Embracing patient choice

In any other branch of medicine today, the question ‘Is it time to introduce patient choice?’ would sound absurd: the only appropriate answer would be an incredulous, ‘Has this not happened already?’ For a significant number of readers of the British Journal of Psychiatry, this question in relation to the matter of antipsychotics is likely, in contrast, to be provocative and controversial. That this is the case shows just how far there is to travel before discrimination on the grounds of mental ill health can be said to have been extinguished.

I welcome the publication of the important editorial by Morrison et al, ¹ which makes clear the extensive levels of coercion surrounding antipsychotic medication for people with diagnoses of psychosis. (Let us recall that the UN Convention on the Rights of Persons with Disabilities ‘require[s] health professionals to provide care of the same quality to persons with disabilities as to others, including on the basis of free and informed consent’.) The authors provide strong arguments and evidence with which to counter the ‘prevailing opinion that all service users with psychosis require antipsychotic medication in order to recover’.

What is notable is how the editorial reprises arguments that writers from the service user and survivor movement have been making for some decades. For example, Morrison and colleagues argue in their editorial that ‘some decisions to refuse or discontinue antipsychotic medication may represent a rational informed choice rather than an irrational decision due to lack of insight or symptoms of suspiciousness’; ¹ Judi Chamberlin, one of the leading American activists in the psychiatric survivors movement, reflected in 1998 on 25 years of activism in the consumer/survivor movement, and wrote, ‘A patient who refuses psychiatric drugs may have very good reasons – the risk of tardive dyskinesia […] or the experience of too many undesirable negative effects. But professionals often assume that we are expressing a symbolic rebellion of some sort when we try to give a straightforward explanation of what we want and what we do not want’. ² (See also writings documented by the Survivors History Group, available at: http://studymore.org.uk/mpu.htm.)

The growing convergence between service user/survivor perspectives and those of parts of the mental health establishment on issues of such critical importance to many mental health service users’ lives is to be celebrated. At the same time, it is important to keep in view the uneven ways in which arguments and evidence originating from different sources are treated and weighed. This will allow us better to understand why service users’ writings are not as frequently referenced – even as they are central to the arguments being made – in mainstream mental health publications.