutional and legislative changes. Some of these are the following: • Spain is divided into 17 autonomous regions, more akin to a federal than a centralised model, and each autonomous region has its own public health care system. • The 1986 Law on General Health was an important step forward in the integration of psychiatry into the general health care system and in the implementation of the community model across Spain. • With the reform of the Civil Code regarding guardianship, civil protection for the mentally ill was granted to judges on the grounds that guardianship was necessary. The Civil Procedure Act of 2000 (Ley de enjuiciamiento civil, LEC 2000) regulates the involuntary admission
⁎ Corresponding author. E-mail address: [email protected] (G. Lera-Calatayud).
of individuals on the grounds of mental disorder when they are not able to decide for themselves. This admission requires the prior authorisation of a judge, except in emergencies, in which case the judge must be advised within 24 h. • Act 41/2002, regulating patient autonomy, rights and duties recognises that any health action requires the prior consent of the patient, and that all patients are entitled to refuse treatment, except in emergency situations where it is impossible to obtain their authorisation, there is a risk to public health or they are incapacitated for decision-making.
Nonetheless, the process of deinstitutionalisation carried out in Spain during the 1980s and 1990s has not been accompanied by the adequate provision of community services that allow those affected to receive appropriate and comprehensive treatment. Despite large gaps in mental health care between developing and developed countries, there is a common problem for both in that many people who could benefit from the psychiatric services available do not use them. Lack of illness awareness is still an important barrier to rehabilitation for patients with mental illness. The mentally ill face many problems in the community, including stigma, difficulties in access to jobs and an adequate system of health care and social resources. Within this broad range of problems, there is also the right of patients to informed consent and the issue of involuntary psychiatric treatment. Internationally, countries with a longer tradition of psychiatric reform and more economic resources, such as the USA, Canada and England, have developed forms of involuntary outpatient commitment alongside forms of involuntary admission (Kisely, Campbell, & Preston, 2005; Mental Health Act, 2007).
http://dx.doi.org/10.1016/j.ijlp.2015.03.004 0160-2527/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Hernández-Viadel, M., et al., Involuntary outpatient treatment (IOT) in Spain, International Journal of Law and Psychiatry (2015), http://dx.doi.org/10.1016/j.ijlp.2015.03.004
2
M. Hernández-Viadel et al. / International Journal of Law and Psychiatry xxx (2015) xxx–xxx
In October 2004, a proposal was brought to the Spanish Parliament (Spanish Justice Comission in “Congreso de Diputados” diary sessions (2005 Mar 1st and 2nd)) at the request of the Spanish Confederation of Groups for the Mentally Ill and their Families (Confederación Española de Agrupaciones de Familiares y Enfermos Mentales, FEAFES). It sought to amend the LEC 2000 in order to regulate the involuntary treatment of individuals with mental disorders, thereby allowing for legally requiring a particular type of patient to follow a treatment plan in the community. The FEAFES proposal was intended as one of a series of measures available to physicians that would allow family members and professionals to ensure treatment compliance of those with serious mental illnesses who are not aware of their disease and who are at serious risk of relapse if they stop their treatment, without the need for more radical intervention such as hospitalisation and civil incapacitation. As in other countries, the controversy over the appropriateness of this type of action has given rise to defenders and detractors. For example, the Spanish Society of Psychiatry (Sociedad Española de Psiquiatría) (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005) and the Spanish Society of Legal Psychiatry SEPL (Sociedad Española Psiquiatría Legal, 2005) have expressed support for the legislative change. In contrast, the Spanish Association of Neuropsychiatry (Asociación Española de Neuropsiquiatría) (AEN (Asociación Española de Neuropsiquiatría), 2005) has spoken out against it and placed more emphasis on its potential drawbacks, arguing for the need to develop community programmes with intensive monitoring and to apply the Law on General Health. Given the absence of consensus, this legislative proposal was eventually withdrawn from parliament. In October 2006, the Spanish government introduced a new legislative proposal on “judicial authorisation for the involuntary treatment of individuals with mental disorders” (Barrios Flores, 2008; Proyecto de Ley 121/000109, 2006). Unlike the 2004 proposal, in which the judicial action was based on the knowledge of the doctor, this new draft would allow the matter to go directly to the courts without the prior reasoned proposal of the specialist. Finally, following debate in the Congress of Deputies, the articles on the regulation of “involuntary treatment” were deleted and rejected by Congress again. 2. Current practice, development and challenges Thirty or forty years ago, clinical decisions by doctors were sufficient to administer treatment even if the patient rejected it and without the authorization of a judge to enforce treatment without the patient's consent (i.e. haloperidol drops were administered in food without patient knowledge or depot medication was injected even the patient expressed reluctance). Nonetheless, the frequency of this type of practice is declining due to an increased awareness within Spanish society in general, and among doctors in particular, of the importance of respecting patient rights and of the consequences and limitations this has on clinical practice. Spanish law 41/2002 regulates patient autonomy, rights and duties and recognises that any health action requires the prior consent of the patient, except when incapacitated for decision-making. Today, individuals whose lives are severely affected by a mental disorder and who lack an awareness of the illness may be involuntarily hospitalized (Civil Procedure Act 2000). The other possibility is to be declared incompetent and given a guardian. 3. Actions and pilot projects in Spain In recent years, IOT experiments have been launched in various Spanish cities (San Sebastián, Barcelona, Alicante, Valencia), with the aim of improving treatment adherence in individuals with severe mental illness, and of avoiding the extremes of hospitalisation and civil incapacitation.
Since 1997, San Sebastián has been conducting an IOT experience with one of the city's courts (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005 Mar 1st and 2nd). The inclusion criteria were the following: patients diagnosed with psychosis, a history of multiple hospitalisations, treatment effectiveness and auto-aggressive or hetero-aggressive risk. Between 1997 and 2003, 45 patients received IOT. Of these, 60% were diagnosed with schizophrenia, 10% with bipolar disorder and the rest with psychosis linked to drugs and/or personality disorders. They were monitored under a protocol drawn up with the judge. The conclusions of IOT experiment in San Sebastian city (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005 Mar 1st and 2nd) indicated that IOT was a useful measure for patients diagnosed with psychosis (schizophrenia or bipolar disorder) and also served to introduce them to therapeutic resources that they had previously refused. The results were not good in cases where drug use or personality disorders were the main diagnosis. A similar experiment is being carried out in Barcelona, where there are two courts specialised in matters of competence and involuntary admission, though with different stances when it comes to interpreting the regulations on the implementation of involuntary outpatient treatment. One court has applied IOT since 1999 as an alternative to more radical actions such as involuntary hospitalisation or be declared incompetent. The other court holds that, in the absence of a written regulation, the issue cannot even be considered, although involuntary hospitalisation may be requested if the individual's condition worsens (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005 Mar 1st and 2nd). In Valencia, following the experience of San Sebastián, IOT has been implemented since 2003. According to data obtained from the court in charge of processing involuntary admission and civil incapacitation, there were 140 patients with IOT in Valencia in 2008, and the prevalence of use was 9/100,000 inhabitants (this court exercises its duties on a population of approximately 1,500,000 people). Most of the psychiatrists treating the patients with IOT have informed the court that their patients' evolution had improved or stabilised (72% of patients). These data are similar to those published previously by our group (Hernandez-Viadel, Lera-Calatayud, Cañete-Nicolás, Pérez Prieto, & Roche, 2007). In the absence of specific legislation, the legal coverage of these judicial actions is based primarily on two regulations: First, a supranational regulation, the 1997 European Convention of Oviedo on Human Rights and Biomedicine, approved and ratified by the Government of Spain in 1999 (Official State Gazette — BOE — No. 251). Article 7 of the Convention states that a person who has a severe mental disorder may be subjected, without personal consent, to an intervention aimed at treating this disorder where, without such treatment, serious personal harm is likely to result. Second is the case of choosing the least restrictive option. Detainment in hospital is considered to involve a series of enforcement actions that limit patient autonomy (restriction of personal liberty, limited communication with the outside world, subjection to treatment). In this sense, involuntary outpatient treatment would be a partial implementation (subjection to treatment) of involuntary admission. One possible criticism of the application of Article 7 of the European Convention is the risk that it could be abused by making a rule out of what should be an exception. We believe, as with all measures restricting rights, that the use of IOT should be the exception rather than the rule. Moreover, the prevalence of IOT in Valencia is 9/100,000 inhabitants, a similar figure to that of countries such as Canada and Australia (5–15/100,000), where this measure has been implemented for far longer (Kisely et al., 2005). As for considering IOT a less restrictive measure than involuntary admission, Crawford, Gibbon, Ellis, & Waters (2004) found that a majority of patients (60%) prefer to continue compulsory treatment outside the hospital. In addition, the “New York State Assisted Outpatient
Please cite this article as: Hernández-Viadel, M., et al., Involuntary outpatient treatment (IOT) in Spain, International Journal of Law and Psychiatry (2015), http://dx.doi.org/10.1016/j.ijlp.2015.03.004
M. Hernández-Viadel et al. / International Journal of Law and Psychiatry xxx (2015) xxx–xxx
Treatment” evaluation programme indicates that participants with IOT do not experience more adverse subjective conditions – including perceived coercion – than do participants without IOT (Swartz, Swanson, Steadman, Robbins, & Monahan, 2009). Despite the use of IOT in some Spanish cities and certain legal references allowing its implementation with the protection of the court, we consider it necessary to adopt an appropriate legal framework that explicitly regulates the implementation of IOT. It should be one that meets the requirements of European regulations and establishes the principle of proportionality (the requirement that the intervention not deviate from the aim of protection, and that it is necessary, appropriate, subject to revision and guided by an assessment procedure to minimise possible interference with the affected right). 4. Conclusions and future directions Our impression is that IOT is a measure that can be beneficial for some patients with severe mental illness. Most developed countries have introduced legislative changes regulating the use of IOT. In Spain, although IOT is implemented in certain cities, there is currently no legislation governing its application. In our opinion, an adequate legal framework is required that explicitly governs its implementation.
3
References AEN (Asociación Española de Neuropsiquiatría) (2005). AEN Document about the IOT regulation proposal. ([On line]. Available:) www.asoc-aen.es Barrios Flores, L. F. (2008). Tratamiento ambulatorio involuntario. In Otero Pérez (Ed.), Psiquiatría y Ley. Guía para la práctica clínica (pp. 71–123). Edimsa Publisher. Crawford, M. J., Gibbon, R., Ellis, E., & Waters, H. (2004). In hospital, at home, or not at all: A cross-sectional survey of patient preferences for receipt of compulsory treatment. Psychiatric Bulletin, 28, 360–363. Ferreirós-Marcos, C. E. (2006). El Tratamiento Ambulatorio: Cuestiones Legales Y Prácticas Colecciones Cermi. Vol. 24, ([On line]. Available: http://www.cermi.es.). Health Act, Mental (2007). ([On line]. Available:) www.opsi.gov.uk/acts/acts2007/pdf/ ukpga_20070012_en.pdf Hernandez-Viadel, M., Lera-Calatayud, G., Cañete-Nicolás, C., Pérez Prieto, J. F., & Roche, Millán T. (2007). Tratamiento ambulatorio involuntario: Opinión de las personas implicadas. Archivio di Psicologia, Neurologia e Psichiatria, 70(1), 65–74. Kisely, S., Campbell, L. A., & Preston, N. (2005). Compulsory community and involuntary outpatient for people with severe mental disorders. The Cochrane library, issue 4. Cochrane review. Proyecto de Ley 121/000109 (2006). Jurisdicción voluntaria para facilitar y agilizar la tutela y garantía de los derechos de la persona. Boletín Oficial de las Cortes Generales. “Congreso de los Diputados”. October 27th, 2006. Number 109-1. SEPL (Sociedad Española Psiquiatría Legal) (2005)). Statement about outpatient treatment and the observation into involuntary diagnosis. ([On line]. Available: www.psiquiatrialegal.org Psiq). Spanish Justice Comission in “Congreso de Diputados” diary sessions (2005 Mar 1st and 2ndd). Proposición de Ley de Modificación LEC para regular los tratamientos no voluntarios de las personas con trastornos psíquicos. Number 206, Session number 11 and number 209, Session number 12. Swartz, M. S., Swanson, J. W., Steadman, H. J., Robbins, P. C., & Monahan, J. (2009). New York State. Assisted outpatient treatment program evaluation. Durham, NC: Duke University School of Medicine.
Please cite this article as: Hernández-Viadel, M., et al., Involuntary outpatient treatment (IOT) in Spain, International Journal of Law and Psychiatry (2015), http://dx.doi.org/10.1016/j.ijlp.2015.03.004
Contents lists available at ScienceDirect
International Journal of Law and Psychiatry
Involuntary outpatient treatment (IOT) in Spain M. Hernández-Viadel a, C. Cañete-Nicolás a, C. Bellido-Rodriguez b, P. Asensio-Pascual a, G. Lera-Calatayud c,⁎, R. Calabuig-Crespo d, C. Leal-Cercós a a
Psychiatry Department, Hospital Clínico Universitario, Valencia, Spain Psychiatry Department, Medical-Legal Institute of Valencia, Spain Psychiatry Department, Hospital De La Ribera, Alzira, Valencia, Spain d Psychiatry Department, Hospital Clínico Universitario Doctor Peset, Valencia, Spain b c
a r t i c l e
i n f o
Available online xxxx Keywords: Involuntary outpatient treatment Serious mental disease
a b s t r a c t In recent decades there have been significant legislative changes in Spain. Society develops faster than laws, however, and new challenges have emerged. In 2004, the Spanish Association of Relatives of the Mentally Ill (FEAFES) proposed amending the existing legislation to allow for the implementation of involuntary outpatient treatment (IOT) for patients with severe mental illness. Currently, and after having made several attempts at change, there is no specific legislation governing the application of this measure. Although IOT may be implemented in local programmes, we consider legal regulation to be needed in this matter. © 2015 Elsevier Ltd. All rights reserved.
1. Background on Spanish mental health legislation, its use and why it is a problem in Spain A number of important events have taken place in psychiatry since the mid-twentieth century: the development of psychopharmacology, new forms of psychosocial intervention, the human rights movement, the promotion of patient rights, equating the rights of the mentally ill to those of other patients, and the integration of mental health care into the general health care system. These developments have allowed developed countries to minimise custodial forms of intervention and to progress in the area of the individual and social freedoms of citizens with mental disorders (Ferreirós-Marcos, 2006). In Spain, the restoration of democracy and the Constitution of 1978 ushered in significant institutional and legislative changes. Some of these are the following: • Spain is divided into 17 autonomous regions, more akin to a federal than a centralised model, and each autonomous region has its own public health care system. • The 1986 Law on General Health was an important step forward in the integration of psychiatry into the general health care system and in the implementation of the community model across Spain. • With the reform of the Civil Code regarding guardianship, civil protection for the mentally ill was granted to judges on the grounds that guardianship was necessary. The Civil Procedure Act of 2000 (Ley de enjuiciamiento civil, LEC 2000) regulates the involuntary admission
⁎ Corresponding author. E-mail address: [email protected] (G. Lera-Calatayud).
of individuals on the grounds of mental disorder when they are not able to decide for themselves. This admission requires the prior authorisation of a judge, except in emergencies, in which case the judge must be advised within 24 h. • Act 41/2002, regulating patient autonomy, rights and duties recognises that any health action requires the prior consent of the patient, and that all patients are entitled to refuse treatment, except in emergency situations where it is impossible to obtain their authorisation, there is a risk to public health or they are incapacitated for decision-making.
Nonetheless, the process of deinstitutionalisation carried out in Spain during the 1980s and 1990s has not been accompanied by the adequate provision of community services that allow those affected to receive appropriate and comprehensive treatment. Despite large gaps in mental health care between developing and developed countries, there is a common problem for both in that many people who could benefit from the psychiatric services available do not use them. Lack of illness awareness is still an important barrier to rehabilitation for patients with mental illness. The mentally ill face many problems in the community, including stigma, difficulties in access to jobs and an adequate system of health care and social resources. Within this broad range of problems, there is also the right of patients to informed consent and the issue of involuntary psychiatric treatment. Internationally, countries with a longer tradition of psychiatric reform and more economic resources, such as the USA, Canada and England, have developed forms of involuntary outpatient commitment alongside forms of involuntary admission (Kisely, Campbell, & Preston, 2005; Mental Health Act, 2007).
http://dx.doi.org/10.1016/j.ijlp.2015.03.004 0160-2527/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Hernández-Viadel, M., et al., Involuntary outpatient treatment (IOT) in Spain, International Journal of Law and Psychiatry (2015), http://dx.doi.org/10.1016/j.ijlp.2015.03.004
2
M. Hernández-Viadel et al. / International Journal of Law and Psychiatry xxx (2015) xxx–xxx
In October 2004, a proposal was brought to the Spanish Parliament (Spanish Justice Comission in “Congreso de Diputados” diary sessions (2005 Mar 1st and 2nd)) at the request of the Spanish Confederation of Groups for the Mentally Ill and their Families (Confederación Española de Agrupaciones de Familiares y Enfermos Mentales, FEAFES). It sought to amend the LEC 2000 in order to regulate the involuntary treatment of individuals with mental disorders, thereby allowing for legally requiring a particular type of patient to follow a treatment plan in the community. The FEAFES proposal was intended as one of a series of measures available to physicians that would allow family members and professionals to ensure treatment compliance of those with serious mental illnesses who are not aware of their disease and who are at serious risk of relapse if they stop their treatment, without the need for more radical intervention such as hospitalisation and civil incapacitation. As in other countries, the controversy over the appropriateness of this type of action has given rise to defenders and detractors. For example, the Spanish Society of Psychiatry (Sociedad Española de Psiquiatría) (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005) and the Spanish Society of Legal Psychiatry SEPL (Sociedad Española Psiquiatría Legal, 2005) have expressed support for the legislative change. In contrast, the Spanish Association of Neuropsychiatry (Asociación Española de Neuropsiquiatría) (AEN (Asociación Española de Neuropsiquiatría), 2005) has spoken out against it and placed more emphasis on its potential drawbacks, arguing for the need to develop community programmes with intensive monitoring and to apply the Law on General Health. Given the absence of consensus, this legislative proposal was eventually withdrawn from parliament. In October 2006, the Spanish government introduced a new legislative proposal on “judicial authorisation for the involuntary treatment of individuals with mental disorders” (Barrios Flores, 2008; Proyecto de Ley 121/000109, 2006). Unlike the 2004 proposal, in which the judicial action was based on the knowledge of the doctor, this new draft would allow the matter to go directly to the courts without the prior reasoned proposal of the specialist. Finally, following debate in the Congress of Deputies, the articles on the regulation of “involuntary treatment” were deleted and rejected by Congress again. 2. Current practice, development and challenges Thirty or forty years ago, clinical decisions by doctors were sufficient to administer treatment even if the patient rejected it and without the authorization of a judge to enforce treatment without the patient's consent (i.e. haloperidol drops were administered in food without patient knowledge or depot medication was injected even the patient expressed reluctance). Nonetheless, the frequency of this type of practice is declining due to an increased awareness within Spanish society in general, and among doctors in particular, of the importance of respecting patient rights and of the consequences and limitations this has on clinical practice. Spanish law 41/2002 regulates patient autonomy, rights and duties and recognises that any health action requires the prior consent of the patient, except when incapacitated for decision-making. Today, individuals whose lives are severely affected by a mental disorder and who lack an awareness of the illness may be involuntarily hospitalized (Civil Procedure Act 2000). The other possibility is to be declared incompetent and given a guardian. 3. Actions and pilot projects in Spain In recent years, IOT experiments have been launched in various Spanish cities (San Sebastián, Barcelona, Alicante, Valencia), with the aim of improving treatment adherence in individuals with severe mental illness, and of avoiding the extremes of hospitalisation and civil incapacitation.
Since 1997, San Sebastián has been conducting an IOT experience with one of the city's courts (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005 Mar 1st and 2nd). The inclusion criteria were the following: patients diagnosed with psychosis, a history of multiple hospitalisations, treatment effectiveness and auto-aggressive or hetero-aggressive risk. Between 1997 and 2003, 45 patients received IOT. Of these, 60% were diagnosed with schizophrenia, 10% with bipolar disorder and the rest with psychosis linked to drugs and/or personality disorders. They were monitored under a protocol drawn up with the judge. The conclusions of IOT experiment in San Sebastian city (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005 Mar 1st and 2nd) indicated that IOT was a useful measure for patients diagnosed with psychosis (schizophrenia or bipolar disorder) and also served to introduce them to therapeutic resources that they had previously refused. The results were not good in cases where drug use or personality disorders were the main diagnosis. A similar experiment is being carried out in Barcelona, where there are two courts specialised in matters of competence and involuntary admission, though with different stances when it comes to interpreting the regulations on the implementation of involuntary outpatient treatment. One court has applied IOT since 1999 as an alternative to more radical actions such as involuntary hospitalisation or be declared incompetent. The other court holds that, in the absence of a written regulation, the issue cannot even be considered, although involuntary hospitalisation may be requested if the individual's condition worsens (Spanish Justice Comission in “Congreso de Diputados” diary sessions, 2005 Mar 1st and 2nd). In Valencia, following the experience of San Sebastián, IOT has been implemented since 2003. According to data obtained from the court in charge of processing involuntary admission and civil incapacitation, there were 140 patients with IOT in Valencia in 2008, and the prevalence of use was 9/100,000 inhabitants (this court exercises its duties on a population of approximately 1,500,000 people). Most of the psychiatrists treating the patients with IOT have informed the court that their patients' evolution had improved or stabilised (72% of patients). These data are similar to those published previously by our group (Hernandez-Viadel, Lera-Calatayud, Cañete-Nicolás, Pérez Prieto, & Roche, 2007). In the absence of specific legislation, the legal coverage of these judicial actions is based primarily on two regulations: First, a supranational regulation, the 1997 European Convention of Oviedo on Human Rights and Biomedicine, approved and ratified by the Government of Spain in 1999 (Official State Gazette — BOE — No. 251). Article 7 of the Convention states that a person who has a severe mental disorder may be subjected, without personal consent, to an intervention aimed at treating this disorder where, without such treatment, serious personal harm is likely to result. Second is the case of choosing the least restrictive option. Detainment in hospital is considered to involve a series of enforcement actions that limit patient autonomy (restriction of personal liberty, limited communication with the outside world, subjection to treatment). In this sense, involuntary outpatient treatment would be a partial implementation (subjection to treatment) of involuntary admission. One possible criticism of the application of Article 7 of the European Convention is the risk that it could be abused by making a rule out of what should be an exception. We believe, as with all measures restricting rights, that the use of IOT should be the exception rather than the rule. Moreover, the prevalence of IOT in Valencia is 9/100,000 inhabitants, a similar figure to that of countries such as Canada and Australia (5–15/100,000), where this measure has been implemented for far longer (Kisely et al., 2005). As for considering IOT a less restrictive measure than involuntary admission, Crawford, Gibbon, Ellis, & Waters (2004) found that a majority of patients (60%) prefer to continue compulsory treatment outside the hospital. In addition, the “New York State Assisted Outpatient
Please cite this article as: Hernández-Viadel, M., et al., Involuntary outpatient treatment (IOT) in Spain, International Journal of Law and Psychiatry (2015), http://dx.doi.org/10.1016/j.ijlp.2015.03.004
M. Hernández-Viadel et al. / International Journal of Law and Psychiatry xxx (2015) xxx–xxx
Treatment” evaluation programme indicates that participants with IOT do not experience more adverse subjective conditions – including perceived coercion – than do participants without IOT (Swartz, Swanson, Steadman, Robbins, & Monahan, 2009). Despite the use of IOT in some Spanish cities and certain legal references allowing its implementation with the protection of the court, we consider it necessary to adopt an appropriate legal framework that explicitly regulates the implementation of IOT. It should be one that meets the requirements of European regulations and establishes the principle of proportionality (the requirement that the intervention not deviate from the aim of protection, and that it is necessary, appropriate, subject to revision and guided by an assessment procedure to minimise possible interference with the affected right). 4. Conclusions and future directions Our impression is that IOT is a measure that can be beneficial for some patients with severe mental illness. Most developed countries have introduced legislative changes regulating the use of IOT. In Spain, although IOT is implemented in certain cities, there is currently no legislation governing its application. In our opinion, an adequate legal framework is required that explicitly governs its implementation.
3
References AEN (Asociación Española de Neuropsiquiatría) (2005). AEN Document about the IOT regulation proposal. ([On line]. Available:) www.asoc-aen.es Barrios Flores, L. F. (2008). Tratamiento ambulatorio involuntario. In Otero Pérez (Ed.), Psiquiatría y Ley. Guía para la práctica clínica (pp. 71–123). Edimsa Publisher. Crawford, M. J., Gibbon, R., Ellis, E., & Waters, H. (2004). In hospital, at home, or not at all: A cross-sectional survey of patient preferences for receipt of compulsory treatment. Psychiatric Bulletin, 28, 360–363. Ferreirós-Marcos, C. E. (2006). El Tratamiento Ambulatorio: Cuestiones Legales Y Prácticas Colecciones Cermi. Vol. 24, ([On line]. Available: http://www.cermi.es.). Health Act, Mental (2007). ([On line]. Available:) www.opsi.gov.uk/acts/acts2007/pdf/ ukpga_20070012_en.pdf Hernandez-Viadel, M., Lera-Calatayud, G., Cañete-Nicolás, C., Pérez Prieto, J. F., & Roche, Millán T. (2007). Tratamiento ambulatorio involuntario: Opinión de las personas implicadas. Archivio di Psicologia, Neurologia e Psichiatria, 70(1), 65–74. Kisely, S., Campbell, L. A., & Preston, N. (2005). Compulsory community and involuntary outpatient for people with severe mental disorders. The Cochrane library, issue 4. Cochrane review. Proyecto de Ley 121/000109 (2006). Jurisdicción voluntaria para facilitar y agilizar la tutela y garantía de los derechos de la persona. Boletín Oficial de las Cortes Generales. “Congreso de los Diputados”. October 27th, 2006. Number 109-1. SEPL (Sociedad Española Psiquiatría Legal) (2005)). Statement about outpatient treatment and the observation into involuntary diagnosis. ([On line]. Available: www.psiquiatrialegal.org Psiq). Spanish Justice Comission in “Congreso de Diputados” diary sessions (2005 Mar 1st and 2ndd). Proposición de Ley de Modificación LEC para regular los tratamientos no voluntarios de las personas con trastornos psíquicos. Number 206, Session number 11 and number 209, Session number 12. Swartz, M. S., Swanson, J. W., Steadman, H. J., Robbins, P. C., & Monahan, J. (2009). New York State. Assisted outpatient treatment program evaluation. Durham, NC: Duke University School of Medicine.
Please cite this article as: Hernández-Viadel, M., et al., Involuntary outpatient treatment (IOT) in Spain, International Journal of Law and Psychiatry (2015), http://dx.doi.org/10.1016/j.ijlp.2015.03.004
