Involuntary outpatient treatment: A proposal of regulation

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-analyses^2,3 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.