A narrative review of studies of refusal of psychotropic medication in acute inpatient psychiatric care

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  This study reviews the current evidence on refusal of psychotropic medication in acute psychiatry.
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  Refusal of medication is common in acute psychiatry, generating conflicts in the form of threats and actual assaults leading to the use of chemical and physical restraints and seclusion.
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  Refusal of medication leads to longer admissions and having more medications.
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  Involuntarily medicating refusers leads to shorter refusal episode and shorter admissions. More rigorous research evidence is needed on the extent, nature, impact and outcome of medication refusal.

This paper offers a narrative review of the 22 studies of medication refusal in acute psychiatry. Because of varied definitions of medication refusal, diverse methodologies and few rigorous studies, it has not been possible to draw firm conclusions on the average rate of refusal of psychotropic medications in acute psychiatry. However, it is clear that medication refusal is common and leads to poor outcomes characterized by higher rates of seclusion, restraint, threats of, and actual, assaults and longer hospitalizations. There are no statistically significant differences between refusers and acceptors in gender, marital status and preadmission living arrangements. Although no firm conclusions on the influence of ethnicity, status at admission and diagnosis on refusal, the refusers are more likely to have higher number of previous hospitalizations and history of prior refusal. The review indicates that staff factors such as the use of temporary staff, lack of confidence in ward staff and ineffective ward structure are associated with higher rates of medication refusal. Comprehensive knowledge of why, and how, patients refuse medication is lacking. Research on medication refusal is still fragmented, of variable methodological quality and lacks an integrating model.