Van Dorn Richard A, Elbogen Eric B, Redlich Allison D, Swanson Jeffrey W, Swartz Marvin S, Mustillo Sarah
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, United States.
Int J Law Psychiatry. 2006 Nov-Dec;29(6):495-506. doi: 10.1016/j.ijlp.2006.08.002. Epub 2006 Oct 27.
In recent decades debate has intensified over both the ethics and effectiveness of mandated mental health treatment for persons residing in the community. Perceived barriers to care among persons subjected to mandated community treatment, and the possibility that fear of involuntary treatment may actually create or strengthen such barriers rather than dissolve them, are key issues relevant to this debate but have been little studied. This article explores the link between receipt of mandated (or "leveraged") community treatment and reasons for avoiding or delaying treatment reported by persons with severe mental illness. It also examines the potential moderating effect of social support on the association between mandated treatment experiences and barriers attributable to fear of involuntary commitment or forced treatment.
Data are presented from a survey of 1011 persons with psychiatric disorders being treated in public-sector mental health service systems in five U.S. cities. Logistic and negative binomial regression analyses were used to examine the association between mandated community treatment and perceptions of barriers to care, controlling for demographic and clinical characteristics.
Across sites, 32.4% to 46.3% of respondents reported barriers attributed to fear of forced treatment. Whereas 63.7% to 76.1% reported at least one non-mandate-related barrier to care; the mean number of non-mandated barriers to care ranged from 1.6 to 2.3 (range 0-7). Between 44.1% and 59.0% of participants had experienced at least one type of leveraged treatment. Persons experiencing multiple forms of mandated treatment were more likely to report barriers to care in comparison to those not reporting mandated treatment. Findings also indicated that social support moderates the relationship between multiple leverages (three or four forms) and mandate-related barriers to care.
Perceived barriers to care associated with mandated treatment experience have the potential to adversely affect both treatment adherence and therapeutic alliance. Awareness of potential barriers to care and how they interact with patients' perceived social support may lead to improved outcomes associated with mandated treatment.
近几十年来，对于社区中强制精神卫生治疗的伦理和有效性的争论愈演愈烈。在接受强制社区治疗的人群中，人们察觉到的护理障碍，以及对非自愿治疗的恐惧实际上可能会造成或强化这些障碍而非消除它们的可能性，是与这场争论相关的关键问题，但却很少有人研究。本文探讨了接受强制（或“杠杆式”）社区治疗与重症精神疾病患者报告的避免或延迟治疗的原因之间的联系。它还研究了社会支持对强制治疗经历与因害怕非自愿住院或强制治疗而产生的障碍之间关联的潜在调节作用。
数据来自对美国五个城市公共部门精神卫生服务系统中接受治疗的1011名精神疾病患者的调查。采用逻辑回归和负二项回归分析来检验强制社区治疗与护理障碍认知之间的关联，并控制人口统计学和临床特征。
在各个地点，32.4%至46.3%的受访者报告了因害怕强制治疗而产生的障碍。而63.7%至76.1%的受访者报告了至少一种与非强制因素相关的护理障碍；非强制护理障碍的平均数量在1.6至2.3之间（范围为0至7）。44.1%至59.0%的参与者至少经历过一种类型的杠杆式治疗。与未报告接受强制治疗的人相比，经历多种形式强制治疗的人更有可能报告护理障碍。研究结果还表明，社会支持缓和了多种杠杆式治疗（三种或四种形式）与与强制治疗相关的护理障碍之间的关系。
与强制治疗经历相关的护理障碍认知有可能对治疗依从性和治疗联盟产生不利影响。了解护理的潜在障碍以及它们如何与患者感知到的社会支持相互作用，可能会改善与强制治疗相关的结果。
