A prospective study of drug treatment refusal will be conducted in 180 state psychiatric hospital admissions, aged 18-55, who are involuntarily committed and legally competent. Three groups appropriately matched on key clinical variables will be studied: refusers who are referred for court decision to treat over the patient's objection (I), refusers who are not referred (II) and consenting patients (III). The course of the index episode the reasons for drug refusal, attitude toward medication and prior medication history of group I and II refusers will be determined . For group I refusers, the decision of the court and the satisfaction of the treating doctor will be determined. Time intervals related to the court process (pre, pending, post-adjudication) will be computed. The incidence and prevalence of drug treatment refusal as defined by court application or prior formal review will be compared with data from other states' formal review programs. For the three groups, patients will be characterized on sociodemographic, past and current clinical characteristics including SCID-P verified diagnosis, symptoms (BPRS or Hamilton scores), medications (specific drugs, daily dosages and chlorpromazine- equivalents for the antipsychotics) and side effects (SAFTEE). Assaultiveness, measured as the number of assault-related incidents/ seclusion/restraints/and transfers to a secure unit, will be compared among the three groups. Treatment outcome measures include discharge status at one-year, length of hospitalization (corrected for placement differences) and readmissions in one-year. From the comparison in the drug management and treatment outcome between consenting patients and the subgroup of severely mentally ill patients who must undergo court review for their refusal to accept medications, epidemiologically based patterns will emerge for pharmacologic treatments targeted to these difficult-to-treat patients.
