Psychiatry - Theses

Outpatient Commitment (OPC) is a legal procedure that allows for involuntary psychiatric treatment in the community. Legislation for OPC first emerged in the 1970s in the USA in an attempt to provide a legal remedy for the problems posed by ideological reforms to institutional psychiatry and mental health law. OPC in particular attempts to address the difficulties presented by persons with chronic relapsing forms of serious mental illness and poor compliance with outpatient treatment - persons whose disadvantage is now particularly visible in the streets of our large cities. OPC sits awkwardly between the developing and expanding frameworks of community mental health services and mental health law. It potentially overlaps with guardianship laws, enduring medical power of attorney and court orders. Despite the growing provision for OPC and its increasing frequency of use in North America, the Antipodes, and most recently on the boarders of the European continent, there remains little understanding of the conceptual mechanisms involved in its application. Even less is known about the group of patients who might respond best to its implementation. Without taking stock of its potential adverse effects, societies run the risk of enthusiastically embracing this rather crude legal mechanism of persuasion, instead of exploring or supporting the development of potentially more effective and sophisticated clinical interventions to address the problem of non-compliance with outpatient psychiatric treatment. Given the current limitations of clinical interventions for serious mental illness and treatment non-compliance, OPC may provide a very useful role in enhancing the efficacy of these interventions/treatments through its effects on the way a treatment service is provided as well as on the patient's treatment adherence. With this aim in mind, many different forms of OPC have now emerged. However, without adequate research evidence, it is not possible to advocate strongly for the development of one form of OPC legislation over another. Nor is it possible to argue for its use in preference to other legal mechanisms of treatment orders e.g., guardianship orders. The final decision about which form of OPC legislation is chosen appears to have relatively little to do with any empirical evidence of clinical efficacy but more to do with historical and legal concerns. This thesis attempts to go some way to further bridge the gap between evidence based psychiatry and the application of mental health law with respect to Outpatient Commitment. Chapters 1 and 2 describe a brief account of the historical context within which OPC has emerged both internationally and in Australia. Chapter 3 provides a review of clinical outcome studies in the USA and elsewhere, concluding that on simple clinical measures of outcome, OPC appears to be associated with significant benefits. It is of note that all these studies have considerable limitations, and none provide a useful comparison of patients' objective clinical ratings with patients' subjective ratings of the "persuasiveness" or "coerciveness" of OPC. Chapters 4 and 5 of this thesis outline the results of a retrospective controlled study of the clinical outcome of all patients on a form of OPC in a sector of metropolitan Melbourne, Victoria, Australia, between 1987-1992. The characteristics of the patients selected has already been reported in a previous study which describes the sample as being mainly those with chronic relapsing forms of psychotic illness complicated by a history of violence and noncompliance with outpatient treatment. In Chapter 4, the results of an analysis of the clinical outcome of this group of patients suggests that the majority of these patients benefit from the application of OPC. In Chapter 5, the results of the control group comparison also indicate that though these OPC patients have evidence of higher levels of morbidity than other involuntary patients discharged directly into the community, OPC patients improve relatively better while on OPC orders. However, a minority of OPC patients do not seem to benefit or even deteriorate with the application of OPC. The study attempts to identify the characteristics that might predict better or worse clinical outcomes associated with OPC. It is important to note that the study, because of its retrospective design, suffers from limitations similar to those evident in other studies and, in particular, it does not account for influence of patients' subjective experiences of OPC. Finally in Chapters 6 & 7, based on the experience of this study and on a review of the literature, a conceptual model is proposed in order to assist with an understanding of how OPC might work. This model focuses on the nature of the impact of OPC on treatment adherence, through its effect on the patient and on the system within which the patient is being treated. It suggests that a balance needs to be struck between the persuasiveness versus the coerciveness of the Outpatient Commitment procedure. An ineffectual mechanism may discredit the procedure as a persuasive aid to treatment adherence. Conversely, an overly coercive mechanism may actually deter patients from accepting any form of assistance for their illness. This model forms the basis of recommendations for future research to test the effectiveness of OPC and to compare or contrast different forms of OPC with each other and with other less formal mechanisms of coerced community psychiatric treatment. Australia, given its relatively uniform structure and administration of mental health services, is in a good position to compare the benefits or otherwise of the rather disparate forms of OPC being introduced into each of its various states and territories. With a multi-centre randomised controlled trial of OPC in this setting, it may then be possible to make recommendations about which form of OPC most effectively and collaboratively assists in the improvement of poor treatment compliance, and which group of patients with serious mental illness are likely to benefit most from its application. It may also assist with determining OPC's relative clinical merit when compared with other less formal coercive/persuasive clinical interventions for treatment non-compliance. Without attempts to study and confirm the empirical evidence for the 'clinical efficacy' of OPC, this increasingly internationally accepted model of OPC oriented community psychiatric care runs the risk of being prematurely challenged in some future wave of mental health reform. As in the example of de-institutionalisation, the ultimate future of OPC may, however, rest not with the law but with the advent of better and more effective treatments for psychotic disorders.

Descriptions of the development of psychiatric symptoms in response to traumatic experience can be found in literature dating back to some of the earliest writings found. Amongst these symptoms there have always been descriptions consistent with what we would now term Post Traumatic Stress Disorder (PTSD). Tomb (1994) describes how such symptoms historically have been most frequently described in relation to combat experience and are contained in such classical texts as Homer’s Iliad. Recognition that such symptoms also occur in association with non combat related trauma is a relatively recent event. This can be seen in description of response to traumas such as The Boston Coconut Grove Fire (Adler 1943) and the Buffalo Creek Dam collapse (Gleser et al 1981). Combined with the massive number of combat veterans with combat experience related to psychiatric disability following the World Wars, significant impetus appears to have developed for separate classification and understanding of trauma related psychiatric symptoms. Together, these forces led to the creation of the diagnostic category of PTSD for the first time in the American Psychiatric Associations DSMIII (APA 1980). In this series of studies, we are thus aiming to further the understanding of the neurobiology of Post Traumatic Stress Disorder by specifically examining a group of male Australian Vietnam veterans with current PTSD, comparing them to two control Vietnam veteran populations, one group of those veterans who previously met criteria for a diagnosis of PTSD and a third group who never have met criteria for a diagnosis of PTSD. We examined these three groups in a number of ways. Firstly, to further understand aspects of central noradrenergic receptor function we utilised a clonidine growth hormone challenge test. Consistent with previous literature on the HPA axis in PTSD from North American we utilised a modified dexamethasone suppression test to investigate feedback within the HPA axis. Finally, we investigated serotonergic receptor function peripherally with a further study of platelet paroxetine binding and performed the first large study examining central serotonergic receptor function using the d-fenfluamine prolactin challenge test. Before describing the methodology and results of these studies I will review relevant findings to these three systems from studies of animal and human models of stress, clinical populations with PTSD and their treatment and previous experimental analysis of relevant biological variables in subjects with PTSD.

Psychiatry - Theses

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