Disclosures: The authors report no relevant financial disclosures.
May 25, 2021
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Most patients with bipolar disorder support self-binding involuntary treatment directives

Disclosures: The authors report no relevant financial disclosures.
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Most patients with bipolar disorder endorsed involuntary treatment via self-binding directives on the basis of impaired decision-making abilities, according to study results published in The Lancet Psychiatry.

“Although a small body of research examining service users’ retrospective views of involuntary treatment found that a substantial proportion thought it was justified, involuntary treatment and substitute decision making — ie, when decisions relating to a person whose decision-making capacity is judged to be impaired are made by another person—are generally seen as deeply controversial,” Tania Gergel, PhD, of the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, and colleagues wrote. “In particular, the U.N. Committee on the Rights of Persons with Disabilities rejects the notion of impaired decision-making capacity and has called for complete abolition of involuntary treatment. This study aims to understand how these ideas relate to highly influential human rights and ethical assumptions surrounding autonomy and psychiatry.”

Infographic with percentage of patients with bipolar disorder who endorse self-binding directives for involutary treatment
Infographic data derived from: Gergel T, et al. Lancet Psychiatry. 2021;doi:10.1016/S2215-0366(21)00115-2.

The researchers conducted a qualitative study in which they analyzed data from an internet-based survey sent to the mailing list of the U.K. charity Bipolar U.K. The survey featured several closed and open questions related to advance decision making for individuals with bipolar disorder. Included participants had been diagnosed with bipolar disorder by a doctor or psychiatrist. A prior study that included a quantitative analysis of a closed question related to self-binding directives showed a high proportion of participants with bipolar disorder who completed the survey endorsed the directives.

In the current study, Gergel and colleagues conducted a thematic analysis of responses from those individuals who answered a subsequent question related to reasons for their endorsement. They conducted the research within a multidisciplinary team that included team members with clinical, legal and ethical expertise, as well as with lived experience of bipolar disorder.

A total of 932 participants with a self-reported clinical diagnosis of bipolar disorder completed the survey; 565 of them, most of whom were white British, gave free-text responses to the open question. Of the 565 participants, 82% (n = 63) endorsed self-binding directives, and of these individuals, 89% (n = 411) said their main reason for endorsement was a determinate shift to distorted thinking and decision making when unwell. Those who were ambivalent (n = 37; 7%) cited logistical concerns related to the drafting and implementation of self-binding directives. Those who rejected self-binding directives (n = 65; 12%) cited logistical concerns, validity of their thoughts upon being unwell and potential contravention of human rights.

“These results highlight both a need to recognize the rights of people with bipolar disorder who want to use self-binding directives to manage their health and advance their autonomy, and the difficulties of trying to find a single approach to maximizing autonomy within human rights in psychiatry,” Gergel and colleagues wrote.