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Attitudes towards compulsory outpatients? treatment for schizophrenic patients with long acting neuroleptics in Bilbao.

Autor/autores: José Guimón , I. Marquez, N. Ozamiz, W. Dávila, A. Ozamiz
Fecha Publicación: 03/05/2013
Área temática: .
Tipo de trabajo: 

RESUMEN

En este artículo se discute la evolución de las actitudes hacia el uso de neurolépticos, en la prevención de la conducta agresiva en las personas con esquizofrenia, la comparación de dos encuestas de opinión realizadas en Bilbao en 1986 y 2013. Parece que hay una tendencia hacia el reconocimiento de la necesidad de los neurolépticos para el tratamiento de las enfermedades mentales, pero bajo supervisión y control. Creemos que los intentos de modificar las actitudes hacia los psicofármacos requieren, además de la puesta en marcha de programas de educación pública, campañas de información dirigidas a los médicos que recetan estos productos con el fin de ayudarles a detectar los prejuicios de un paciente y cómo pueden ser modificados. 

Palabras clave: actitudes; neuroléptico.

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Avances en Salud Mental Relacional
Advances in Relational Mental Health
ISSN 1579-3516 - Vol. 12 - Núm. 1 - Abril 2013
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-Line / An International On-Line Journal

http://hdl.handle.net/10401/6193/

ATTITUDES TOWARDS COMPULSORY OUTPATIENT TREATMENT FOR SCHIZOPHRENIC
PATIENTS WITH LONG ACTING NEUROLEPTICS IN BILBAO
Guimón, J., Marquez I., Ozamiz, N., Dávila, W., Ozamiz, A.
Universidad del País Vasco. Bilbao
jose.guimon@ehu.es

ABSTRACT
The Mental Health principles were included in the Spanish Health Act (Law 14) passed
on April 25th 1986 to avoid the establishment of a Mental Health Act which was considered
stigmatizing by the professionals. Further on, a compulsory outpatient legislation on
legislating outpatient medication, already accepted in the Civil Penal Code (Artícle 105 1­a),
was extended to mental patients, in particular to those with psychotic syndromes. This
elicited some controversy because of the difficulties in the management of side effects
related to the administration of i.m. long acting neuroleptics.
The present article, through the comparison of two surveys done in Bilbao in 1986
and 2013, discusses the evolving attitudes towards use of neuroleptics in prevention of
aggressive behaviour in people with Schizophrenia. Results seem to reflect a shift towards
the recognition of the necessity of i.m. neuroleptics in the treatment of the mental illness,
but under supervision and control. We think that the attempts made to modify attitudes
towards psycho-pharmacological substances require the setting up of public education
programs as well as informative campaigns aimed at physicians who prescribe these
products in order to detect prejudices and how they can be modified.
KEY WORDS: Attitudes. Neuroleptics.

© 2013 CORE Academic, Instituto de Psicoterapia

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Attitudes towards compulsory outpatients' treatment for
schizophrenic patients with long acting neuroleptics in Bilbao

RESUMEN
En este artículo, a través de la comparación entre dos encuestas de opinión
realizadas en Bilbao en 1986 y 2013, se analiza la evolución de las actitudes hacia el uso de
neurolépticos y su papel en la prevención de conductas agresivas en personas que padecen
esquizofrenia. Los resultados parecen reflejar una tendencia hacia el reconocimiento de la
necesidad de neurolépticos en el tratamiento de las enfermedades mentales, pero bajo
supervisión y control regular. Creemos que los intentos de modificar las actitudes hacia los
psicofármacos requieren de la puesta en marcha de programas de educación pública así
como de campañas informativas dirigidas a los médicos que los recetan con el fin de ayudar
en la detección de prejuicios y permitir modificarlos.
PALABRAS CLAVE: Actitudes. Neuroléptico.
1. THE USE OF NEUROLEPTICS IN DANGEROUS SCHIZOPHRENIC PATIENTS
The public image tends to link psychosis, (mainly schizophrenia), to a concept of
danger, justifying the commitment of people suffering from this disorder to a protected
environment- the asylum- and to life-long pharmacological treatment.
The undesirable collateral effects

i

of neuroleptics are constantly denounced but

biases against them seem to have diminished during the last 30 years. In fact, in the last
years Depot antipsychotics tend to be better understood and managed. A recent Cochrane
survey [1] shows the efficacy and safetyii, iii

iv

of this form of medication v in Schizophrenic

patients. Nevertheless, criticism persists and compulsory pharmacological treatment is still
the cause of a considerable number of lawsuits brought against services and psychiatrists.
On the other hand, overall attitudes toward long-acting injectable antipsychotics among
psychiatrists, nurses and patients seem to be positive even in elderly patients. The attitude
and reluctance of some psychiatrists, rather than just patient resistance, may contribute to
the under-use of these products [7].
It is true that mental patients can be dangerous, but this is not frequent.
Schizophrenic patients are as likely to commit homicide as any member of the general
population. The news media frequently gives sensational information when a person
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suffering from a mental disorder kills someone. When this does occur it is important to note
that most were under the influence of abusive substances such as alcohol and/or other illicit
drugs. And, even when taking this in consideration, only 2% of criminals are recognized as
having committed a crime due to a psychotic disorder vi
Aggressive behaviour can be the first sign of a psychotic illness vii. and, excluding
homicide, is a common denominator in Schizophrenic patients and certain Manic patients.
They have little impulse control and can present sometimes acute and unexpected
agitation viii. Some of their violent behaviour may be due to hallucinations and/or delusions
which are commanding the patient to act.ix
Other reasons frequently given to lobby against allowing Schizophrenics to live in the
community is the fact that many of the mentally ill people who did commit a crime had just
left the psychiatric hospital. But, of course, no one speaks about the thousands of psychiatric
patients who are discharged from hospital and do not commit a crime. The opposite is,
however, true. Many patients behaved aggressively before being admitted to hospital and
not after discharge.
The image of the dangerous madman prevails in the media and in the public[8] x. The
fear with which psychiatric patients are regarded is completely out of proportion but
probably persists due to the fact that violence among mental health patients is difficult to
predict and that a few are a real danger to others. The use of medications and restraints are
not only justified, but necessary, when a reasonable risk of violence exists. The violent
patients frequently accept this measure because they are frightened by their own aggressive
impulses and seek help to prevent loss of control. Nevertheless, it is easy for fear to become
excessive and unjustified. This can lead to premature and excessive use of sedation and/or
physical restraint.
The best predictors of potential violent behaviour are: brain damage, substance
abuse, history of childhood abuse and history of a previous violent act or dangerous
behaviour. In patients with schizophrenia the presence of hallucinations or delusions of a
persecutory nature, combined with the above mentioned factors indicate reasonable risk of
aggressive behaviour.

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2. MODIFYING NEGATIVE ATTITUDES.
The negative attitudes towards mental illness can be based not only on ignorance
and intolerance, but also on real factors such as: dangerousness, unpredictability, disability
and the burden that the psychiatric patient represents for the community, particularly for
members of the family and professionals who experience the stress that results from caring
for them.
Mental health professionals, mainly psychiatrists, are subject to the same prejudices
as the patients they serve, on the grounds of their own allegedly fragile mental health,
ineffectualness or even their authoritarian, `bad cop' practices[15]. As a consequence of a
«progressive» legislation, many professionals (mainly psychiatrists and psychiatric nurses)
have legal complaints filed against them because of occurrences during treatment [16]. It is
obvious that these professionals must, as would any other citizen, be held liable for the
consequences of their actions. Nevertheless, it is important to remember that the increasing
number of malpractice suits against health-care professionals in certain developed countries
has resulted in a "defensive position". Moreover, the side effects of some psychiatric
treatments are highly exaggerated by the media and some advocacy groups, creating an
unnecessary prejudice against psychiatric treatments, especially against biological
procedures, thus hampering the compliance of the patients with these treatments[17].
Prejudice and stigmatization partly depend on deep individual psychological (normal
or pathological) factors, ignorance and intolerance. They also depend on real factors such as
aggressive behavior or lack of social skills in patients. In effect, some people with psychiatric
disorders, (especially those with an organic or some type of functional psychosis) present a
"psychic" handicap, a disadvantage that limits their fulfillment of certain roles[18]. On the
other hand, the burden that the psychiatric patient represents for the community,
particularly for members of the family[19] can be very painful to face and leads to serious
stress. Severe patients can be difficult to manage even in the best hospital conditions. In any
case, chronically ill patients or those who are getting worse are not easy to live with, and
even professionals may prefer not to work with them.
When social support networks are not consistent enough to assure the maintenance
of minimal physical needs and enhance self-esteem, the precarious homeostasis assuring the
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adaptation of the patient to society is unbalanced and a de-compensation arises. This, in
turn, produces a worsening in social functioning and leads to a dangerous vicious circle.
Anti-psychiatry's radical criticism of the very existence of mental illness, of the
excessive power of psychiatrists in society, and of the justification of the existence of
psychiatric hospitals, has been of the utmost importance in contributing to certain aspects of
the present-day status of psychiatric patients and the profession of psychiatry itself. Antipsychiatry called for the respect of the human rights of mental patients, contributed to
dismantling old-style psychiatric asylums and roused classical psychiatrists out of their smug
self-satisfaction.
During the eighties [20], once the existence of mental disorders was accepted, antipsychiatrists began to discuss different issues such as whether a patient "should" be
catalogued as an ill person or "whether he/she must" be treated (prescriptive level of the
question), "the right to be mad", "the power of the patient", "democratization of
management", "the right of society" to compel a mad person to be treated against their will.
Over the last few years, controversy has been focused mainly on the question of
whether we can force a treatment on a person who is opposed to it, when his or her health
is not threatened. In psychiatry the main argument in favor was traditionally based on the
risk of auto- and hetero-aggression. Recent trends ask that non-voluntary treatment or
placement be justified by reasons other than dangerousness. There must be two conditions:
a) that not only the health of the patient is at risk, but that his/her illness implies a risk to
others and b) that therapeutic measures adopted must be beneficial therapeutically for the
person receiving it. The problem with the first condition is that the intellectual capacity of
the mental patient can be disturbed and for this reason, his/her consent can be replaced by
judicial intervention.
On the other hand, sometimes mental disturbance can lead to a negligence of vital
functions or to self-destruction. But of course odd behavior or eccentricity alone should not
be considered as justification for non-voluntary treatment. Conversely, violence is not
exclusive to the mental patient, but sometimes mental patients are dangerous. Nonvoluntary psychiatric treatment can sometimes be applied when a person has shown that he
or she needs it (because of behavior having endangered others or their property) and, if

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untreated, the person will be abandoned to possibly criminal interpretation of his/her
actions.
3. THE PROBLEMS WITH MEDICATION COMPLIANCE
The attitudes in the general public toward oral administration in outpatient situations
have close ties to the problem of compliance. As for treatment with neuroleptics, oral
administration in outpatient situations resulted in a 10% to 76% rate of non-compliance [20].
Negative attitudes towards psychotropic medication had a correlation with weak
compliance, as was shown in the study we carried out in Geneva (Fischer et al.). In an study
[21] a 10% of subjects showed negative attitudes towards psychotropic medication and this
had a correlation with weak compliance[22]. Other studies have looked more specifically at
the prescription practices of therapists, particularly general practitioners: posology, mode of
administration, optimal dosage so as to decrease as much as possible the secondary effects
which are largely responsible for non-compliance and which occur principally at the
beginning of pharmacological treatment.
DiMatteo et al. [22] considered non-compliance not as an irrational act, but rather as
a rational choice based on the following factors: Firstly, the patient's lack of faith in the
usefulness and effectiveness of the drug and the fact that its benefits might be judged to be
insufficient when compared to the disadvantages caused by its cost and the inconvenience
associated with compliance. Secondly, the difficulty in complying with the prescription itself,
as well as the lack of family and social support.
Angermeyer & Matschinger [9] found that pressure to comply with a prescription was
greater when the patient believed the therapy to be effective. In contrast, when a patient
doubted the beneficial effects of treatment, they also doubted psychiatric knowledge with
regard to etiology, to prognosis as well as to adequate therapy for the disorder. Thus, a lowlevel of compliance of patients and their entourage constituted a quasi-unavoidable
consequence.
From a slightly different perspective, Goerg et al. [23], of the Department of
Psychiatry of the University of Geneva showed that treatment drop-out probability was
higher when patients did not share the same values as the psychiatric institution and when
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little convergence existed between the attitudes of patients and those of therapists
regarding the defining of problems and the treatment of expectations. The fact that a certain
number of patients sustained treatment despite an absence of shared values must be
analyzed in structural terms (conformity, submissiveness, and other pressures) rather than in
cultural ones (values and normative expectations) xi.
Data was, lacking on how to improve compliance with medication. Within the
framework of a controlled study, our group examined with Eguiluz [26-28], the progress of
schizophrenic patients who took part in a group program concerned with neuroleptic
medication in an outpatient facility. These patients attended eight semi-structured weekly
group meetings; their families were also included in a similar program. Their attitudes
towards psychotropic medication, their compliance and their clinical evolution were
measured at quarterly intervals over a year and compared to those of the control group
which did not benefit from any intervention.
Medication compliance and BPRS ratings improved significantly more in the
experimental group than in the control group. Attitudes towards medication improved
similarly in both groups after the 12-month observation period, although (during the first
two months) significantly more in the experimental group. Attitude changes were also
noticed in the families of patients, both in the experimental group and in the control group.
During a later study with Gonzalez Torres and Eguiluz[27, 28], we were able to show,
through similar techniques, that patients taking part in psycho-educational group therapy
presented fewer cases of readmission than those of the control group.
Some authors [29] point out that in spite of the effort made by professionals, by their
example and through campaigns to improve attitudes, there are much stronger forces, such
as the representation of mental illness in the media (television, radio, magazines, etc.) that
exert negative influences. Finally, the results of some studies varied according to the
contents of the different attitude-modifying programs. Rabkin [30] contends that among
health-care workers, contact with patients rather than supplementary educational programs
was a critical ingredient in any attitude change.
-One of the most complete studies has been made by Yllá et al. [31] who
observed a more substantial increase in authoritarianism in control groups than in
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experiential groupsxii. However, this dimension did not change significantly in the
experiential groups exposed to dynamic sensitization. These results coincide with those
obtained by Augoustinus et al. [32], who reported an increase in authoritarianism in medical
students after a six-week training program in psychiatry. Likewise, it coincides with the
results we obtained in a study carried out among professionals in the field of mental health
following a program of group sensitization [33]. These findings may support the idea that
«classical pedagogical methods» offer information about real problems, previously unknown
by the students, and that this could be the cause of the more authoritarian attitude. Group
sensitization experiences could preserve this increase in authoritarianism, since it facilitates
the understanding of one's own difficulties and those of others easier.
The conclusion from these studies is that, unfortunately, social representations of
mental illness cannot be changed in a dayxiii. New images and theories must be created over
a long period of time and spread via the media, if we want to bring about a change.
Ultimately, the only way to reduce prejudice in the population may be by trying to decrease
the alienation of patients, improving their self-esteem, and creating alternatives to
hospitalization and work activities that dignify their existence. Working with target
populations by means of small groups seems to be preferable to massive media campaigns.
A program's first objective would be to detect prejudiced attitudes through
interviews with patients and their families and to determine the most common negative
attitudes and discrimination maneuvers to which they have been subjected during the
course of the illness.
In a pilot qualitative study with focus groups study we made in Bilbao [36], three
focus groups with clinically stable schizophrenic outpatients (N = 18) and relatives (N = 26)
were performed. Patients and relatives described a great variety of stigmatic experiences in
all areas of life, including health care xiv.

4. A NEW SURVEY OF ATTITUDES TOWARDS NEUROLEPTICS
Episodic fatal criminal incidents committed at Bilbao against the general public and a
mental health professional by psychiatric patients at the beginning of 2012 had a large social
impact. This generated (as did in other countries [3]) an unusual heated debate among the
public and mental health professionals [33]. This public discussion was carefully documented
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by the authors. Previously, in 1986, Ozamiz et al had explored the attitudes of our
population towards the therapeutic use of neuroleptics with an ad hoc Lickert questionnaire.
With this study in mind a new study was performed to re-analyze the present situation.
The

1986

study

[11,

12]

found

a

high

negative

attitude

towards

psychopharmacological consumption [13, 14] in patients attending primary care
practitioners (n = 400) in Guecho (Basque Country) xv. The factor analysis of replies on a scale
of attitudes towards psychotropic drugs helped us extract five factors: (a) attitudes based on
the negative effects of psychotropic agents (stiffness, personality changes, hallucinations,
loss of contact with reality) (38.9% variance); (b) attitudes favouring the use of natural
products for treating psychological problems (18% variance); (c) attitudes which accuse the
socio-economic system of being the cause of the use of psychotropic drugs (12% variance);
(d) attitudes which accuse psychotropic drugs of harming reproductive and sexual functions
(12% variance); and (e) attitudes highlighting undesirable side effects caused by these drugs,
while conceding their use in extreme cases (9% variance) xvi.
4.1. COMPARATIVE RESULTS
This new study intended to examine the evolving attitudes toward neuroleptics in our
immediate environment. For this purpose, we worked with a sample of medical students of
the University of the Basque Country maintaining criteria similar to that used in our previous
study (Ozamiz et al. 1986).
In any case, to ponder the following observations we must keep in mind that:
-

The 1986 study was carried out with the general population and regarding

psychotropic drugs. In the present study (2013), the sample group only included medical
students and specifically regarded neuroleptic drugs.
-

100 second year medical students responded to the same questions answered by the

general public in 1986. Among the most frequent answers we chose twenty eight. These
twenty eight were used to develop the Lickert questionnaire. (Six possible scores that ranged
from "totally agree" to totally disagree".
-

Three questions were added regarding: forced treatment, legislation regarding said

measures, and diagnostic procedure regarding neuroleptic treatment without the patients´

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consent. This questionnaire was passed to another group of students also studying second
year of medicine.
-

Results show elements that remain constant and others that have evolved regarding

attitudes toward pharmaceutical drugs:
SIMILARITIES:

o


In the two studies we did a multiple correspondence analysis.



Results seem to share a "naturalistic view". A persistent idea that
natural remedies are better than neuroleptics because thy have no
side- effects.



The two studies show significant differences between men and
women regarding distrust towards neuroleptics and current
legislation. Females tend to be significantly more suspicious, more
frequently.
DIFFERENCES:

o


In the recent study two factors which were present in the 1986
study do not appear; the negative attitude towards psychotropic
drugs due to their side effects, and an opinion that the socioeconomic system is to blame because it promotes the use of those
psychotropic drugs. The 2013 study shows a factor which is in
direct opposition to this opinion.-A subgroup in this study believes
in the use of pharmaceutical drugs and favors forced, or
compulsory, neuroleptic treatment.

-

The items in the 2013 study that show a greater weight are:
o Item 1: A supervised prescription of neuroleptics is a necessary health
requirement in certain cases.
o Item 3: The use of psychotropic drugs generates dependency
o Item 15: It is necessary to control the use and traffic of psychotropic drugs
in order to prevent damage.
o Item 20: The use of neuroleptics during pregnancy can affect the fetus and
cause problems or abnormalities.

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o Item 30: It is vital to adequately register in writing the risk that patients
under involuntary neuroleptic treatment represent.
There seems to be an evolution towards the recognition of neuroleptics as necessary
for the treatment of mental disorders, but under adequate control and supervision. Along
these lines, prejudices toward the socio-economic interests involved in the use of
neuroleptics and the dangerousness of medication (even for therapeutic reasons) seem to
have decreased over time. This data has led us to propose some actions to influence
decisions regarding policy.
5. USES AND ABUSES OF LEGAL REGULATIONS
5.1. SELECTED INTERNATIONAL DOCUMENTS
Different international documents speak indirectly about the citizens' rights to
mental health[10]. Others deal more directly with the questions involving the human rights
of psychiatric patients. xvii to be treated in the community in an environment suited to his or
her cultural background;
Mental health legislation should not only include laws ensuring the appropriate
health care for people with a mental disorder but also a civil legislation for the protection of
other rights, including property and other civil rights, such as an anti-discrimination
legislation for the protection of their human rights outside of the health care setting. It
would also provide appropriate protection of the rights of offenders suffering from a mental
disorder.
Several international documents regulate involuntary hospitalization and some
treatment procedures (isolation, restraint of movement, etc.) that diminish a patient's
freedom. Involuntary admission should only be effected with several prerequisites. On the
other hand, many controversies have arisen during the last decades about the advantages
and the risks of de-institutionalization and on the need to avoid some paradoxical effects of
anti-commitment laws.
Different proposals seek measures to avoid the possible abuses which can arise from
psychiatric diagnosis. Labelling people with a diagnosis of mental disorder contributes to
stigma and should be very carefully monitored. In this way, a diagnosis should only be made
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under certain conditions keeping in mind that diagnosis is a necessary process for psychiatric
treatment, but is ideologically biased.
The risk of discrimination against children, mentally handicapped[39] and criminals with
psychiatric symptoms is twice as high due to their weak social position. Legislation has been
proposed to ensure the protection of their rights and avoid the "double discrimination" of
these populations.
Many legal documents state that treatment in psychiatric services should be the less
intrusive and of a quality similar to that encountered for physical illness and, whenever
possible, be dispensed in a community setting. Additionally, it is stipulated that the patient
has the right to make a complaint and that the respect of human rights in mental health
facilities must be inspected.
5.2. ASSURING RIGHTS IN REAL LIFE
There are a series of principles that governments, psychiatric institutions and mental
health providers propose to promote the rights of persons with mental illness over recent
decades. Recommendations on equity and non-discrimination, diagnosis, treatment,
research and other relevant issues have been adopted by national legislatures. However,
violations are still being denounced in many countries. Conversely, too strict an application
of the regulations can lead to a defensive attitude among psychiatrists with negative
repercussions on the freedom of patients[40].
Proposed regulations should be stated in operational formats that allow the creation
of instruments for the quality evaluation of mental health care in. Instruments are needed to
help evaluate the effects of policies on human rights and dignity. Gostin and Mann [41]
proposed a "Human Rights Impact Assessment" tool to help those working in the public
health domain, human rights organizations and advocacy groups to develop effective
strategies that assure the respect of the human rights of patients, seeking out policies that
do not create a ghetto whilst keeping an eye on the common good and choosing the least
restrictive alternatives, increasingly limiting coercive measures only in cases of necessity.
Careful monitoring is needed to detect any violation of the human rights of people
with mental disorders and disabilities within the framework of international covenants and
treaties. The OMS and the other quasi-judicial institutions at the national level could work as
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meaningful partners. However, in many countries, no legal framework exists to protect the
people with mental health problems and in those that do have mental health legislation; it is
somewhat outdated, unimplemented or biased. Moreover, people with psychiatric
disabilities do not have a voice in the vast majority of countries and international networks
like the World Network of Users and Survivors of Psychiatry are still very weak. One
consequence of the non-existent voice of people with psychiatric disabilities is that this
group is very seldom at the table when governments discuss plans and developments in
mental health, particularly in the disability field.
WHO has provided support to a number of countries that have undertaken to
improve their laws addressed to people with mental disorders [42]. Other international
organizations try to influence national mental health legislation by adopting guidelines
which, even if not directly enforceable, can influence legislation in many countries.
An independent, multi-disciplinary, monitoring body is in any case needed to ensure
the implementation of mental health legislation. This agency should be financially
independent of service providers and have quasi-legal status with the necessary powers to
enforce compliance. Moreover, special education is needed for the public in general and for
authorities at all levels. Non-governmental consumer organizations and families should be
involved in education procedures and in the development of mental health legislation.
Nevertheless, one has to bear in mind that too strict an application of the laws
protecting the rights of patients (refusal of treatment, obtaining the least restrictive
treatment, etc.) can lead to an increase in risk for society, risks that it must assume if it
wishes to be considered tolerant, modern and progressive. With the civil rights movement
of the 60s and the uproar over the rights of the individual in Western societies, increasing
obstacles to commitment emerged, espousing the theory that patients needed to be
protected from a repressive society. As a result, psychiatric patients in Western countries,
who had in the past been legally vulnerable, can currently count on specific laws to
effectively protect their rights, although the implementation of these laws has not, in every
case, been adequate.
From the 80s on, this attitude has been yielding to demands to protect society
against the threat presumably posed by out-of-control mental patients. Mental health
professionals (especially psychiatrists) remain under attack for hypothetical errors in
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diagnosis (not having detected suicidal or homicidal tendencies in a patient, the existence of
an underlying medical illness, or the possibility of side-effects) and for possible malpractice
(excessive, insufficient or erroneous treatment).
Managing mental health within the community will require a combination of
psychological approaches that modify public attitudes towards disabled people, social
efforts that confront the concrete realities of mental disability and legal measures (including,
in the opinion of the authors, positive discrimination when previous steps are not enough).
5.3. WORKING IN MENTAL HEALTH
The violence as a social phenomenon is not necessarily only linked to a severe mental
illness but also to factors such as: the budget allocated to mental health workers and
resources regarding appropriate treatment. The personal responsibility of each intervenient
in formalizing the risks (authorities, judges and the family) should be stressed and enhanced,
especially mental health professionals. Work has to be done on an ethical level, individually
and collectively. We have to modify our paternalistic attitude towards the patient within the
mental health system. Frequently, we stress the patients' bill of rights but not their duties
and responsibilities.
The Spanish Neuropsychiatric Association, (Asociación Española de Neuropsiquiatría,
AEN) disagrees with certain regulations of Involuntary Ambulatory Treatment intended to
have its effects on the civilian laws. xviii
It does subscribe to the Involuntary outpatient treatment conclusion of the Working
Group of the UEMS (European Union of Medical Specialists) developed in Geneva and
Copenhagen which contains the following conclusions:
"It would be misleading to believe that the introduction of legal measures for
involuntary treatment in the community could be successful by itself. There should also be
an investment in community services, especially in the training and recruitment of
professionals able to provide the treatment and support to users and their carers.
Psychiatry Section of the UEMS is aware that in many countries EU community care is
still at a rudimentary stage. We would advise that no measures were introduced to

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involuntary community care has been established and tested a robust system care in the
community."
It is obviously necessary to spearhead an effort aimed at modifying bias in the
general public in relation to the therapeutic use of psychopharmacological substances.
Media campaigns on the effects of these products, their indications and counter-indications,
could help to decrease prejudice which is prevalent among people of a low cultural level.

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Purgato, M. and C. Adams, Bromperidol decanoate (depot) for schizophrenia.
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Kishimoto, T., et al., Long-Acting Injectable vs Oral Antipsychotics for Relapse
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Guimon, J., Mass Media and Psychiatry. Current Opinion in Psychiatry, 2001. 14(6.):
p. 533-534.
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of the General Public: Results of a Survey in the Federal Republic of Germany.
Pharmacopsychiatry, 1993. 26: p. 114-120.
Fredenrich-Mülebach, A., et al., Ten years of Analytical Group Training in "blocks" in
Geneva. The European Journal of Psychiatry., 2004. 18(Sup): p. 44-49.
Ozamiz, J.A., Actitudes hacia las enfermedades mentales en el Pais Vasco. 1980:
Madrid.
Ozamiz, J.A. and Z. Sarabia, Prejudices of the general public towards neuroleptics.
European Psychiatry, 1997. 12(suppl. 2): p. 132s.
Bulbena, A., et al., Adaptación castellana y estudio factorial del cuestionario del
chocolate y dulces (CCHD). Anales de Medicina, 1993. 9(6): p. 251-255.
García-Sevilla, J.A., et al., Immunodetection and Quantitation of Imidazoline, Receptor
Proteins in Platelets of Patients with Major Depression and in Brains of Suicide
Victims. Archives of General Psychiatry, 1996. 53: p. 801-810.
García Sevilla, J., et al., Density of imidazoline receptors in platelets of euthymic
patients with bipolar affective disorder and in brains of lithium-treated rats. Biol
Psychiatry, 1998. 43: p. 616-618.
Guimón, J., Liberté et risque dans l'assistance psychiatrique. Médecine & Hygiène,
1994. 45(4).
Brandli, H., The Image of Mental Illness in Switzerland, in The Image of Madness, J.
Guimón, W. Fischer, and N. Sartorius, Editors. 1999, Karger: Basel. p. 29-38.

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Proposed, in The Image of Madness.The Public Facing Mental Illness and Psychiatric
Treatment., J. Guimon, W. Fischer, and N. Sartorius, Editors. 1999, Karger: Basel.
Eker, D. and H. Arkar, Experienced Turkish nurses' attitudes towards mental illness
and the predictor variables of their attitudes. The International Journal of Social
Psychiatry, 1991. 37(3): p. 214-222.
Davila, R., et al., Dopaminergic balance and subtypes of schizophrenia. The British
Journal of Psychiatry, 1989. 154: p. 33-38.
Fischer, W., et al., Determining Factors and the Effects of Attitudes towards
Psychotropic Medication, in The Image of Madness
Public Facing Mental Illness and Psychiatric Treatment, J. Guimon, W. Fischer, and N.
Sartorius, Editors. 1999, Karger Medical and Scientific Publishers: Basel. p. 162-186.
DiMatteo, M.R. and a. et, Enhancing Medication Adherence through Communication
and Informed Collaborative Choice. Health Communication, 1994. 6(4): p. 253-265.
Goerg, D. and a. et, Congruence patients - thérapeutes et dropout en psychiatrie
ambulatoire publique. Sciences Sociales et Santé, 1990. 8(3): p. 49-71.
Ciancetta, M.D., Individual vs Group medication review programs for chronic
Psychiatry patients. Disertation Abstracts, 1983. B - 44(2).
Pakes, G.E., Group medication counseling conducted by a pharmacist for severly
disturbed clients. Hospital Community Psychiatry, 1979. 30(4): p. 237-238.
Eguiluz, I., M.A. González Torres, and J. Guimón, Psychoeducational Groups in
Schizophrenic Patients, in The Image of Madness. The Public Facing Mental Illness
and Psychiatric Treatment, J. Guimón, W. Fischer, and N. Sartorius, Editors. 1999,
Karger: Basel.
Gonzalez Torres, M.A. Aspectos contratransferenciales en el analista en formación. in
II Jornadas de Profesionales del Psicoanálisis. . 1989. Almería
Gonzalez Torres, M.A., Stereotypes towards neuroleptics compliance. European
Psychiatry, 1997. 12(suppl. 2): p. 132s.
Hillert, A., et al., The General Public's Cognitive and Emotional Perception of Mental
Illnesses: An Alternative to Attitudes Research, in The Image of Maedness, J. Guimón,
W. Fischer, and N. Sartorius, Editors. 1999, Karger: Basel.
Rabkin, J., Public attitudes toward mental illness : a review of the literature.
Schizophrenia Bulletin, 1974(10): p. 9-33.
Ylla Segura, L. and A. Gonzalez-Pinto Arrillaga, Group therapy and attitudinal changes
in mental illness in medical students. European Psychiatry, 1997. 12(suppl. 2): p. 114s.
Augustinos, M., et al., Medical students attitudes towards psychiatry: a conceptual
shift. Psichological Medicine, 1985. 15: p. 671-678.
Gonzales-Pinto-Arrillaga and a. et, Cambios en la actitud ante la enfermedad mental
tras un programa de sensibilizacion grupal. Psiquis, 1993. 14(4): p. 139-151.
Eker, D. and B. Oner, Attitudes toward Mental Illness among he General Public and
Professionals, Social Representations and Change, in The Image of Madness, J.
Guimon, W. Fischer, and N. Sartorius, Editors. 1999, Karger: Basel. p. 1-13.
Malla, A. and T. Shaw, Attitudes towards mental illness: The influence of education
and experience. The International Journal of Social Psychiatry, 1987. 33(1): p. 33-41.

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36.

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Gonzalez-Torres, M., et al., Stigma and discrimination towards people with
schizophrenia and their family members : A qualitative study with focus groups. Soc
Psychiatry Psychiatr Epidemiol., 2006. Oct 11; [Epub ahead of print]
PMID: 17036263.
Guimon, J., Liberté et risque dans l'assistance psychiatrique. . Médecine & Hygiène,
1994(décembre): p. 2064,.
Gostin, L. and J.M. Mann, Towards the development of a Human Rights Impact
Assesment for the Formulation and Evaluation of Public Health policies. Health and
Human Rights, 1994. 1(1): p. 59-81.
Ehrensperger, S., et al., Práctica de grupo entre los miembros de la Federación
Española de Psicoterapeutas. Intersubjetivo, 2002.

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i

Though cardiovascular difficulties and other problems may occur, extrapyramidal side-effects are the most frequent risk
and account for low tolerance to these products. Acute dystonia, which causes sustained muscular contractions, results in
abnormal contortions (5% of patients treated with antipsychotic drugs) which are disturbing but, in general, benign, except
in rare cases of spasms of the larynx. Parkinson's disease (approximately 10% of cases) - with bradykinesia, rigidity,
immobile facies, a slow shuffling gait - and acathisia (which causes resting tremor) are the disorders which most often lead
patients and their families to interrupt medication. Tardive dyskinesia, which can occur after prolonged pharmacological
blockage, cannot be therapeutically remedied effectively and has resulted, in certain countries, in malpractice suits. The
neuroleptic malignant syndrome, associated with very powerful antipsychotic drugs, is fortunately very rare, though
sometimes fatal.

ii

Spanarello says that an intramuscular injection given at intervals of from 1 to 4 weeks will produce adequate plasma
concentrations that are sufficient to prevent relapse over the dosage interval. Such medication is useful in patients who do
not reliably take their oral medication. He reviews the clinical pharmacokinetics of the depot antipsychotics for which
plasma level studies are available (i.e. fluphenazine enanthate and decanoate, haloperidol decanoate, bromperidol
decanoate, clopenthixol decanoate, flupenthixol decanoate, perphenazine onanthat, pipotiazine undecylenate, pipotiazine
palmitate, fluspirilene, Long-acting injectable risperidone, olanzapine pamoate, paliperidone palmitate, Longacting iloperidone, Long-acting injectable aripiprazole) are reviewed.
iii
( bromperidol decanoate, clopenthixol decanoate, flupenthixol decanoate, perphenazine onanthat, pipotiazine
undecylenate, pipotiazine palmitate, fluspirilene,and specially de new products, as Long-acting injectable risperidone,
olanzapine pamoate, paliperidone palmitate, Long-acting iloperidone, Long-acting injectable aripiprazole the efficacy )
iv
iv
Their Efficacy(5,6). .
v
v
In fact Risperidone long-acting injectable, olanzapine pamoate and paliperidone palmitate have been recommended not
only for chronic recidival patients but in patients with first episodes of acute schizophrenia (2) . Other studies, however, find
v
v
poor results with one product (3)
and rare but prolonged side effects with another (4).
vi

Other data which are frequently used to lobby against allowing schizophrenics to live in the community is the fact that
many people who did commit crimes had just left psychiatric hospitals. But of course no one speaks about the thousands of
psychiatric patients who are discharged from hospital and never commit a crime. The opposite is, however, true. Many
patients behaved aggressively before being admitted to hospital; aggression is obviously an important indication for
hospitalisation, so the percentage is biased.

vii

Aggression is not indiscriminately directed and most people (except male adolescents) with and without mental disorders
who commit aggressive acts are likely to do so against people they know, usually family members.
viii

Research does not give evidence of a direct, simple relation between criminality and mental illness. In a critical review,
Ollier Spadone quoted research conducted in New York City on cases of 59 innocent victims who had been pushed onto
subway rails during the period1975 - 1991. Thirty-six of these cases were provoked by people with an excessive tendency to
isolation, 90% of whom were psychotics with delusions (60%), hallucinations (50%) and thought disorders (70%). Four
subjects were not capable of giving any reason for their action. Forty percent of the persons in the sample were under the
influence of toxic substances, and evidence that substance abuse and schizophrenia contribute to criminal behaviour is
abundantly documented.
In a Swedish study of people born between 1920 and 1959 and diagnosed as schizophrenic and who left hospital in 1971,
85% still had schizophrenic symptoms. These 644 patients were followed up over a 14-year period and their risk of criminal
behaviour was 1.2 times greater than that of the general population for men and 2.2 times greater for women. Another
significant feature was that the aggression carried out by schizophrenics was of a much more violent nature than that
committed by other members of the public
ix
Research does not give evidence of a direct, simple relation between criminality and mental illness. In a critical review,
Ollier Spadone quoted research conducted in New York City on cases of 59 innocent victims who had been pushed onto
subway rails during the period1975 - 1991. Thirty-six of these cases were provoked by people with an excessive tendency to
isolation, 90% of whom were psychotics with delusions (60%), hallucinations (50%) and thought disorders (70%). Four
subjects were not capable of giving any reason for their action. Forty percent of the persons in the sample were under the
influence of toxic substances, and evidence that substance abuse and schizophrenia contribute to criminal behaviour is
abundantly documented.
In a Swedish study of people born between 1920 and 1959 and diagnosed as schizophrenic and who left hospital in 1971,
85% still had schizophrenic symptoms. These 644 patients were followed up over a 14-year period and their risk of criminal
behaviour was 1.2 times greater than that of the general population for men and 2.2 times greater for women. Another
significant feature was that the aggression carried out by schizophrenics was of a much more violent nature than that
committed by other members of the public

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x

Frequently one tries to detect in the month previous to the act, some signs that could have predicted the behaviour and
this is generally the case. Thus violent patients can arouse a realistic fear in their relatives and in the professionals who care
after them.

xi

Techniques to improve compliance

It is obviously necessary to spearhead an effort aimed at modifying bias in the general public in relation to the therapeutic
use of psychopharmacological substances. Media campaigns on the effects of these products, their indications and
counter-indications, could help to decrease prejudice which is prevalent, as we have seen, among persons of a low cultural
level.
We should undoubtedly begin by modifying the attitudes of caregivers themselves. Bury et al. (30) showed that a
significant change occurred in attitudes toward psychopharmacological substances among medical students before and
after their courses in psychiatry. But they did not ascertain whether this modification endured in their subsequent careers.
A study[5] among medical students showed that stereotypes which were comparable at the beginning of medical studies to
those held by the general public, decreased progressively with advancing knowledge.
Although we believe it possible to modify certain cognitive aspects of attitudes toward these products, we are more
pessimistic with regard to the possibility of influencing all the other aspects which are based on affective reactions and
which are often unconscious and very difficult to modify. On this topic, it is important for the reader to remember the
celebrated study which related the failure of an attempt to modify the attitudes on mental illness of citizens of a town in
North America (31). The campaign, waged through various media over a period of several months did not succeed in
modifying public attitudes in an appreciable manner. To the contrary, it elicited an irritated response in those persons it
sought to influence.
Effectively, a rejection of medication may result from deep psychological factors arising in the relationship
between the patient and his or her psychiatrist. One example of this consisted in either the negative placebo effect, or took
the form of collateral symptoms which could not be explained from a pharmacological point of view (32). These effects
were frequently caused by the patient's deep-seated resistance. Van Putten et al. (33) have shown, for example, that an
ego-syntonic sense of psychotic grandeur was the most important factor which distinguished schizophrenic patients
showing poor compliance from those with a strong compliance.
In the same way, an excessive tendency to deny illness led many patients to put up a determined resistance to
pharmacotherapy. Other patients were not compliant because of the existence of "secondary benefits", which caused
them to prefer illness to health. These patients might even "hang on to symptoms" once they had been treated, thereby
rendering medication ineffective. Some others refused medication in order to deny that their illness really existed from a
psychiatric point of view.

The prescription of medication by a psychiatrist could, on the other hand, activate an unconscious parental transference
which can drive the patient to weak compliance. This was particularly true for patients who have been termed
manipulative help-rejectors. When psychiatrists adopted an authoritarian tone which these patients, it only contributed to
increasing the patient's opposition.
Some might even have threatened to drop patients who did not comply or they might have instilled feelings of
guilt so that patients only obeyed in order to avoid offending their psychiatrist. Some psychiatrists might also have
accepted that patients interrupt medication in order to demonstrate how ill they would feel without it [34]. In contrast,
some psychotherapists might not have prescribed a very necessary medication because they narcissistically feared that it
might bring into question the effectiveness of their technique.
xii

48 second-year medical students were randomly assigned to four groups. Two were theoretical formative groups,
centered on combating prejudices by studying psychiatric cases, and the other two groups on providing sensitivity to
psychodynamic processes based on Foulkes' technique
xiii
In one WHO project, positive changes in attitudes towards mental illness were noted in certain primary health-care
workers in some developing countries who had been trained in classroom lectures and had undergone supervised
experiences of exposure to patients. However, at the end of a training program, other studies failed to reveal differences in
attitudes among a group of psychiatric nurses, who had had first-hand experience with this kind of patient, and nurses in
other fields of medicine 18. Eker, D. and B. Oner, Attitudes toward Mental Illness among he General Public and
Professionals, Social Representations and Change, in The Image of Madness, J. Guimon, W. Fischer, and N. Sartorius,
Editors. 1999, Karger: Basel. p. 1-13., nor between nursing students at the beginning or the conclusion of their studies in
mental health (19. Malla, A. and T. Shaw, Attitudes towards mental illness: The influence of education and experience. The
International Journal of Social Psychiatry, 1987. 33(1): p. 33-41.. Training and direct contact with psychiatric patients did not
influence most attitudes. Likewise, Eker 20.
Eker, D. and H. Arkar, Experienced Turkish nurses' attitudes towards mental

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illness and the predictor variables of their attitudes. The International Journal of Social Psychiatry, 1991. 37(3): p. 214-222.
found that clinical workers with psychiatric experience demonstrated attitudes similar to those of inexperienced students of
psychology. Neither were changes in attitude observed after three-week psychiatric training courses 13. Arkar, H. and D.
Eker, Effect of psychiatric labels on attitudes toward mental illness in a Turkish sample. The International Journal of Social
Psychatry, 1994. 40(3): p. 205-213., nor after seven months of weekly sensitivity groups 21.
Ylla, L. and A. Gonzalez
Pinto, Group Therapy and attitudinal changes to mental ilness in medical students, in The image of madness, J. Guimón, W.
Fischer, and N. Sartorius, Editors. 1999, Karger: Basel..
xiv

Six categories of stigma and discrimination experiences were extracted from the patients' data: Mental illness
vs. Lack of will, Prejudice related to dangerousness, Over-protection-infantilization, Daily social discrimination,
Discrimination in health care, Descendants, Avoidance-social isolation. Data from relatives were divided into three sets:
discrimination towards the patients witnessed by relatives, discrimination suffered by the relatives themselves and
discrimination exerted by the relatives on the patients. Isolation and avoidance are common reactions to those
experiences.
xv

This consumption, therefore, gave evidence to favour the theory of self-medication as a remedy against mental illness
which has been neither diagnosed nor treated in an adequate manner.
xvi
Women expressed more reservations than men about the use of psychotropic drugs, except in extreme cases. Negative
attitudes increased with age, and older people clearly favored natural remedies. The higher the social status, the lower the
expressions of fear about psychotropic drugs. Paradoxically, consuming any type of psychoactive substances (drugs,
alcohol) had a negative correlation with attitudes towards psychotropic drugs. Likewise, conservative persons were far
more reserved when it came to the use of psychotropic drugs. Finally, subjects who presented symptoms of more serious
mental pathologies favored psychotropic drugs more and were less fearful of their side effects.
xvii

The United Nations, the Council of Europe, WHO, some international psychiatric associations, private foundations and
patient and family advocacy groups play a very active role in supporting the fight for the human rights of mental patients. In
view of the significant impact of public health policy on human rights, the need for a human rights impact assessment is
stressed .Questions concerning the relationship between health and human rights are summarily addressed in different
international documents. In the Universal Declaration of Human Rights there is an indirect warning against arbitrary
involuntary hospitalization and a vague reference to the universality of mental health care. On the other hand, there exist
other more specific international documents concerning the human rights of mental health patients in particular: the U.N
principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care and the
Recommendation on the Situation of the Mentally Ill of the Council of Europe. These documents recognize that mental
patients have several rights: to dignity and freedom from stigmatization; to have access to a mental health facility in the
same way as they would to any other health-care facility; to protection against discrimination on the grounds of mental
illness; to receive the same standards of treatment as any other sick person; to be treated if possible on a voluntary basis in
outpatient facilities without hospitalization

xviii

Involuntary outpatient treatment, as a security measure imposed by judges to sick criminal who has committed a crime,
is regulated by the Spanish Criminal Code (Article 105 1 - a), about what.Thus, Article 20 of the Health Act 1986 dedicated
to Mental Health, proclaims the principles of "full integration" and "total equality". Daily Record of the House of
Representatives - (Justice Committee) - Day 17 May 2007 ­

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