I would not argue against the underlying principles espoused by Sugarman et al Reference Sugarman, Ikkos and Bailey1 and Warner. Reference Warner2 The principle of working with patients to help them to make informed decisions about options for their healthcare is embodied in the General Medical Council's (GMC) guidance, 3 which says that doctors must listen to and work in partnership with patients, and respond to their preferences.
Many psychiatric disorders are exacerbated or precipitated by stress. Autonomy of action is associated with enhanced self-esteem, reduced stress and improved health. Meaningful employment contributes in many ways, giving a sense of purpose and value, enhanced social status, structure and stability, opportunities for social interaction, and improved leisure and social opportunities as a result of greater disposable income.
Those working with individuals who have mental illness should be aware of these principles and seek to incorporate them in the care they offer. In practice, however, professionals nominally subscribing to a ‘recovery model’ may have a poor understanding of its complexity. An inappropriate application of the concept of empowering patients can lead to a laissezfaire approach of simply endorsing the patient's choice. This can result in justifying a patient's discontinuation of treatment and withdrawal from engagement with professionals. Such withdrawal can lead to relapse and a deteriorating prognosis, and may itself be indicative of incipient relapse.
Professionals do not enjoy a monopoly of wisdom. We cannot reliably predict the course of a patient's illness or how they might respond to treatment. Those with capacity have the right to decide not to accept treatment or to deal with their illness in ways which professionals may consider unwise. However, GMC guidelines also say that doctors must provide effective treatments based on the best available evidence. The doctor's duty to provide the best advice may include advising a patient that their intended course of action is likely to lead to an adverse outcome. It is incumbent upon us to inform patients of the probable consequences of their decisions and to continue efforts to engage them when we consider them to be at significant risk of deterioration or relapse.
Additionally, UK and European law takes a special view of mental disorder and allows for the patient's autonomy to be overridden. It is a matter of judgement, governed by legislative safeguards, as to when this should occur. Such powers are generally only exercised when the patient's ability to understand is so impaired as to render them incapacitated but a decision to override the decision of a capable patient may be made when the protection of others is in question.
It is right to adopt a positive approach, hopeful of recovery, after a first episode of psychosis. However, rather than adopt unqualified optimism, we should refine our approach using our knowledge of factors favouring a good prognosis. Such features include: acute as opposed to insidious onset; clear and proximate psychogenesis; and the presence of marked affective features in the symptomatology. Several interventions can improve the prognosis and reduce the risk of relapse. Warner Reference Warner2 points out the more favourable prognosis in low- and middle-income countries. One explanatory hypothesis is that the recovering patient is more likely to have a valued occupational role. Continued antipsychotic medication reduces the risk of relapse. Psychosocial interventions to assist the patient in better understanding the illness and its behaviour, as well as working to modify family attitudes and environments appear to help. Complete resolution of symptoms encourages optimism about prognosis, but hopes for a meaningful and lasting recovery need to be underpinned by appropriate support and treatment to reduce the risk of relapse.
Despite the advances made in treating the acute symptoms of schizophrenia and preventing acute relapse, social recovery rates do not appear to have improved since Eugen Bleuler coined the term schizophrenia. Reference Bleuler4 Warner quotes a 40% social recovery level but, at the start of the 20th century, Bleuler considered that 60% of his patients showed only ‘mild deterioration’, that is, had preserved the ability to pursue an occupation.
Whereas, therefore, I accept that significant numbers of patients with schizophrenia can remain symptom-free and that others lead reasonably productive lives, it is still the case that the majority will experience a degree of impairment of function and many will suffer frank relapses of their positive symptoms or chronic levels of such symptoms.
Psychiatrists should strive to achieve that those diagnosed with schizophrenia are treated so that they become as free as possible of symptoms (including adverse effects of treatment) and that they, their families and carers have as good as possible an understanding of the nature and behaviour of the illness, so that they can make effective informed decisions about their future healthcare. True empowerment requires the individual to have the best information available and the fullest command of their intellectual abilities in order to reach considered decisions based on that information.
The experience of psychosis is traumatic and bewildering. The course of the illness is unpredictable and frequently fluctuating. Those who have experienced it should have ongoing advice, support and treatment to cope with this.