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Journal Information
Vol. 12. Issue 4.
Pages 251-252 (October - December 2019)
Vol. 12. Issue 4.
Pages 251-252 (October - December 2019)
Letter to the Editor
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Involuntary outpatient treatment: A proposal of regulation
Tratamiento ambulatorio involuntario: una propuesta de regulación
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Sergio Ramos Pozón
Departamento de Enfermería Fundamental y Médico-Quirúrgica, Facultad Enfermería, Universidad de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
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Dear Editor,

An article appeared recently in Diario Médico1 debating the need to regulate involuntary outpatient treatment (IOT).

IOT is aimed at patients with severe mental disorders, with no insight, multiple hospital admissions, who stop their treatment when they leave hospital resulting in physical and mental deterioration, and who display auto and hetero-aggressive behaviours.

Its application could reduce the number of readmissions and days in hospital, violent behaviours and arrests. However, studies based on meta-analyses2,3 indicate that there is no significant reduction in health service use, or improvement in clinical outcomes in terms of social function or quality of life; although there are fewer victims of violence and non-violent crime.

Due to this apparent lack of clarity,4 which also implies a reduction in fundamental rights, the legitimacy of IOT is now being debated. Those who reject it maintain that: (1) it is a discriminatory and stigmatising measure; (2) there are no conclusive studies that assess its pros and cons, its reliability and efficacy are dubious; and (3) the lack of resources available in the community to achieve maximum coverage and enable a comprehensive plan constitutes the essential issue.

Its defenders claim: (1) the treatment is necessary for the health of the patient; (2) it can reduce auto and hetero-aggressive behaviours, drug and alcohol abuse; (3) it could be a less restrictive option than admission to hospital, and (4) it is a protective measure of the person's legal safety, and it promotes continuity of treatment and recovery of autonomy and competence.

Attempts were made to regulate IOT by an extension to the Code of Civil Procedure (art. 763.5), about which there was much debate. Furthermore, the Constitutional Court, by court ruling STC 132/2010, declared paragraphs 1 and 3 of article 763 unconstitutional. Although it could seem that involuntary admissions are “illegal” because they are unconstitutional, the Constitutional Court did not declare the measure null and void, but asked for an amendment to avoid this legal vacuum. This was resolved with “Organic Law 8/2015, of 22 July, amending the system for the protection of children and adolescents”, rendering article 763 organic in nature, and therefore no longer unconstitutional.

As has been debated recently,5 we want to discuss the proposal of article 763.5, and develop it further with the following clarifications:

  • 1.

    The rights to non-discrimination, equality and dignity, protection of integrity, right to life and health, and habilitation and rehabilitation,6 must be taken as the cornerstone, thus respecting the “Convention on the Rights of Persons with Disabilities”.7

  • 2.

    A maximum application period of 18 months is set but no mention is made of a minimum. Swartz et al.8–10 argue that application for less than 6 months does not achieve good outcomes.

  • 3.

    Its target patient “profile” should be specified.

  • 4.

    The proposal argues that IOT should be applied “when the patients’ health requires it”; however, mention should be made of the deterioration of an untreated person, avoidance of auto/hetero-violent behaviours, etc.

  • 5.

    Although it encourages reporting the progress and follow-up of the process to the Court every 3 months, it is also advisable to indicate the need for the patient to be given a hearing.

References
[2]
S. Kisely, L. Campbell, R. O’Reilly.
Compulsory community and involuntary outpatient treatment for people with severe mental disorders.
Cochrane Database Syst Rev, 3 (2017),
[3]
S.R. Kisely, L.A. Campbell.
Compulsory community and involuntary outpatient treatment for people with severe mental disorders.
Schizophr Bull, 41 (2015), pp. 542-543
[4]
M. Swartz, J. Swanson.
Why the evidence for outpatient commitment is good enough.
Psychiatr Serv, 65 (2014), pp. 808-811
[5]
J. Fuertes, J. Rodríguez, C. Fuertes, J. Naranjo.
Necesidad de regulación legal del tratamiento ambulatorio involuntario en pacientes psiquiátricos.
Diario La Ley, (2018), pp. 9132
[6]
S. Ramos.
La Convención sobre los derechos de las personas con discapacidad en Salud Mental. Una cuestión de derechos humanos.
Rev Psiquiatr Salud Ment (Barc), 9 (2016), pp. 126-127
[7]
Convención sobre los Derechos de las Personas con Discapacidad.
(2006),
[8]
M. Swartz, C. Wilder, J. Swanson, R. van Dorn, P. Clarck, H. Steadman, et al.
Assessing outcomes for consumers in New York's assisted outpatient treatment program.
Psychiatr Serv, 61 (2010), pp. 976-981
[9]
M. Swartz, J. Swanson, R. Wagner, B. Burns, V. Hiday, R. Borum.
Can involuntary out-patient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals.
Am J Psychiatry, 156 (1999), pp. 1968-1975
[10]
M. Swartz, J. Swanson, V. Hiday, R.H. Wagner, B. Burns, R. Borum.
A randomized controlled trial of outpatient commitment in North Carolina.
Psychiatr Serv, 52 (2001), pp. 325-329

Please cite this article as: Ramos Pozón S. Tratamiento ambulatorio involuntario: una propuesta de regulación. Rev Psiquiatr Salud Ment (Barc). 2019;12:251–252.

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