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Hofstad T, Nyttingnes O, Markussen S, Johnsen E, Killackey E, McDaid D, Rinaldi M, Dean K, Brinchmann B, Douglas K, Gröning L, Bjørkly S, Palmstierna T, Strømme MF, Blindheim A, Rugkåsa J, Hofmann BM, Pedersen R, Widding‐Havneraas T, Rypdal K, Mykletun A. Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project. Int J Methods Psychiatr Res 2023; 33:e1980. [PMID: 37421245 PMCID: PMC10807697 DOI: 10.1002/mpr.1980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVES Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. METHODS By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories. CONCLUSIONS This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.
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Affiliation(s)
- Tore Hofstad
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Medical EthicsUniversity of OsloOsloNorway
| | - Olav Nyttingnes
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Health Services Research UnitAkershus University HospitalLørenskogNorway
| | | | - Erik Johnsen
- Division of PsychiatryHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
- NORMENTCentre of ExcellenceHaukeland University HospitalBergenNorway
| | - Eoin Killackey
- OrygenMelbourneAustralia
- Centre for Youth Mental HealthThe University of MelbourneMelbourneAustralia
| | - David McDaid
- Care Policy and Evaluation CentreDepartment of Health PolicyLondon School of Economics and Political ScienceLondonUK
| | - Miles Rinaldi
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
- South West London and St George's Mental Health NHS TrustLondonUK
| | - Kimberlie Dean
- Discipline of Psychiatry and Mental HealthSchool of Clinical MedicineUniversity of New South WalesSydneyAustralia
- Justice Health and Forensic Mental Health NetworkSydneyNSWAustralia
| | - Beate Brinchmann
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
| | - Kevin Douglas
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Department of PsychologySimon Fraser UniversityVancouverBritish ColumbiaCanada
- Regional Centre for Research and Education in Forensic PsychiatryOslo University HospitalOsloNorway
| | - Linda Gröning
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Faculty of LawUniversity of BergenBergenNorway
| | - Stål Bjørkly
- Regional Centre for Research and Education in Forensic PsychiatryOslo University HospitalOsloNorway
- Faculty of Health and Social SciencesMolde University CollegeMoldeNorway
| | - Tom Palmstierna
- Department of Clinical NeuroscienceCentre for Psychiatric ResearchKarolinska InstitutetStockholmSweden
- Faculty of Medicine and Health SciencesDepartment of Mental HealthNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Maria Fagerbakke Strømme
- Division of PsychiatryHaukeland University HospitalBergenNorway
- NORMENTCentre of ExcellenceHaukeland University HospitalBergenNorway
| | - Anne Blindheim
- Division of PsychiatryHaukeland University HospitalBergenNorway
| | - Jorun Rugkåsa
- Health Services Research UnitAkershus University HospitalLørenskogNorway
- Centre for Care ResearchUniversity of South‐Eastern NorwayPorsgrunnNorway
- Department of Mental HealthOslo Metropolitan UniversityOsloNorway
| | - Bjørn Morten Hofmann
- Centre for Medical EthicsUniversity of OsloOsloNorway
- Faculty of Medicine and Health SciencesDepartment of Health SciencesNorwegian University of Science and TechnologyGjøvikNorway
| | | | - Tarjei Widding‐Havneraas
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
| | - Knut Rypdal
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
| | - Arnstein Mykletun
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
- UiT—The Arctic University of NorwayTromsøNorway
- Division for Health ServicesNorwegian Institute of Public HealthOsloNorway
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2
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Finding Common Ground for Diverging Policies for Persons with Severe Mental Illness. Psychiatr Q 2020; 91:1193-1208. [PMID: 32857286 DOI: 10.1007/s11126-020-09821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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."
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3
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Duncan C, Weich S, Moon G, Twigg L, Fenton SJ, Bhui K, Canaway A, Crepaz-Keay D, Keown P, Madan J, McBride O, Parsons H, Singh S. Moving beyond randomized controlled trials in the evaluation of compulsory community treatment. J Eval Clin Pract 2020; 26:812-818. [PMID: 31359526 DOI: 10.1111/jep.13245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
Abstract
Compulsory community treatment for people with severe mental illness remains controversial due to conflicting research evidence. Recently, there have been challenges to the conventional view that trial-based evidence should take precedence. This paper adds to these challenges in three ways. First, it emphasizes the need for critiques of trials to engage with conceptual and not just technical issues. Second, it develops a critique of trials centred on both how we can have knowledge and what it is we can have knowledge of. Third, it uses this critique to develop a research strategy that capitalizes on the information in large-scale datasets.
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Affiliation(s)
- Craig Duncan
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Scott Weich
- School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Graham Moon
- School of Geography and Environmental Science, University ofSouthampton, Southampton, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Sarah-Jane Fenton
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Queen Mary University of London, London, UK
| | | | | | - Patrick Keown
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Orla McBride
- School of Psychology, Ulster University, Coleraine, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Swaran Singh
- Warwick Medical School, University of Warwick, Coventry, UK
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4
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Segal SP. The utility of outpatient civil commitment: Investigating the evidence. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 70:101565. [PMID: 32482302 PMCID: PMC7394121 DOI: 10.1016/j.ijlp.2020.101565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Outpatient civil commitment (OCC), community treatment orders (CTOs) in European and Commonwealth nations, require the provision of needed-treatment to protect against imminent threats to health and safety. OCC-reviews aggregating all studies report inconsistent outcomes. This review, searches for consistency in OCC-outcomes by evaluating studies based on mental health system characteristics, measurement, and design principles. METHODS All previously reviewed OCC-studies and more recent investigations were grouped by their outcome-measures' relationship to OCC statute objectives. A study's evidence-quality ranking was assessed. Hospital and service-utilization outcomes were grouped by whether they represented treatment provision, patient outcome, or the conflation of both. RESULTS OCC-studies including direct health and safety outcomes found OCC associated with reduced mortality-risk, increased access to acute medical care, and reduced violence and victimization risks. Studies considering treatment-provision, found OCC associated with improved medication and service compliance. If coupled with assertive community treatment (ACT) or aggressive case management OCC was associated with enhanced ACT success in reducing hospitalization need. When outpatient-services were limited, OCC facilitated rapid return to hospital for needed-treatment and increased hospital utilization in the absence of a less restrictive alternative. OCC-studies measuring "total hospital days", "prevention of hospitalization", and "readmissions" report negative and/or no difference findings because they erroneously conflate their intervention (provision of needed treatment) and outcome. CONCLUSIONS This investigation finds replicated beneficial associations between OCC and direct measures of imminent harm indicating reductions in threats to health and safety. It also finds support for OCC as a less restrictive alternative to inpatient care.
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Affiliation(s)
- Steven P Segal
- Professor, University of Melbourne, Australia; Professor of the Graduate Division and Director of the Mental Health and Social Welfare Research Group, University of California, Berkeley, USA.
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5
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Barkhuizen W, Cullen AE, Shetty H, Pritchard M, Stewart R, McGuire P, Patel R. Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study. BMJ Open 2020; 10:e035121. [PMID: 32139493 PMCID: PMC7059496 DOI: 10.1136/bmjopen-2019-035121] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Limited evidence is available regarding the effect of community treatment orders (CTOs) on mortality and readmission to psychiatric hospital. We compared clinical outcomes between patients placed on CTOs to a control group of patients discharged to voluntary community mental healthcare. DESIGN AND SETTING An observational study using deidentified electronic health record data from inpatients receiving mental healthcare in South London using the Clinical Record Interactive Search (CRIS) system. Data from patients discharged between November 2008 and May 2014 from compulsory inpatient treatment under the Mental Health Act were analysed. PARTICIPANTS 830 participants discharged on a CTO (mean age 40 years; 63% male) and 3659 control participants discharged without a CTO (mean age 42 years; 53% male). OUTCOME MEASURES The number of days spent in the community until readmission, the number of days spent in inpatient care in the 2 years prior to and the 2 years following the index admission and mortality. RESULTS The mean duration of a CTO was 3.2 years. Patients receiving care from forensic psychiatry services were five times more likely and patients receiving a long-acting injectable antipsychotic were twice as likely to be placed on a CTO. There was a significant association between CTO receipt and readmission in adjusted models (HR: 1.60, 95% CI 1.42 to 1.80, p<0.001). Compared with controls, patients on a CTO spent 17.3 additional days (95% CI 4.0 to 30.6, p=0.011) in a psychiatric hospital in the 2 years following index admission and had a lower mortality rate (HR: 0.66, 95% CI 0.50 to 0.88, p=0.004). CONCLUSIONS Many patients spent longer on CTOs than initially anticipated by policymakers. Those on CTOs are readmitted sooner, spend more time in hospital and have a lower mortality rate. These findings merit consideration in future amendments to the UK Mental Health Act.
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Affiliation(s)
- Wikus Barkhuizen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alexis E Cullen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Hitesh Shetty
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Megan Pritchard
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Robert Stewart
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Rashmi Patel
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
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6
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Weich S, Duncan C, Twigg L, McBride O, Parsons H, Moon G, Canaway A, Madan J, Crepaz-Keay D, Keown P, Singh S, Bhui K. Use of community treatment orders and their outcomes: an observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Scott Weich
- School of Health and Related Research, University of Sheffield, Sheffield, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Craig Duncan
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Orla McBride
- School of Psychology, Ulster University, Londonderry, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Graham Moon
- School of Geography and Environmental Science, University of Southampton, Southampton, UK
| | | | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Patrick Keown
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Swaran Singh
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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7
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Jager F, Perron A. The social utility of community treatment orders: Applying Girard's mimetic theory to community-based mandated mental health care. Nurs Philos 2019; 21:e12280. [PMID: 31441197 DOI: 10.1111/nup.12280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 11/27/2022]
Abstract
Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non-compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.
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Affiliation(s)
- Fiona Jager
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Amélie Perron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
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8
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Harris A, Chen W, Jones S, Hulme M, Burgess P, Sara G. Community treatment orders increase community care and delay readmission while in force: Results from a large population-based study. Aust N Z J Psychiatry 2019; 53:228-235. [PMID: 29485289 DOI: 10.1177/0004867418758920] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There is debate about the effectiveness of community treatment orders in the management of people with a severe mental illness. While some case-control studies suggest community treatment orders reduce hospital readmissions, three randomised controlled trials find no effects. These randomised controlled trials measure outcomes over a longer period than the community treatment order duration and assess the combined effectiveness of community treatment orders both during and after the intervention. This study examines the effectiveness of community treatment orders in a large population-based sample, restricting observation to the period under a community treatment order. METHODS All persons ( n = 5548) receiving a community treatment order in New South Wales, Australia, over the period 2004-2009 were identified. Controls were matched using a propensity score based on demographic, clinical and prior care variables. A baseline period equal to each case's duration of treatment was constructed. Treatment effects were compared using zero-inflated negative binomial regression, adjusting for demographics, clinical characteristics and pre-community treatment order care. RESULTS Compared to matched controls, people on community treatment orders were less likely to be readmitted (odds ratio = 0.90, 95% confidence interval = [0.84, 0.97]) and had a significantly longer time to their first readmission (incidence rate ratio = 1.47, 95% confidence interval = [1.36, 1.58]), fewer hospital admissions (incidence rate ratio = 0.90, 95% confidence interval = [0.84, 0.96]) and more days of community care (incidence rate ratio = 1.55, 95% confidence interval = [1.51, 1.59]). Increased community care and delayed first admission were found for all durations of community treatment order care. Reduced odds of readmission were limited to people with 6 months or less of community treatment order care, and reduced number of admissions and days in hospital to people with prolonged (>24 months) community treatment order care. CONCLUSION In this large population-based study, community treatment orders increase community care and delay rehospitalisation while they are in operation. Some negative findings in this field may reflect the use of observation periods longer than the period of active intervention.
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Affiliation(s)
- Anthony Harris
- 1 Brain Dynamics Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, Australia.,2 Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Wendy Chen
- 3 InforMH, Mental Health and Drug and Alcohol Office, NSW Health, North Ryde, NSW, Australia
| | - Sharon Jones
- 3 InforMH, Mental Health and Drug and Alcohol Office, NSW Health, North Ryde, NSW, Australia
| | - Melissa Hulme
- 4 Department of Psychiatry, Westmead Hospital, Wentworthville, NSW, Australia
| | - Philip Burgess
- 5 School of Public Health, The University of Queensland, Herston, QLD, Australia
| | - Grant Sara
- 2 Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,3 InforMH, Mental Health and Drug and Alcohol Office, NSW Health, North Ryde, NSW, Australia
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9
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Weich S, Duncan C, Bhui K, Canaway A, Crepaz-Keay D, Keown P, Madan J, McBride O, Moon G, Parsons H, Singh S, Twigg L. Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study. BMJ Open 2018; 8:e024193. [PMID: 30341141 PMCID: PMC6196959 DOI: 10.1136/bmjopen-2018-024193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Supervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form of community treatment orders (CTOs). CTOs have been used more than expected, with significant variations between people and places. There is conflicting evidence about the effectiveness of SCT; studies based on randomised controlled trials (RCTs) have suggested few positive impacts, while those employing observational designs have been more favourable. Robust population-based studies are needed, because of the ethical challenges of undertaking further RCTs and because variation across previous studies may reflect the effects of sociospatial context on SCT outcomes. We aim to examine spatial and temporal variation in the use, effectiveness and cost of CTOs in England through the analysis of routine administrative data. METHODS AND ANALYSIS Four years of data from the Mental Health Services Dataset (MHSDS) will be analysed using multilevel models. Models based on all patients eligible for CTOs will be used to explore variation in their use. A subset of CTO-eligible patients comprising a treatment group (CTO patients) and a matched control group (non-CTO patients) will be used to examine variation in the association between CTO use and study outcomes. Primary outcome will be total time in hospital. Secondary outcomes will include time to first readmission and mortality. Outputs from these models will be used to populate predictive models of healthcare resource use. ETHICS AND DISSEMINATION Ethical approval has been granted by the National Health Service Data Access and Advisory Group and Warwick University. To ensure patient confidentiality and to meet data governance requirements, analyses will be carried out in a secure microdata laboratory using de-identified data. Study findings will be disseminated through academic channels and shared with mental health policy-makers and other stakeholders.
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Affiliation(s)
- Scott Weich
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Craig Duncan
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Barts and The London School of Medicine & Dentist, University of London, London, UK
| | | | | | - Patrick Keown
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Orla McBride
- School of Psychology, Ulster University, Londonderry, UK
| | - Graham Moon
- Geography and Environment, Ulster University, Southampton, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Swaran Singh
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
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10
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Francombe Pridham K, Nakhost A, Tugg L, Etherington N, Stergiopoulos V, Law S. Exploring experiences with compulsory psychiatric community treatment: A qualitative multi-perspective pilot study in an urban Canadian context. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 57:122-130. [PMID: 29548499 DOI: 10.1016/j.ijlp.2018.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 12/27/2017] [Accepted: 02/11/2018] [Indexed: 06/08/2023]
Abstract
As medical, ethical and clinical effectiveness debates about the use of compulsory psychiatric treatment continues, it is important to further explore the actual experiences and perspectives of all relevant stakeholders in community treatment orders (CTOs). This qualitative pilot study engaged a total of twenty-seven clients, their family members, and care providers in Toronto, Canada. Semi-structured, one-on-one interviews were conducted between February and July 2013 and analyzed using thematic analysis. Top key themes from all the participants identified include, among others: 1) clients' experiences of coercion while treated under CTO, but a preference for CTOs compared to involuntary hospitalization, nevertheless; 2) limited real opportunities for collaboration in treatment decisions expressed by clients and family members; 3) acceptance of the potential for clinical recovery on CTOs while debating the role of CTO in a broader recovery journey by all stakeholders; 4) general preservation of therapeutic relationships between clients and care providers, while acknowledging the tension of taking on an "enforcer" role by providers; and 5) existence of different avenues for asserting agency by clients. The findings of this research illuminate the nuanced, complex, and adaptive perspectives held by different stakeholders, point to the importance of preserving and enhancing procedural justice in their use, and alert the field to incorporate recovery-based approaches in this controversial practice that is a widely and commonly used clinical tool across many jurisdictions.
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Affiliation(s)
- Kate Francombe Pridham
- Mental Health Services, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario M5B 1W8, Canada.
| | - Arash Nakhost
- Mental Health Services, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Faculty of Medicine, University of Toronto, 250 College Street, 8th Floor, Toronto, Ontario M5T 1R8, Canada.
| | - Lorne Tugg
- Faculty of Medicine, University of Toronto, 250 College Street, 8th Floor, Toronto, Ontario M5T 1R8, Canada; North York General Hospital, Toronto, Canada.
| | - Nicole Etherington
- Mental Health Services, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
| | - Vicky Stergiopoulos
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Ontario M5B 1W8, Canada; Faculty of Medicine, University of Toronto, 250 College Street, 8th Floor, Toronto, Ontario M5T 1R8, Canada; Centre for Addiction and Mental Health, 100 Stokes Street, Toronto, Ontario M6J 1H4, Canada.
| | - Samuel Law
- Mental Health Services, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Faculty of Medicine, University of Toronto, 250 College Street, 8th Floor, Toronto, Ontario M5T 1R8, Canada.
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Abstract
SummaryIn the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.Learning Objectives• Gain an overview of the development and use of CTOs in the UK and internationally• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future
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Abstract
BACKGROUND In recent years, an increasing number of countries have introduced outpatient commitment orders (OC), which imply that patients can be subject to compulsory follow-up and treatment while living in the community. However, few studies on how OC is practised have been published. METHOD Retrospective case register study based on medical files of all patients receiving an OC order in 2008-2012. We used a pre/post design, recording the use of inpatient services three years before and three years after for those patients who received their first ever OC order in 2008 and 2009. RESULTS A total of 345 OC orders applying to 286 persons were identified in the study period 2008-2012. Incidence and prevalence rates were relatively stable, but decreased during the last years of the study period. For all the 54 patients receiving their first ever OC order in 2008 and 2009, need for treatment was the reason for imposing OC, and all received psychotropic medication. The number of inpatient admissions and inpatient days was greater, while the number of days for each admission was lower three years after the OC order than three years before. The first ever OC lasted under a year for 76% of the patients. Receiving depot medication and follow-up by psychiatrists predicted longer OC durations than such treatment and care by psychologists. Only nine patients were not hospitalized during the three-year follow-up after the first ever OC order. CONCLUSION Patients on first ever OC orders in Northern Norway used inpatient services more after OC orders than before. Further studies are needed to explore whether increased use of inpatient services by OC patients is beneficial or a failure of OC.
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What does being on a community treatment orders entail? A 3-year follow-up of the OCTET CTO cohort. Soc Psychiatry Psychiatr Epidemiol 2017; 52:465-472. [PMID: 27816998 DOI: 10.1007/s00127-016-1304-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order. AIMS To investigate CTO implementation in England in terms of the use of specified conditions, and judicial hearings; whether these change over time, and; the level of continued coercion. METHOD 36-month observational prospective study of patients on CTO in the OCTET follow-up study. RESULTS The number of CTO conditions remained stable over time but consolidated around medication adherence and remaining in contact with services. Ten percent of Mental Health Tribunal Hearings and only 1 percent of Hospital Managers Hearings resulted in discharge. Twenty-seven percent of patients experienced more than one CTO episode and eighteen percent remained under compulsion until the end of follow-up. CONCLUSIONS CTOs seem to be used primarily to oblige patients to take medication and stay in contact with services. There is agreement between clinical and legal judgements about their appropriateness and threshold for use. A pattern of continuous coercion for a significant group of patients raises concerns. If CTOs are to be continued to be imposed, their use should be carefully monitored with further cohort studies with long-term follow-up.
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Kisely SR, Campbell LA, O'Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2017; 3:CD004408. [PMID: 28303578 PMCID: PMC6464695 DOI: 10.1002/14651858.cd004408.pub5] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Steve R Kisely
- The University of QueenslandSchool of MedicinePrincess Alexandra HospitalIpswich RoadWoolloongabbaQueenslandAustraliaQLD 4102
| | - Leslie A Campbell
- Dalhousie UniversityDepartment of Community Health and EpidemiologyRoom 415, 5790 University AvenueHalifaxNSCanadaB3K 1V7
| | - Richard O'Reilly
- Western UniversityMental Health Building, Parkwood InstituteLondon, OntarioCanadaN6C 0A7
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Schneeberger AR, Huber CG, Lang UE, Muenzenmaier KH, Castille D, Jaeger M, Seixas A, Sowislo J, Link BG. Effects of assisted outpatient treatment and health care services on psychotic symptoms. Soc Sci Med 2017; 175:152-160. [PMID: 28092756 DOI: 10.1016/j.socscimed.2017.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 12/14/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
RATIONALE An ongoing debate concerns acceptability, benefits, and shortcomings of coercive treatment such as assisted outpatient treatment (AOT). The hypothesis that involuntary commitment to outpatient treatment may lead to a better clinical outcome for a subgroup of persons with severe mental illness (SMI) is controversial. Nonetheless, positive effects of AOT may be mediated by an increased availability of healthcare resources or increased service use. OBJECTIVE The purpose of the present study is to evaluate the course of delusions, hallucinations, and negative symptoms among patients with SMI receiving AOT compared to patients receiving non-compulsory treatment (NCT). Moreover, we assessed if the effects of AOT on psychotic symptoms were mediated by increased healthcare service use. METHODS This study used a quasi-experimental design to examine the effect of AOT and the use of healthcare services on psychotic symptoms. In total, 76 (41.3%) participants with SMI received AOT, and 108 (58.7%) received NCT. The participants were interviewed at baseline every 3 months up to 1 year. Propensity score matching was used to control for group differences. RESULTS In the basic model, AOT was associated with lower severity of psychotic symptoms over all follow-up points. In the model including healthcare service use, the frequency of case manager visits predicted a reduction in severity of all psychotic symptoms. The frequency of visits to the outpatient clinics, frequency of emergency room, and psychiatrist visits were independently associated with lower levels of delusional symptoms. Psychiatrist visits were related to a decrease in negative symptoms. CONCLUSION Results indicate that the treatment benefits of AOT are enhanced with the increased use of mental healthcare services, suggesting that the positive effect of AOT on psychotic symptoms is related to the availability of mental healthcare service use. Coercive outpatient treatment might be more effective through greater use of intensive services.
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Affiliation(s)
- Andres R Schneeberger
- Psychiatrische Dienste Graubuenden, Plazza Paracelsus 2, 7500 St. Moritz, Switzerland; Universitaere Psychiatrische Kliniken, Universitaet Basel, Wilhelm Klein-Strasse 27, 4012 Basel, Switzerland; Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences, 1300 Morris Park Avenue, Belfer Building, Room 402, 10461 Bronx, NY, USA.
| | - Christian G Huber
- Universitaere Psychiatrische Kliniken, Universitaet Basel, Wilhelm Klein-Strasse 27, 4012 Basel, Switzerland
| | - Undine E Lang
- Universitaere Psychiatrische Kliniken, Universitaet Basel, Wilhelm Klein-Strasse 27, 4012 Basel, Switzerland
| | - Kristina H Muenzenmaier
- Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences, 1300 Morris Park Avenue, Belfer Building, Room 402, 10461 Bronx, NY, USA
| | | | - Matthias Jaeger
- Psychiatrische Universitaetsklinik, Zuerich, Lenggstrasse 31, 8032 Zuerich, Switzerland
| | - Azizi Seixas
- Center for Healthful Behavior Change, New York University School of Medicine, 227 East 30th Street, 10016 New York, NY, USA
| | - Julia Sowislo
- Universitaere Psychiatrische Kliniken, Universitaet Basel, Wilhelm Klein-Strasse 27, 4012 Basel, Switzerland
| | - Bruce G Link
- Mailman School of Public Health, Columbia University, 722 W 168th St, 10032 New York, NY, USA
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Recall of patients on community treatment orders over three years in the OCTET CTO cohort. BMC Psychiatry 2016; 16:392. [PMID: 27829396 PMCID: PMC5103421 DOI: 10.1186/s12888-016-1102-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Randomised studies consistently show that Community Treatment Orders (CTOs) do not have the intended effect of preventing relapse and readmissions of patients with severe and enduring mental illness. Critics suggest this in part can be explained by RCTs studying newly introduced CTO regimes and that patients therefore were not brought back to hospital for short-term observations ('recall') as frequently as intended. Our purpose was (i) to test the hypothesis that CTO practice as regards recall of patients to hospital in England and Wales was as rigorous under the OCTET trial period as in current routine use and (ii) to investigate the reasons for and outcomes of recalls and whether this changed over time. METHOD Thirty six-month observational prospective study of 198 patients in the OCTET Follow-up Study. RESULTS Forty percent of patients were recalled, 19 % more than once. This is in line with current national use. Deterioration in clinical condition was the most common reason for recalls (49 %), and 68 % of recalls resulted in revocation of the order (i.e., retention in hospital under compulsion). This pattern remained stable over time. CONCLUSION The use of recall cannot explain why RCTs have not confirmed any benefits from CTOs, and their continued use should be reconsidered. TRIAL REGISTRATION The OCTET Trial was retrospectively registered on 12 November 2009 ( ISRCTN73110773 ).
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Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers. BMC Psychiatry 2016; 16:82. [PMID: 27030136 PMCID: PMC4815077 DOI: 10.1186/s12888-016-0791-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Treatment Orders (CTOs) are often complex because of the ethical tensions created by an intervention that aims at promoting the patient's good through an inherently coercive process. There is limited research that examines the complexity of CTOs and how patients on CTOs and workers administering CTOs make sense of their experiences. METHODS The study involved in-depth interviews with 8 patients on CTOs and 10 community mental health workers in South Australia, to explore how they constructed their experiences of CTOs. Critical discourse analysis (CDA) was used to analyse the data, supported by NVIVO software. RESULTS Analysis of the interviews revealed that patients and workers experienced the CTO process as multi-dimensional, including some positive as well as more negative constructions. The positive metaphor of CTOs as a safety net is described, followed by a more detailed description of the metaphors of power and control as the dominant themes, with five sub-themes of the CTO as control, wake-up, punishment, surveillance, and tranquiliser. DISCUSSION Metaphors are a way that mental health patients and mental health workers articulate the nature of CTOs. The language used to construct these metaphors was quite different, with patients overwhelmingly experiencing and perceiving CTOs as coercive (that is, punishing, controlling and scrutinizing), whereas workers tended to perceive them as necessary, beneficial and supportive, despite their coerciveness. CONCLUSIONS By acknowledging the role of metaphors in these patients' lives, workers could enhance opportunities to engage these patients in more meaningful dialogue about their personal experiences as an alternative to practice predominantly focused on risk. Such a dialogue could enhance workers' reflection on their work and promote recovery-based practice. More understanding of how to promote autonomy, capacity and supported decision-making, and how to address the impacts of coercion within care, is needed.
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Affiliation(s)
- Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Room 4 T306 Margaret Tobin Centre, PO Box 2100, Adelaide, South Australia, 5001, Australia.
| | - Toni Delany
- Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, South Australia, Australia
| | | | - Ann Smith
- C/o Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia
| | - John McMillan
- The Bioethics Centre, University of Otago, Dunedin, New Zealand
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Rugkåsa J. Effectiveness of Community Treatment Orders: The International Evidence. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:15-24. [PMID: 27582449 PMCID: PMC4756604 DOI: 10.1177/0706743715620415] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Social Psychiatry Group, Lørenskog, Norway Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders. BMC Psychiatry 2015; 15:274. [PMID: 26541546 PMCID: PMC4635603 DOI: 10.1186/s12888-015-0653-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 10/19/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Mental health recovery involves acknowledging the importance of building the person's capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness. METHODS This study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013-14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data. RESULTS Moral framing was apparent in participants' constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients' positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients' shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy. CONCLUSIONS Experiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.
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Affiliation(s)
- Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Flinders Drive, Adelaide, 5042, Australia.
| | - Toni Delany
- Southgate Institute for Health, Society and Equity, Flinders University, Flinders Drive, Adelaide, 5042 Australia
| | - Mariastella Pulvirenti
- Discipline of Public Health, Flinders University, Flinders Drive, Adelaide, 5042 Australia
| | | | - John McMillan
- The Bioethics Centre, University of Otago, Frederick Street, Dunedin, 9016 New Zealand
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Kisely S, O'Reilly R. Reappraising community treatment orders - can there be consensus? Med J Aust 2015; 202:415-6. [PMID: 25929496 DOI: 10.5694/mja14.00663] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/21/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Steve Kisely
- University of Queensland, Brisbane, QLD, Australia.
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Vine R, Komiti A. Carer experience of Community Treatment Orders: implications for rights based/recovery-oriented mental health legislation. Australas Psychiatry 2015; 23:154-7. [PMID: 25653304 DOI: 10.1177/1039856214568216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Our aim was to determine the views and experiences of carers of people with severe mental illness in regard to Community Treatment Orders (CTOs). METHOD Questionnaires were posted using the mailing lists of two well-established carer support organisations in Victoria. The questionnaires included information about the person with a mental illness, the carer and their experience of care (ECI) and knowledge of recovery (RKI). RESULTS In total, 278 questionnaires were sent and 63 returned, of which 62 provided valid data. Those who responded were predominantly female (90%) and older (mean age 63 years), and were the carer of a person with a severe and recurrent mental illness. Some 60% had experience of caring for a person on a CTO. Most felt the CTO had been of benefit, and in 89% the person relapsed and needed further treatment when the CTO was stopped. CONCLUSION Mental health legislation is shifting to bring a greater focus on rights, individual choice and autonomy in line with recovery-oriented care. This study describes the impact of severe mental illness and decisions in relation to CTOs on carers.
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Affiliation(s)
- Ruth Vine
- Executive Director NorthWestern Mental Health, Melbourne Health, Parkville, VIC, Australia
| | - Angela Komiti
- Department of Psychiatry, the University of Melbourne, Parkville, VIC, Australia
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Rugkåsa J, Dawson J, Burns T. CTOs: what is the state of the evidence? Soc Psychiatry Psychiatr Epidemiol 2014; 49:1861-71. [PMID: 24562319 DOI: 10.1007/s00127-014-0839-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/03/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Community Treatment Orders (CTOs) require outpatients to adhere to treatment and permit rapid hospitalisation when necessary. They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence. In this article, we appraise the current literature on CTOs from the viewpoint of Evidence-Based Medicine and discuss the way forward for using and researching CTOs. RESULTS Non-randomised outcome studies show conflicting results, but their lack of standardisation of methods and measures makes it difficult to draw conclusions. In contrast, all three randomised controlled trials (RCTs) conducted concur in their findings that CTOs do not impact on hospital outcomes. No systematic review or meta-analysis has identified any clear clinical advantage to CTOs. CONCLUSION The evidence-base does not support the use of CTOs in their current form. Involuntary clinical interventions must conform to the highest standard of evidence-based care. To enable clinicians to take an evidence-based approach and to settle remaining uncertainties about the current evidence, high-quality RCTs should be designed and undertaken, using standardised outcome measures.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, 1478, Lørenskog, Norway,
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Kisely S, Hall K. An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment orders. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:561-4. [PMID: 25565690 PMCID: PMC4197791 DOI: 10.1177/070674371405901010] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 03/01/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES It is unclear whether community treatment orders (CTOs) for people with severe mental illnesses can reduce health service use, or improve clinical and social outcomes. Randomized controlled trials of CTOs are rare because of ethical and logistical concerns. This meta-analysis updates available evidence. METHOD A systematic literature search was performed of the Cochrane Schizophrenia Group Register, Science Citation Index, PubMed, MEDLINE, and Embase to November 2013. Inclusion criteria were studies comparing CTOs with standard care including those where control subjects received voluntary care, for most of the trial. RESULTS Three studies provided 749 subjects for the meta-analysis. Two compared compulsory treatment with entirely voluntary care, while the third had control subjects receiving voluntary treatment for the bulk of the time. Compared with control subjects, CTOs did not reduce readmissions (risk ratio 0.98, 95% CI 0.82 to 1.16) or bed days (mean difference [MD] -16.36; 95% CI -40.8 to 8.05) in the subsequent 12 months (n = 749). Moreover, there were no significant differences in psychiatric symptoms (standardized MD -0.03; 95% CI -0.25 to 0.19; n = 331) or the Global Assessment of Functioning (MD -1.36; 95% CI -4.07 to 1.35; n = 335). Only including the 2 studies that compared compulsory treatment with entirely voluntary care made no difference to the results. CONCLUSIONS CTOs may not lead to significant differences in readmission, social functioning, or symptomatology, compared with standard care. Their use should be kept under review.
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Affiliation(s)
- Steve Kisely
- Professor, School of Medicine, The University of Queensland, Brisbane, Australia; Professor, Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia
| | - Katharine Hall
- Researcher, School of Medicine, The University of Queensland, Brisbane, Australia
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Clinical stability in the community associated with long-term approved leave under the Mental Health Act 2001. Ir J Psychol Med 2014; 31:143-148. [PMID: 30189514 DOI: 10.1017/ipm.2014.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Introduction We present the case of a 27-year-old man with a background diagnosis of treatment resistant schizophrenia and absent insight who for the last 3 years has been residing in a high support residential setting on approved leave under the Mental Health Act (MHA) 2001. The case demonstrates how this man achieved clinical stability in the community with the assistance of long-term involuntary admission under the MHA 2001, in contrast to the previous years of his illness in which he had suffered multiple relapses of his psychotic illness with ssociated distress, poor self-care and repeated in-patient re-admissions. We discuss the equivalent use of community treatment orders in other jurisdictions and how the judicious use of approved leave under the MHA 2001 may be used as an alternative in Ireland where community treatment orders are not currently available. METHOD Case Report. CONCLUSION The case report highlights how the use of long-term approved leave under the MHA2001 may be used as alternative in Ireland to mimic CTOs for certain difficult to treat patients with psychotic illness who would benefit from ongoing treatment, but lack capacity to engage in such treatment due to persistent symptoms and lack of insight.
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Rugkåsa J, Dawson J, Burns T. The OCTET RCT - a reply to Dr Mustafa. MEDICINE, SCIENCE, AND THE LAW 2014; 54:118-119. [PMID: 24619992 DOI: 10.1177/0025802413518528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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Kisely SR, Campbell LA. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2014:CD004408. [PMID: 25474592 DOI: 10.1002/14651858.cd004408.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND 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. OBJECTIVES To examine the effectiveness of CCT for people with SMI. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register and Science Citation Index (2003, 2008, and 2012). We obtained all references of identified studies and contacted authors where necessary. We further updated this search on the 8 November 2013. 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 compulsory community treatment such as supervised discharge. DATA COLLECTION AND ANALYSIS Review authors independently selected studies, assessed their quality and extracted data. We used The Cochrane Collaboration's tool for assessing risk of bias. For binary outcomes, we calculated a fixed-effect risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat statistic (NNT). For continuous outcomes, we calculated a fixed-effect mean difference (MD) and its 95% CI. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table for outcomes we rated as important and assessed the risk of bias of included studies. MAIN RESULTS All studies (n=3) involved patients in community settings who were followed up over 12 months (n = 752 participants).Two RCTs from the USA (total n = 416) compared court-ordered 'Outpatient Commitment' (OPC) with voluntary community treatment. OPC did not result in significant differences compared to voluntary treatment in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.21, low grade evidence); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52, low grade evidence); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15, low grade evidence) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89, low grade evidence). However, risk of victimisation decreased with OPC (1 RCT, n = 264, RR 0.50 CI 0.31 to 0.80). Other than perceived coercion, no adverse outcomes were reported. In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5).One further RCT compared community treatment orders (CTOs) with less intensive supervised discharge in England and found no difference between the two for either the main outcome of readmission (1 RCT, n = 333, RR for readmission to hospital by 12 months 0.99 CI 0.74 to 1.32, medium grade evidence), or any of the secondary outcomes including social functioning and mental state. It was not possible to calculate the NNT. The English study met three out of the seven criteria of The Cochrane Collaboration's tool for assessing risk of bias, the others only one, the majority being rated unclear. AUTHORS' CONCLUSIONS CCT results in no significant difference in service use, social functioning or quality of life compared with standard voluntary care. 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 evidence we rated as low to medium quality.
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Affiliation(s)
- Steve R Kisely
- School of Medicine, The University of Queensland, Princess Alexandra Hospital, Ipswich Road Woolloongabba, Queensland, QLD 4102, Australia. .
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Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E, Segal S. An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res 2013; 47:650-6. [PMID: 23415453 DOI: 10.1016/j.jpsychires.2013.01.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/15/2013] [Accepted: 01/15/2013] [Indexed: 10/27/2022]
Abstract
Many studies of compulsory community treatment have assessed their effect early on after the implementation of legislation. Although compulsory community treatment may not prevent readmission to hospital, there is evidence of an effect on length of stay before and after the intervention when compared to controls. This paper examines whether outcomes change as clinicians gain experience in the use of community treatment orders (CTOs). Cases and controls from three linked Western Australian databases were matched on age, sex, diagnosis and time of hospital discharge or community placement. We compared changes in bed-days and outpatient visits of CTO cases and controls using multivariate analyses to further control for confounders. We identified 2958 CTO cases and controls from November 1997 to December 2008 (total n = 5916). The average age was 37 years and 64% were male. Schizophrenia and other non-affective psychoses were the commonest diagnoses (73%). CTO placement was associated with a mean decrease of 5 bed-days from before the order when compared to controls (B = -5.23, s.e. = 1.60, t = -3.26, p < 0.001). There was an increase of 8 days in outpatient contacts (B = 8.31, s.e. = 1.17, t = 7.11, p < 0.001). There was little change in CTO use and outcomes over the 11 years. Compared to controls, CTOs may therefore reduce lengths of stay from before placement on the order. They also increase outpatient contacts. This study illustrates the importance of selecting an outcome that directly addresses the objective of the intervention.
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Affiliation(s)
- Steve Kisely
- School of Population Health, University of Queensland, Herston, Australia.
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Affiliation(s)
| | - Wes Shera
- b Factor-Inwentash Faculty of Social Work, University of Toronto
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Kisely SR, Campbell LA, Preston NJ. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2011:CD004408. [PMID: 21328267 PMCID: PMC4164937 DOI: 10.1002/14651858.cd004408.pub3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation. OBJECTIVES To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness. SEARCH STRATEGY We undertook searches of the Cochrane Schizophrenia Group Register 2003, 2008, and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study. SELECTION CRITERIA All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness. DATA COLLECTION AND ANALYSIS We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H). MAIN RESULTS We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8). In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review. AUTHORS' CONCLUSIONS Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment 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. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.
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Affiliation(s)
- Steve R Kisely
- School of Population Health, The University of Queensland, Brisbane, Australia
| | | | - Neil J Preston
- Mental Health Directorate, Fremantle Hospital and Health Service, Fremantle, Australia
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Lambert TJ, Singh BS, Patel MX. Community treatment orders and antipsychotic long-acting injections. Br J Psychiatry 2010; 52:S57-62. [PMID: 19880919 DOI: 10.1192/bjp.195.52.s57] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The community treatment order (CTO) is the legal framework by which people in the community are compelled to accept treatment. Both antipsychotic long-acting injections (LAIs) and CTOs are used to address treatment non-adherence. AIMS To investigate the relationship between CTOs and LAI use in patients with schizophrenia. METHOD Prescribing, demographic and CTO data were collected for patients from four community mental health clinics in Melbourne, Australia, in 1998 and 2002. RESULTS Against a background of increasing use of oral second-generation antipsychotic (SGA) medication and decreasing use of LAIs, the rates of CTO implementation doubled from 13% to 26% of patients with schizophrenia between 1998 and 2002. Proportionally more patients with a CTO are prescribed LAIs rather than oral SGAs. CONCLUSIONS The relationship between receiving an LAI and being subject to a CTO is significant, and reflects the consideration given to enhancing adherence in a community mental health setting.
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Affiliation(s)
- Tim J Lambert
- Discipline of Psychological Medicine, Brain and Mind Research Institute, University of Sydney, Camperdown, New South Wales, Australia
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Mfoafo-M'Carthy M, Williams CC. Coercion and Community Treatment Orders (CTOs): One Step Forward, Two Steps Back? ACTA ACUST UNITED AC 2010. [DOI: 10.7870/cjcmh-2010-0006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kahan DM, Braman D, Monahan J, Callahan L, Peters E. Cultural cognition and public policy: the case of outpatient commitment laws. LAW AND HUMAN BEHAVIOR 2010; 34:118-140. [PMID: 19169799 DOI: 10.1007/s10979-008-9174-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 12/22/2008] [Indexed: 05/27/2023]
Abstract
What explains controversy over outpatient commitment laws (OCLs), which authorize courts to order persons with mental illness to accept outpatient treatment? We hypothesized that attitudes toward OCLs reflect "cultural cognition" (DiMaggio, P. Annl Rev Sociol 23:263-287, 1997), which motivates individuals to conform their beliefs about policy-relevant facts to their cultural values. In a study involving a diverse sample of Americans (N = 1,496), we found that individuals who are hierarchical and communitarian tend to support OCLs, while those who are egalitarian and individualistic tend to oppose them. These relationships, moreover, fit the cultural cognition hypothesis: that is, rather than directly influencing OCL support, cultural values, mediated by affect, shaped individuals' perceptions of how effectively OCLs promote public health and safety. We discuss the implications for informed public deliberation over OCLs.
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Affiliation(s)
- Dan M Kahan
- Yale Law School, PO Box 208215, New Haven, CT 06520, USA.
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Dahlin MK, Gumpert CH, Torstensson-Levander M, Svensson L, Radovic S. Mentally disordered criminal offenders: legal and criminological perspectives. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2009; 32:377-382. [PMID: 19793615 DOI: 10.1016/j.ijlp.2009.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Legal research in Sweden has traditionally focused on a systematization of the legal rules and their practical application, while the task of studying the effects of the application of the laws has been handed over to other branches of the social sciences. In contrast, new legal theories focusing on proactive and therapeutic dimensions in law have gained increasing attention in the international arena. These approaches may be better suited for evaluating legislation governing compulsory psychiatric care. Theoretical discussions and studies of causal mechanisms underlying criminal behaviour, as well as the implementation and value of instruments for predicting behaviour, are relevant to contemporary criminological research. Criminal behaviour varies across different groups of perpetrators, and the causes can be sought in the interplay between the individual and social factors. Multi-disciplinary efforts, integrating research from forensic psychiatry, psychology, sociology, and criminology, would be beneficial in leading to a better understanding of the causes underlying criminal behaviour.
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Swanson J, Swartz M, Van Dorn RA, Monahan J, McGuire TG, Steadman HJ, Robbins PC. Racial Disparities In Involuntary Outpatient Commitment: Are They Real? Health Aff (Millwood) 2009; 28:816-26. [DOI: 10.1377/hlthaff.28.3.816] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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O'Brien AJ, McKenna BG, Kydd RR. Compulsory community mental health treatment: literature review. Int J Nurs Stud 2009; 46:1245-55. [PMID: 19296950 DOI: 10.1016/j.ijnurstu.2009.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 01/15/2009] [Accepted: 02/09/2009] [Indexed: 10/21/2022]
Abstract
Following their introduction in the United States in the 1970s various forms of compulsory treatment in the community have been introduced internationally. Compulsory treatment in the community involves a statutory framework that mandates enforceable treatment in a community setting. Such frameworks can be categorized as preventative, least restrictive, or as having both preventative and least restrictive features. Research falls into two categories; descriptive, naturalistic studies and controlled and uncontrolled comparative studies. The research has produced equivocal results, and presents numerous methodological challenges. Where programmes have demonstrated improved outcomes debate continues as to whether these outcomes are associated with legal compulsion or enhanced service provision. Service user, family and clinician perspectives demonstrate a divergence of views within and across groups, with clinicians more strongly in support than service users. The issue of compulsory community treatment is an important one for nurses, who are often at the forefront of clinical service provision, in some cases in statutory roles. Critical reflection on the issue of compulsory community treatment requires understanding of the limitations of empirical investigations and of the various ethical and social policy issues involved. There is a need for further research into compulsory community treatment and possible alternatives.
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Affiliation(s)
- Anthony J O'Brien
- School of Nursing, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Abstract
PURPOSE OF REVIEW This paper highlights issues in the field of coercion in psychiatry which have gained importance in 2007. RECENT FINDINGS Reviews on 'involuntary hospital admission' demonstrated negative and positive consequences on various outcome domains. Papers on 'coercion and the law' identified cross-national differences of legal regulations, or addressed justice and equality issues. Studies on the 'patient's perspective', and 'family burden of coercion' showed that involuntariness is associated with feeling excluded from participation in the treatment. A review on 'outpatient commitment' recommended the evaluation of a range of outcomes if this specific legislation is introduced. 'Coercion in special (healthcare) settings and patient subgroups' needs to be assessed in detail. This refers to somatic hospitals, establishments for mentally retarded patients, prisons, forensic settings, and coercion mechanisms for addiction treatment, eating disorders, and minors. Empirical findings in other areas focused on attitudes towards involuntary treatment; decision variables for involuntary commitment; guidelines on the use of coercive measures; and intervention programs for staff victims of patient assaults. SUMMARY Coercion in psychiatry is an important area for future clinical and research initiatives. Because of the linkages with legal, human rights and ethical issues, a huge number of individual questions needs to be addressed.
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Kisely S, Campbell LA. Does compulsory or supervised community treatment reduce 'revolving door' care? Legislation is inconsistent with recent evidence. Br J Psychiatry 2007; 191:373-4. [PMID: 17978314 DOI: 10.1192/bjp.bp.107.035956] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Supervised community treatment to address 'revolving door' care is part of the new Mental Health Act in England and Wales. Two recent epidemiological studies in Australia (n>118 000), as well as a systematic review of all previous literature using appropriately matched or randomised controls (n=1108), suggest that it is unlikely to help.
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Affiliation(s)
- Stephen Kisely
- Centre for Clinical Research, Dalhousie University, 5790 University Avenue, Halifax, Nova Scotia, Canada.
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