Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Epistemic problems with mental health legislation in the doctor-patient relationship

Mental health legislation that requires patients to accept 'care' has come under increasing scrutiny, prompted primarily by a human rights ethic. Epistemic issues in mental health have received some attention, however, less attention has been paid to the possible epistemic problems of mental health legislation existing. In this manuscript, we examine the epistemic problems that arise from the presence of such legislation, both for patients without a prior experience of being detained under such legislation and for those with this experience. We also examine how the doctor is legally obligated to compound the epistemic problems by the knowledge they prioritise and the failure to generate new knowledge. Specifically, we describe the problems of testimonial epistemic injustice, epistemic silencing, and epistemic smothering, and address the possible justification provided by epistemic paternalism. We suggest that there is no reasonable epistemic justification for mental health legislation that creates an environment that fundamentally unbalances the doctor-patient relationship. Significant positive reasons to counterbalance this are needed to justify the continuation of such legislation.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Reconsidering the ethics of compulsive treatment under the light of clinical psychiatry

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It focuses on how patients experience CT and its impact on their mental health and treatment programs, the reasons for the use of CT versus voluntary treatment and what efforts have been made to reduce, replace and refine the presence of CT in psychiatry.

Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature

The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.

Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders' opinions

BACKGROUND

Multiple studies have examined the effects of compulsory community treatment (CCT), amongst them there were three randomized controlled trials (RCT). Overall, they do not find that CCT affects clinical outcomes or reduces the number or duration of hospital admissions more than voluntary care does. Despite these negative findings, in many countries CCT is still used. One of the reasons may be that stakeholders favor a mental health system including CCT.

AIM

This integrative review investigated the opinions of stakeholders (patients, significant others, mental health workers, and policy makers) about the use of CCT.

METHODS

We performed an integrative review; to include all qualitative and quantitative manuscripts on the views of patients, significant others, clinicians and policy makers regarding the use of CCT, we searched MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science Core Collection, Cochrane CENTRAL Register of Controlled Trials (via Wiley), and Google Scholar.

RESULTS

We found 142 studies investigating the opinion of stakeholders (patients, significant others, and mental health workers) of which 55 were included. Of these 55 studies, 29 included opinions of patients, 14 included significant others, and 31 included mental health care workers. We found no studies that included policy makers. The majority in two of the three stakeholder groups (relatives and mental health workers) seemed to support a system that used CCT. Patients were more hesitant, but they generally preferred CCT over admission. All stakeholder groups expressed ambivalence. Their opinions did not differ clearly between those who did and did not have experience with CCT. Advantages mentioned most regarded accessibility of care and a way to remain in contact with patients, especially during times of crisis or deterioration. The most mentioned disadvantage by all stakeholder groups was that CCT restricted autonomy and was coercive. Other disadvantages mentioned were that CCT was stigmatizing and that it focused too much on medication.

CONCLUSION

Stakeholders had mixed opinions regarding CCT. While a majority seemed to support the use of CCT, they also had concerns, especially regarding the restrictions CCT imposed on patients' freedom and autonomy, stigmatization, and the focus on medication.

Finding Common Ground for Diverging Policies for Persons with Severe Mental Illness

Two diametrically opposed positions predominate discourse for the care and treatment of persons with severe mental illness: anti-deinstitutionalization and anti-institutionalization. Both share the same goal of ensuring best quality of life for those with severe psychiatric disorders, but pathways to achieving this goal are very different and have resulted in much contention. Supporters of each position espouse a different belief system regarding people with psychiatric disorders and their presumed capabilities, placing varying emphasis on maximizing protection of the community versus protection of individual rights, and result in contrasting mental health policies and practice orientations. The authors delineate the history from which these positions evolved, consequent views, and policies and practices that emerged from these differing attitudes. The article culminates in a proposed practice approach that offers a more balanced approach to serving adults with mental illness -navigating risk management by preserving freedom and opportunities of risk while affording mutually satisfactory "risk control."

Use of community treatment orders and their outcomes: an observational study

Background

Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes.

Objectives

To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs.

Design

Secondary analysis using multilevel statistical modelling.

Setting

England, including 61 NHS mental health provider trusts.

Participants

A total of 69,832 patients eligible to be subject to a community treatment order.

Main outcome measures

Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality.

Data sources

The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England.

Results

There was significant variation in community treatment order use between patients, provider trusts and local areas. Most variation arose from substantially different practice in a small number of providers. Community treatment order patients were more likely to be in the ‘severe psychotic’ care cluster grouping, male or black. There was also significant variation between service providers and local areas in the time patients remained on community treatment orders. Although slightly more community treatment order patients were re-admitted than non-community treatment order patients during the study period (36.9% vs. 35.6%), there was no significant difference in time to first re-admission (around 32 months on average for both). There was some evidence that the rate of re-admission differed between community treatment order and non-community treatment order patients according to care cluster grouping. Community treatment order patients spent 7.5 days longer, on average, in admission than non-community treatment order patients over the study period. This difference remained when other patient and local area characteristics were taken into account. There was no evidence of significant variation between service providers in the effect of community treatment order on total time in admission. Community treatment order patients were less likely to die than non-community treatment order patients, after taking account of other patient and local area characteristics (odds ratio 0.69, 95% credible interval 0.60 to 0.81).

Limitations

Confounding by indication and potential bias arising from missing data within the Mental Health Services Data Set. Data quality issues precluded inclusion of patients who were subject to community treatment orders more than once.

Conclusions

Community treatment order use varied between patients, provider trusts and local areas. Community treatment order use was not associated with shorter time to re-admission or reduced time in hospital to a statistically significant degree. We found no evidence that the effectiveness of community treatment orders varied to a significant degree between provider trusts, nor that community treatment orders were associated with reduced mental health treatment costs. Our findings support the view that community treatment orders in England are not effective in reducing future admissions or time spent in hospital. We provide preliminary evidence of an association between community treatment order use and reduced rate of death.

Future work

These findings need to be replicated among patients who are subject to community treatment order more than once. The association between community treatment order use and reduced mortality requires further investigation.

Study registration

The study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-2015-1623).

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Trust and Community Treatment Orders

There are conflicting views about the benefits of community treatment orders (CTOs) for people with mental illness. While there is a significant literature on the coercive nature of CTOs, there is less on the impact that CTOs have upon trust. A recovery-oriented approach requires a trusting therapeutic relationship and the coercion inherent in the CTO process may make it difficult for trust to be built, nurtured, and sustained between workers and patients. Our aim was therefore to examine the role of trust within the CTO experience for mental health workers and patients on CTOs. Methods: We conducted a thematic discourse analysis of 8 in-depth interviews with people who were currently on a CTO and 10 interviews with multi-disciplinary mental health workers in Adelaide, Australia (total N = 18 interviews). The interviews were coded and analyzed with the assistance of a patient representative. The findings reveal the challenges and opportunities for trust within the coercive relationship of a CTO. Findings: We found that patients have diverse experiences of CTOs and that trust or mistrust played an import role in whether or not they found the CTO beneficial.

Cross-Cultural Notions of Risk and Liberty: A Comparison of Involuntary Psychiatric Hospitalization and Outpatient Treatment in New York, United States and Zurich, Switzerland

Involuntary hospitalization is a frequently discussed intervention physicians must sometimes execute. Because this intervention has serious implications for the citizens' civil liberties it is regulated by law. Every country's health system approaches this issue differently with regard to the relevant laws and the logistical processes by which involuntary hospitalization generally is enacted. This paper aims at analyzing the regulation and process of involuntary hospitalization in New York (United States) and Zurich (Switzerland). Comparing the respective historical, political, and economic backgrounds shows how notions of risk and liberty are culture-bound and consequently shape legislation and local practices. It is highly relevant to reconsider which criteria are required for involuntary hospitalization as this might shape the view of society on psychiatric patients and psychiatry itself. Furthermore, this article discusses the impact that training and experience of the person authorized to conduct and maintain an involuntary hospitalization has on the outcome.

Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study

PURPOSE

Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients' social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients' long-term social outcomes.

METHODS

A sub-sample (n = 114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health.

RESULTS

No significant association was found between the duration of CTO intervention and social network size (IRR = 0.996, p = .63), objective social outcomes (B = -0.003, p = .77), health-related quality of life (B = 0.001, p = .77), and capabilities (B = 0.046, p = .41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SD = 5.9) contacts in their social networks, 42% of whom were relatives.

CONCLUSIONS

CTO duration was not associated with improvements in patients' social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.

Community Treatment Order: Identifying the need for more evidence based justification of its use in first episode psychosis patients

OBJECTIVES

Community Treatment Order (CTO) is a legal regime that obliges patients suffering mental disorder to adhere to treatment in the community and allows for a swift admission to hospital if necessary. Study aims were to: (i) determine CTO frequency in a large representative sample of first episode psychosis (FEP) patients; (ii) compare the characteristics of patients with or without CTO before entry, during treatment and at discharge from an early psychosis program.

METHODS

Information on 660 patients treated at the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1998 and 2000 was collected from medical files.

RESULTS

19.2% of patients were under CTO at least once during treatment and they differed on most pre-treatment, baseline, treatment and service discharge variables. They were less educated, more likely to have a history of offending behavior, had lower pre-morbid functioning, longer duration of untreated psychosis, increased prevalence and more persistent substance use disorders, greater severity of symptoms, lower functioning, poorer insight at any time during treatment and were more likely to be admitted to hospital.

CONCLUSIONS

CTO frequency was high, likely related to the representativeness of the cohort. Characteristics of patients on CTO are comparable to those with serious and persistent mental illness. Considering the absence of solid evidence regarding the effectiveness of this form of compulsion, it is crucial to study the use of CTO in FEP patients in order to explore its impact and identify patients for whom it may be beneficial.

Associations between compulsory community treatment and continuity of care in a three year follow-up of the Oxford Community Treatment Order Trial (OCTET) cohort

BACKGROUND

Most studies investigating the effectiveness of Community Treatment Orders (CTOs) use readmission to hospital as the primary outcome. Another aim of introducing CTOs was to improve continuity of care. Our study was a 3-year prospective follow-up which tested for associations between CTOs and continuity of care.

METHODS

Our study sample included 333 patients recruited to the Oxford Community Treatment Order Trial (OCTET). We collected data on continuity of care using eight previously operationalized measures. We analysed the association between CTOs and continuity of care in two ways. First, we tested the association between continuity of care and OCTET randomisation arm (CTO versus voluntary care via Section 17 leave). Second, we analysed continuity of care and CTO exposure independent of randomisation; using any exposure to CTO, number of days on CTO, and proportion of outpatient days on CTO as outcomes.

RESULTS

197 (61%) patients were made subject to CTO during the 36-month follow-up. Randomisation to CTO arm was significantly associated with having a higher proportion of clinical documents copied to the user but no other measures of continuity. Having a higher proportion of outpatient days on CTO (irrespective of randomisation) was associated with fewer 60 day breaks without community contact. A sensitivity analysis found that any exposure to CTO and a higher proportion of outpatient days on CTO were associated with fewer days between community mental health team contacts and 60 day breaks without contact.

CONCLUSION

We found some evidence of an association between CTO use and better engagement with the community team in terms of increased contact and fewer breaks in care. Those with CTO experience had a higher number of inpatient admissions which may have acted as a mediator of this association. We found limited evidence for an association between CTO use and other measures of continuity of care.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

BACKGROUND

It is controversial whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning.

OBJECTIVES

To examine the effectiveness of compulsory community treatment (CCT) for people with severe mental illness (SMI).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (2003, 2008, 2012, 8 November 2013, 3 June 2016). We obtained all references of identified studies and contacted authors where necessary.

SELECTION CRITERIA

All relevant randomised controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another pre-existing form of CCT such as supervised discharge.

DATA COLLECTION AND ANALYSIS

Authors independently selected studies, assessed their quality and extracted data. We used Cochrane's tool for assessing risk of bias. For binary outcomes, we calculated a fixed-effect risk ratio (RR), its 95% confidence interval (95% CI) and, where possible, the number needed to treat for an additional beneficial outcome (NNTB). For continuous outcomes, we calculated a fixed-effect mean difference (MD) and its 95% CI. We used the GRADE approach to create 'Summary of findings' tables for key outcomes and assessed the risk of bias of these findings.

MAIN RESULTS

The review included three studies (n = 749). Two were based in the USA and one in England. The English study had the least bias, meeting three out of the seven criteria of Cochrane's tool for assessing risk of bias. The two other studies met only one criterion, the majority being rated unclear.Two trials from the USA (n = 416) compared court-ordered 'outpatient commitment' (OPC) with entirely voluntary community treatment. There were no significant differences between OPC and voluntary treatment by 11 to 12 months in any of the main health service or participant level outcome indices: service use - readmission to hospital (2 RCTs, n= 416, RR 0.98, 95% CI 0.79 to 1.21, low-quality evidence); service use - compliance with medication (2 RCTs, n = 416, RR 0.99, 95% CI 0.83 to 1.19, low-quality evidence); social functioning - arrested at least once (2 RCTs, n = 416, RR 0.97, 95% CI 0.62 to 1.52, low-quality evidence); social functioning - homelessness (2 RCTs, n = 416, RR 0.67, 95% CI 0.39 to 1.15, low-quality evidence); or satisfaction with care - perceived coercion (2 RCTs, n = 416, RR 1.36, 95% CI 0.97 to 1.89, low-quality evidence). However, one trial found the risk of victimisation decreased with OPC (1 RCT, n = 264, RR 0.50, 95% CI 0.31 to 0.80, low-quality evidence).The other RCT compared community treatment orders (CTOs) with less intensive and briefer supervised discharge (Section 17) in England. The study found no difference between the two groups for either the main health service outcomes including readmission to hospital by 12 months (1 RCT, n = 333, RR 0.99, 95% CI 0.74 to 1.32, moderate-quality evidence), or any of the participant level outcomes. The lack of any difference between the two groups persisted at 36 months' follow-up.Combining the results of all three trials did not alter these results. For instance, participants on any form of CCT were no less likely to be readmitted than participants in the control groups whether on entirely voluntary treatment or subject to intermittent supervised discharge (3 RCTs, n = 749, RR for readmission to hospital by 12 months 0.98, 95% CI 0.82 to 1.16 moderate-quality evidence). In terms of NNTB, it would take 142 orders to prevent one readmission. There was no clear difference between groups for perceived coercion by 12 months (3 RCTs, n = 645, RR 1.30, 95% CI 0.98 to 1.71, moderate-quality evidence).There were no data for adverse effects.

AUTHORS' CONCLUSIONS

These review data show CCT results in no clear difference in service use, social functioning or quality of life compared with voluntary care or brief supervised discharge. People receiving CCT were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non-effective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and low- to moderate-quality evidence. In addition, clinical trials may not fully reflect the potential benefits of this complex intervention.

Involuntary Outpatient Commitment and the Elusive Pursuit of Violence Prevention

OBJECTIVE

Involuntary outpatient commitment (OPC)-also referred to as 'assisted outpatient treatment' or 'community treatment orders'-are civil court orders whereby persons with serious mental illness and repeated hospitalisations are ordered to adhere to community-based treatment. Increasingly, in the United States, OPC is promoted to policy makers as a means to prevent violence committed by persons with mental illness. This article reviews the background and context for promotion of OPC for violence prevention and the empirical evidence for the use of OPC for this goal.

METHOD

Relevant publications were identified for review in PubMed, Ovid Medline, PsycINFO, personal communications, and relevant Internet searches of advocacy and policy-related publications.

RESULTS

Most research on OPC has focussed on outcomes such as community functioning and hospital recidivism and not on interpersonal violence. As a result, research on violence towards others has been limited but suggests that low-level acts of interpersonal violence such as minor, noninjurious altercations without weapon use and arrests can be reduced by OPC, but there is no evidence that OPC can reduce major acts of violence resulting in injury or weapon use. The impact of OPC on major violence, including mass shootings, is difficult to assess because of their low base rates.

CONCLUSIONS

Effective implementation of OPC, when combined with intensive community services and applied for an adequate duration to take effect, can improve treatment adherence and related outcomes, but its promise as an effective means to reduce serious acts of violence is unknown.

Violence prevention in psychiatry: an umbrella review of interventions in general and forensic psychiatry

Relative risks of violence in psychiatric patients are high compared to the general population and existing evidence in non-psychiatric populations may not translate to reductions in violence in psychiatric populations. We searched 10 databases including Medline, EMBASE, CINAHL and Scopus, from inception until August 2015 for systematic reviews and meta-analyses of violence prevention interventions in psychiatry. Reviews were included if they used a hard outcome measure (i.e. police or hospital recorded violence, or reincarceration) and contained randomized or non-randomized controlled studies. Five reviews met our inclusion criteria (n = 8876 patients in total), of which four received a GRADE rating of 'low' or 'very low'. Three randomized studies (n = 636) reported that therapeutic community interventions may reduce reincarceration in drug-using offenders with co-occurring mental illness ('moderate' GRADE rating). The lack of intervention research in violence prevention in general and forensic psychiatry suggests that interventions from non-psychiatric populations may need to be relied upon.

Community Treatment Orders-A pause for thought

Community Treatment Orders (CTO) have been available for several decades in some countries and are being progressively introduced worldwide, with significant uptake in Asian countries as they move more mental health care into the community. However the evidence for the effectiveness of CTOs is limited. The evidence from local audits and evaluations is conflicted with some studies showing clear benefit and others not. The same is the case for uncontrolled before and after studies. The higher levels of evidence such as randomised controlled trials, systematic reviews, and Cochrane reviews have consistently failed to demonstrate benefits from CTO use on key measures such as symptom levels, functioning, and healthcare use. Despite this they are increasingly available internationally and often greeted enthusiastically by clinicians and families who want to ensure care and follow up for the mentally ill. This article briefly discusses the evidence before describing potential alternatives to the use of compulsion that do have an evidence base, such as multidisciplinary community working, housing initiatives, and employment support.

Preventing Criminal Recidivism Through Mental Health and Criminal Justice Collaboration

Criminal justice system involvement is common among persons with serious mental illness in community treatment settings. Various intervention strategies are used to prevent criminal recidivism among justice-involved individuals, including mental health courts, specialty probation, and conditional release programs. Despite differences in these approaches, most involve the use of legal leverage to promote treatment adherence. Evidence supporting the effectiveness of leverage-based interventions at preventing criminal recidivism is mixed, however, with some studies suggesting that involving criminal justice authorities in mental health treatment can increase recidivism rates. The effectiveness of interventions that utilize legal leverage is likely to depend on several factors, including the ability of mental health and criminal justice staff to work together. Collaboration is widely acknowledged as essential in managing justice-involved individuals, yet fundamental differences in goals, values, and methods exist between mental health and criminal justice professionals. This article presents a six-step conceptual framework for optimal mental health-criminal justice collaboration to prevent criminal recidivism among individuals with serious mental illness who are under criminal justice supervision in the community. Combining best practices from each field, the stepwise process includes engagement, assessment, planning and treatment, monitoring, problem solving, and transition. Rationale and opportunities for collaboration at each step are discussed.

Are community treatment orders counterproductive?

OBJECTIVE

This article briefly reviews the literature pertaining to community treatment orders (CTOs) specifically how and why they are utilised and how effective mandated community treatment really is. This review discusses the use of CTOs in the context of the recovery model.

CONCLUSIONS

This article highlights the shortfalls in the current CTO system while also demonstrating the increase in acute coercive care. The literature pertaining to the effectiveness of CTOs is inconsistent with more recent reviews denoting that there is now robust evidence the CTOs are not effective. Further treatment that aligns with the recovery model as oppose to mandated treatment is known to increase treatment compliance.

Effectiveness of Community Treatment Orders: The International Evidence

OBJECTIVE

Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness.

METHOD

The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies.

RESULTS

The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion.

CONCLUSION

There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs.

Canadian Studies on the Effectiveness of Community Treatment Orders

OBJECTIVES

Community treatment orders (CTOs) for people with severe mental illnesses are used across most of Canada. It is unclear if they can reduce health service use, or improve clinical and social outcomes. This review summarizes the evidence from studies conducted in Canada.

METHOD

A systematic literature search of PubMed and MEDLINE to March 2015 was conducted. Inclusion criteria were quantitative and qualitative studies undertaken in Canada that presented data on the effect of CTOs on outcomes.

RESULTS

Nine papers from 8 studies were included in the review. Four studies compared health service use before and after compulsory treatment as well as engagement with psychosocial supports. Three were qualitative evaluations of patients, family, or staff and the last was a postal survey of psychiatrists. Hospital readmission rates and days spent in hospital were all reduced following CTO placement, while outpatient attendance and participation in psychiatric services and housing all improved. Family members and clinicians were generally positive about the effect of CTOs but patients were ambivalent. However, the strength of the evidence was limited as many of the studies were small, only one included control subjects, and there was no adjustment for potential confounders using either matching or multivariate analyses. Only 2 qualitative studies included the views of patients and their families.

CONCLUSIONS

The evidence base for the use of CTOs in Canada is limited and this lack of Canadian research is in marked contrast to other countries where there have been large studies that have used randomized or matched control subjects. Their use should be kept under review.

One-year incidence and prevalence of seclusion: Dutch findings in an international perspective

BACKGROUND

The Netherlands started a nationwide coercion reduction program in 2007. In 2011, accurate registration of coercive measures became obligatory by law.

OBJECTIVE

The aim of this study was to compare number and duration of coercive measures in the Netherlands with international data.

METHODS

2011 data on coercive measures were collected, using a system developed in Germany. To understand determinants of coercion, multilevel logistic regression was performed.

RESULTS

12.0 % (n = 5169) of patients (n = 42.960) in 2011 experienced at least one coercive measure. Exposure to coercion was comparable to other countries, and duration was higher. Medication use seemed to half average times in seclusion. In the Netherlands, coercion mainly constituted of seclusion and occurred in bipolar and psychotic disorders. In Germany, coercion was mostly mechanical restraint and occurred in organic disorders and schizophrenia.

CONCLUSIONS

Gathering comprehensive data allows comparisons between countries, increasing our understanding of the impact of different cultures, legislation and health care systems on coercion. In the Netherlands, seclusion is still the main type of coercion, despite significant improvements in the last few years. It is shorter when applied in combination with enforced medication.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

There is controversy as to whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use or improves clinical outcome and social functioning. To examine the effectiveness of CCT for people with SMI. We searched the Cochrane Schizophrenia Group's Trials Register and Science Citation Index (2003, 2008, 2012, and 2013). We obtained all references of identified studies and contacted authors where necessary. All relevant randomized controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another preexisting form of compulsory community treatment such as supervised discharge. We found 3 trials with a total of 752 people. Two trials compared a form of CCT called 'Outpatient Commitment' (OPC) versus standard voluntary care, whereas the third compared Community Treatment Orders with intermittent supervised discharge. CCT was no more likely to result in better service use, social functioning, mental state, or quality of life compared with either standard voluntary or supervised care. However, people receiving CCT were less likely to be victims of crime than those on voluntary care. Further research is indicated into the effects of different types of CCT as these results are based on 3 relatively small trials.