Assisted outpatient treatment in New York: regional differences in New York's assisted outpatient treatment program

How clinicians make decisions about CTOs in ACT: a qualitative study

BACKGROUND

The first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams' first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting.

METHODS

Semi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.

RESULTS

The participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians' legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.

CONCLUSIONS

According to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients' need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.

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

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

Outpatient commitment and procedural due process

A large empirical literature on Kendra's Law has assessed the impact of court ordered outpatient treatment on outcomes such as treatment adherence, psychiatric hospitalization, quality of life, and treatment costs. Missing from the empirical literature, however, is a better understanding of procedural due process under Kendra's Law. Procedural due process concerns the safeguards that must be in place when governments deprive persons of their liberties, for example--notice, the right to a hearing and the right to appeal. This article reports the findings from a qualitative study of procedural due process and assisted outpatient treatment hearings under Kendra's Law. Attorneys reported significant barriers to effective advocacy on behalf of their clients. Further, despite the shift from a medical model of civil commitment to a judicial model in the 1970s, by and large judges continue to accord great deference to clinical testimony.

A systematic review of the effect of community treatment orders on service use

PURPOSE

The evidence regarding community treatment order effectiveness has been conflicting. This systematic review aims to bring up to date the review performed by Churchill and colleagues in 2005 by assessing and interpreting evidence of CTO effectiveness defined by admission rates, number of inpatient days, community service use, and medication adherence published since 2006.

METHOD

Databases were searched to obtain relevant studies published from January 2006 to March 2013.

RESULTS

18 studies including one randomised controlled trial were included. There remains lack of evidence from randomised and non-randomised studies that CTOs are associated with or affected by admission rates, number of inpatient days or community service use. The most recent and largest RCT is included in this review and found no significant impact on admission rate (RR = 1.0, 95% CI 0.75-1.33) or number of days in hospital (IR = 0.90, 95% CI 0.65-1.26). Results from the two largest longitudinal datasets included in this review do not concur. Studies using the New York dataset found that CTOs were associated with reduced admission rates and inpatient days, while studies using the Victoria dataset generally found that they were associated with increased admission rates and inpatient days.

CONCLUSION

There is now robust evidence in the literature that CTOs have no significant effects on hospitalisation and other service use outcomes. Non-randomised studies continue to report conflicting results. Distinguishing between CTO recall and revocation and different patterns of community contact is needed in future research to ensure differentiation between CTO process and outcome.

Changes in guideline-recommended medication possession after implementing Kendra's law in New York

OBJECTIVE

This study examined changes in possession of guideline-recommended medication among three groups of New York State Medicaid enrollees with severe mental illness: those who received an involuntary outpatient commitment order, voluntary enhanced services, or neither of these interventions.

METHODS

An observational study was conducted with New York State Medicaid claims data for enrollees with bipolar, schizophrenia, or schizoaffective disorders in New York City, Long Island, and the Hudson River regions from 2000 to 2005 (N=7,762). With adjustment for clinical and demographic characteristics, logistic regression models predicted the probability of a monthly medication possession ratio (MPR) ≥ 80% for medications recommended by expert guidelines or by the U.S. Food and Drug Administration for the indicated psychiatric diagnosis. Separate models were fit by region and for patients who ever received assisted outpatient treatment (AOT), voluntary enhanced services but never AOT, or neither treatment.

RESULTS

In all three regions, for all three groups, the predicted probability of an MPR ≥ 80% improved over time (AOT improved by 31-40 percentage points, followed by enhanced services, which improved by 15-22 points, and "neither treatment," improving 8-19 points). Some regional differences in MPR trajectories were observed.

CONCLUSIONS

After New York implemented AOT and increased community resources for enhanced services, guideline-recommended medication possession improved among Medicaid enrollees with severe mental illness--even among those who never received these interventions or services. However, further study is needed to understand why there were different regional trajectories and why some groups did not gain similarly across regions.