Assessing outcomes for consumers in New York's assisted outpatient treatment program

Impact of statutory revisions to family-petitioned civil commitment in South Korea

INTRODUCTION

This study examined the impact of statutory revisions in 2016 which aimed to enhance procedural justice within the process of civil commitment for persons diagnosed with mental illnesses (PDMI) in South Korea. These changes included requiring that PDMI pose a threat of danger to self or others and the need for treatment simultaneously as criteria for petitioning civil commitment. Additionally, the revision established a public entity to oversee the legitimacy of petitions to involuntarily commit PDMI to inpatient treatment. Despite these statutory changes, families providing care for PDMI still appear to depend on civil commitment as a way to seek respite from care burden, not necessarily to respond to psychiatric emergencies involving dangerousness. This practice seems to be aided by processes within the public entity providing oversight. Due to such barriers we hypothesized that, even after the statutory revision in 2016, PDMI who had been civilly committed following petitions from families will not exhibit elevated dangerousness compared to PDMI who had never been hospitalized during the same period.

METHODS

Trained interviewers recruited 331 participants self-identified as PDMI from psychiatric rehabilitation agencies in the community and aided them in completing a survey including measures of self-reported hospitalization history, suicidality, and aggression toward others. Participants were classified into four groups: Family-petition committed (FPC) group (n = 30, 9.1%), voluntarily hospitalized (VH) group (n = 34, 10.3%), public-petition committed (PPC) group (n = 31, 9.4%), and never hospitalized (NH) group (n = 236, 71.3%). We conducted logistic regression analyses to compare self-reported dangerousness between groups with the NH group as the reference group.

RESULTS

In the past 12 months, 43.5% of PDMI participants had self-reported behaviors that may have met the dangerousness criteria for civil commitment. Controlling for confounding factors, the PPC group was 2.96 times and 3.02 times as likely to report suicidal ideation and physical aggression, respectively, compared to the NH group. However, as hypothesized, the FPC group did not differ from the NH group on any indicator of self-reported dangerousness.

CONCLUSION

The findings were based on cross-sectional correlational data and should not be viewed as conclusive evidence that the 2016 statutory revision is ineffective in preventing family-petitioned civil commitment in cases where dangerousness is not apparent. Nevertheless, these findings encourage further empirical studies that illuminate the etiology of procedural justice in civil commitments petitioned by family members and that assess factors and contexts that promote the consideration of least coercive treatments, rather than resorting to involuntary hospitalization when psychiatric emergencies arise.

[Failure to draw up medical certificates increase judiciary releases]

OBJECTIVES

In France, a systematic control of compulsory psychiatric admissions has existed since the enactment of the law of July 5th 2011. The Court of Cassation clarified that the liberty and custody judges (JLD) cannot supersede the medical opinion described in the medical certificates. In 2015, the JLD ordered the release of 8.4 % of all compulsory psychiatric admissions. The goal was to compare the quality of medical certificates derived from judicial release based on medical grounds with non-released witnesses from the cohort of compulsory psychiatric admissions ordered in the Groupe Hospitalier Universitaire Paris Psychiatrie & Neurosciences (GHU-Paris) between November 1, 2017 and October 31, 2018.

METHODS

We included as cases all the medical certificates derived from judicial release based exclusively on medical grounds from the release cohort of the GHU-Paris from November 1, 2017 to October 31, 2018, concerning the systematic control 12 days after compulsory psychiatric admissions. A witness whose compulsory care had been maintained was matched according to the same judge, place and date of hearing, mode of compulsory care and site of hospitalization. Each certificate was analyzed according to a reading grid relating to the good decisions in matters of compulsory admission and medical certificates' redaction. An overall score, based on the description of the clinical and symptomatic evolution, the level of discernment, the capacity of consent and the mode of compulsory care was awarded to each certificate.

RESULTS

Seventeen release files were included in the comparative study. Globally, the clinical progression, psychiatric symptoms, level of consciousness and ability to consent did not differ in the two groups. The grade of quality of certificate was lower in case of withdrawal (2.92±1.08 VS 3.28±0.88, P=0.026). Psychiatric symptoms in "justifiable notice" (the last medical certificate prior to the judicial hearing) were less specified in case of withdrawal (58.8 % VS 94.1 %, P=0.015). Not describing any symptoms led to a 12.51 risk of withdrawal (95 % CI=[1.16; 135.19], P=0.038). Even with witness certificate, clinical progression was noticed in only 85.3 % of cases, in 89.3 % of psychiatric symptoms, in 68.0 % of level of consciousness and 80.0 % for the ability to consent.

CONCLUSIONS

Judiciary releases of compulsory psychiatric admissions exclusively based on medical grounds are not arbitrarily decided by the JLD but are based on a failure to draw up medical certificates. Doctors must comply with a careful drafting of all medical certificates: description of symptoms, clinical course, level of consciousness and ability to consent. It is necessary to be attentive to judiciary releases based on medical grounds to evaluate and improve medical practices concerning the drafting of medical certificates.

Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type

Although it is widely accepted that patients do better when evidence-based health care practices are used, there is less acknowledgment of the positive outcomes associated with evidence-based policy making. To address the need for high-quality evidence to inform mental health policies, Psychiatric Services has recently launched a new article format: the Policy Review. This review type defines a specific policy-relevant issue affecting behavioral health systems, describes current knowledge and limitations, and discusses policy implications. Reviews can focus on mental health policies or examine how other health or social policies affect people with mental illness or substance use disorders. This brief overview of the need for a policy review article type describes differences between evidence-based policy making and practices and looks at research approaches focused on evidence-based policy making, as well as legislative and other efforts to support it. Broad guidelines for potential submissions are also provided.

Client Outreach in Los Angeles County's Assisted Outpatient Treatment Program: Strategies and Barriers to Engagement

Purpose

Assisted Outpatient Treatment (AOT) programs can compel treatment-refusing individuals to participate in mental health treatment via civil court order. In California's AOT programs, individuals first must be offered 30 days of outreach services and can accept services voluntarily. This study examines the use of outreach strategies in an AOT program with the potential for voluntary or involuntary enrollment.

Methods

Outreach staff completed a survey in which they reported and rated outreach strategies and barriers to treatment for 487 AOT-referred individuals.

Results

Outreach staff reported using a broad array of strategies to persuade and engage clients. Supportive and persuasive strategies were most common. More coercive strategies, including court order, were used when needed. More clients enrolled voluntarily (39.4%) than involuntarily (7.2%).

Conclusions

Outreach, coupled with the strategic used of potential court involvement, can lead to voluntary enrollment of treatment-refusing individuals with many, often severe, barriers to engaging in outpatient treatment.

Impact of diagnosis on outcomes for compulsory treatment orders in New Zealand

BACKGROUND

Compulsory community treatment orders (CTOs) are controversial because they enforce psychiatric treatment of patients in the community. It is important to know which patients benefit from compulsory treatment to better inform CTO use.

AIMS

To examine the effect of a range of diagnoses on outcomes associated with CTOs to determine whether there are specific outcome signatures for CTOs according to diagnosis.

METHOD

New Zealand's Ministry of Health databases provided demographic, service use and medication-dispensing data for all individuals placed on a CTO between 2009 and 2018. We used a hierarchical approach to categorise individuals according to diagnosis. Admission rates, admission days per year, community care and medication dispensing were analysed according to diagnosis and CTO status.

RESULTS

In total, 14 726 patients were placed on a CTO over the 10-year period between 1 January 2009 and 31 December 2018. For psychotic disorders, CTOs were associated with reduced admission frequency and duration. However, the opposite occurred for dementia disorders, bipolar disorders, major depressive disorder and personality disorders. Higher rates of medications, including depot antipsychotic medications, were dispensed on CTOs for all diagnostic groups.

CONCLUSIONS

CTOs were associated with reduced admission frequency and admission days per year for patients with psychotic disorders, whereas the opposite occurred for other diagnostic groups. Rather than seeking to establish whether CTOs are effective, we suggest that there are specific outcome signatures associated with CTOs for different disorders and knowledge of these can improve understanding and clinical practice in this area.

Protecting Health and Safety with Needed-Treatment: the Effectiveness of Outpatient Commitment

Outpatient civil commitment (OCC) requires the provision of needed-treatment, as a less restrictive alternative (LRA) to psychiatric-hospitalization in order to protect against imminent-threats to health and safety associated with severe mental illness (SMI). OCC-reviews aggregating all studies report inconsistent outcomes and interpret such as intervention failure. This review, considering those studies whose outcome criteria are consistent with the provisions of OCC-law, seeks to determine OCC-effectiveness in meeting its legislated objectives. This review incorporated studies from previous systematic-reviews, used their search methodology, and added investigations through August 2020. Selected OCC-studies evaluated samples of all eligible patients in a jurisdiction. Their outcome-measures were threats to health or safety or the receipt of needed-treatment exclusive of post-OCC-assignment- hospitalization, the latter being the OCC-default for providing needed-treatment in the absence of an LRA and dependent on bed-availability. A study's evidence-quality was evaluated with the Berkeley Evidence Ranking and the New Castle Ottawa systems. Thirty-nine OCC-outcome-studies in six-outcome-areas directly addressed OCC-statute objectives: 21 considered imminent threats to health and safety, 10 compliance with providing needed-treatment, and 8 conformity to the LRA-standard. With the top evidence-rank equal to one, the studies M = 2.55. OCC-assignment was associated with reducing mortality-risk, increasing access to acute-medical-care, and reducing risks of violence and victimization. It enabled reaching these objectives as a LRA to hospitalization and facilitated the use of community-services by individuals refusing such assistance when outside of OCC-supervision. OCC's appears to enable recovery by reducing potentially life-altering health and safety risks associated with SMI.

Compulsory Community Treatment Orders in New Zealand and the provision of care: An examination of national databases and predictors of outcome

BACKGROUND

Compulsory Community Treatment Orders (CTOs) are contentious because they impose severe restrictions on individuals in community settings. The existing evidence for CTOs is constrained by ethical and methodological limitations and may not support usual clinical practise. This study examines the effectiveness of CTOs using routine data in the New Zealand context.

METHODS

Ministry of Health, New Zealand databases provided demographic, service use, and medication dispensing data for all individuals placed on a CTO between 2009 and 2018. We examined the effectiveness of CTOs through a comparison of psychiatric endpoints identified as useful in the literature according to CTO status. Further analyses examined the moderating influences of age, sex, ethnicity, and diagnosis on outcome.

FINDINGS

14,726 patients were placed under a CTO over the 10 year period between 1 January 2009 and 31 December 2018. Patients on CTOs experienced a reduced frequency of admissions (rate ratio of 0∙94, 95% CI 0.93-0.95, p<0.01) reduced admission days (rate ratio 0∙97, 95% CI 0.97-0.98 p<0∙01), increased frequency of psychiatric community contacts (rate ratio 3∙03, 95% CI 3.02-3.03 p<0.01), and increased dispensing of psychiatric medication (rate ratio 2.27, 95% CI 2.27-2.28, p<0.01). When sub-group analyses were undertaken, the association between treatment under a CTO and reduced admission frequency was only present for those with Psychotic Disorders.

INTERPRETATION

CTOs in New Zealand are associated with increased community care, and increased dispensing of psychiatric medication. Patients with Psychotic Disorders also experienced reduced frequency and length of admissions whilst under a CTO.

FUNDING

No specific funding was received for this study.

Hospital Utilization Outcomes Following Assignment to Outpatient Commitment

Outpatient civil commitment (OCC) requires people with severe mental illness (SMI) to receive needed-treatment addressing imminent-threats to health and safety. When available, such treatment is required to be provided in the community as a less restrictive alternative (LRA) to psychiatric-hospitalization. Variance in hospital-utilization outcomes following OCC-assignment has been interpreted as OCC-failure. This review seeks to specify factors accounting for this outcome-variation and to determine whether OCC is used effectively. Twenty-five studies, sited in seven meta-analyses and subsequently published investigations, assessing post-OCC-assignment hospital utilization outcomes were reviewed. Studies were grouped by structural pre-determinants of hospital-utilization and OCC-implementation-i.e. deinstitutionalization (bed-availability), availability of a less restrictive alternative to hospitalization, and illness severity. Design quality at study completion was ranked on causal-certainty. In OCC-follow-up-studies, deinstitutionalization associated hospital-bed-cuts, when not taken into account, ensured lower hospital-bed-day utilization. OCC-assignment coupled with aggressive case-management was associated with reduced-hospitalization. With limited community-service, hospitalizations increased as the default option for providing needed-treatment. Follow-up studies showed less hospitalization while on OCC-assignment and more outside of it. Studies using fixed-follow-up periods usually found increased-utilization as patients spent less time under OCC-supervision than outside it. Comparison-group-studies reporting no between-group differences bring more severely ill OCC-patients to equivalent use as less disturbed patients, a success. Mean evidence-rank for causal-certainty 2.96, range 2-4, of 5 with no study ranked 1, the highest rank. Diverse mental health systems yield diverse OCC hospital-utilization outcomes, each fulfilling the law's legal mandate to provide needed-treatment protecting health and safety.

Role of Mandated Community Treatment for Justice-Involved Individuals With Serious Mental Illness

OBJECTIVE

Research has suggested that increased length of mandated community treatment for individuals with a serious mental disorder leads to better outcomes, but few studies have described whether these outcomes are maintained after treatment ends. The goal of this study was to evaluate the impact of court-mandated treatment on outcomes for individuals found not guilty by reason of insanity (NGRI) and released to the community.

METHODS

Ninety-three patients who were found to be NGRI participated in this study. Rearrest rates were compared for three groups: patients released to the community with court-mandated treatment (conditional release), patients who were conditionally released but later "restored to sanity" with no further court supervision, and patients released from the hospital to the community by the court with no court-imposed conditions. Patients were followed for an average of 4.83 years after discharge.

RESULTS

Nearly half (43.8%) of the patients released to the community without court-mandated supervision were arrested for another offense in the study period, compared with 8.2% of patients released under the supervision of the conditional release program. In contrast, those who were restored to sanity and ultimately released unconditionally had higher arrest rates (25%).

CONCLUSIONS

This study suggests that court oversight on an ongoing basis may be necessary to help justice-involved individuals with a serious mental disorder avoid the criminal justice system and remain engaged in community treatment. More research is needed to determine whether these findings can be extrapolated to civil commitment procedures.

Gender-specific participation and outcomes among jail diversion clients with co-occurring substance use and mental health disorders

Men and women with co-occurring substance use disorders and mental illness are at relatively high risk for becoming involved in the criminal justice system. Programs, such as post-booking jail diversion, aim to connect these individuals to community-based treatment services in lieu of pursuing criminal prosecution. Gender appears to have an important influence on risk factors and pathways through the criminal justice system, which in turn may influence how interventions like jail diversion work to engage men and women in treatment services and reduce recidivism. Different circumstances, levels of engagement, and outcomes by gender may be related to both person-level characteristics and external factors such as availability of gender-specific services and resources. This mixed-methods study identified specific ways in which men and women use services and reoffend after being diverted, and complemented those findings with in-depth insights from program clinicians about how program experiences and resources differ in important ways by gender. We matched and merged administrative records from 2007 to 2009 for 16,233 adults from several state agencies in Connecticut, and included data on demographic characteristics, clinical diagnoses, outpatient and inpatient behavioral health treatment utilization, arrest, and incarceration. Using propensity analysis, the 1693 men and women who participated in the statewide jail diversion program were matched to respective comparison groups of nondiverted men and women. We used longitudinal multivariable regression analyses to estimate the effects of jail diversion participation on treatment utilization, arrest, and incarceration, separately for men and women. We conducted three focus groups with jail diversion clinicians from around the state (n = 21) to gain in-depth insight from them about how circumstances, program experiences, and resources differ by gender in important ways; these subjective clinician insights complement the quantitative analyses of diversion outcomes for men and women. For both men and women, diversion was associated with reductions in risk for incarceration and increases in utilization of outpatient treatment services. For men only, diversion was associated with higher utilization of inpatient mental health care. No differences in treatment or criminal justice outcomes were observed in models that compared men and women directly. Major themes from the focus groups included: the existence of too few inpatient and residential resources for women with co-occurring disorders; different challenges to treatment engagement that men and women face; and a need for more effective, gender-specific services for all program participants. Results from this mixed-methods study offer information on gender-specific program outcomes and surrounding circumstances that can help programs to better understand and address unique risks and needs for men and women with co-occurring substance use and mental health disorders who are involved in the criminal justice system.

The utility of outpatient civil commitment: Investigating the evidence

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.

Risk factors for rehospitalization for patients following release from court-ordered evaluation: A retrospective study

We have noticed an increase in the number of patients who go through the court-ordered evaluation (COE) process but are not placed on a court-ordered treatment, and who then return to the hospital on another COE petition within one year from their initial discharge. The aim of this study is to examine what factors might be involved in rehospitalization in this population of psychiatric patients. The records of 146 readmitted patients and 146 randomized patients not readmitted were compared for various risk factors. Data were analyzed using univariate and mutivariate procedures. All patients who had diagnoses of substance-induced mood or psychotic disorders were readmitted within one year. Other risk factors included younger age, seriously mentally ill (SMI) status, longer length of stay and having a psychotic or schizophrenia spectrum disorder. Substance-induced mood or psychotic disorder may play significant roles for patients who are rehospitalized within a year of initial COE.

Pharmacological treatment of violence in schizophrenia

Chronic aggression and violence in schizophrenia are rare, but receive disproportionate negative media coverage. This contributes to the stigma of mental illness and reduces accessibility to mental health services. Substance Use Disorders (SUD), antisocial behavior, non-adherence and recidivism are known risk factors for violence. Treatment with antipsychotic medication can reduce violence. Aside from clozapine, long-acting injectable antipsychotics (LAI) appear to be superior to oral antipsychotics for preventing violence, addressing adherence and recidivism. LAI also facilitate the implementation of functional skills training. For the high-risk recidivist target population with schizophrenia, better life skills have the potential to also reduce the risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others. High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in comorbid risk factors such as SUDs.

Deinstitutionalization and other factors in the criminalization of persons with serious mental illness and how it is being addressed

One of the major concerns in present-day psychiatry is the criminalization of persons with serious mental illness (SMI). This trend began in the late 1960s when deinstitutionalization was implemented throughout the United States. The intent was to release patients in state hospitals and place them into the community where they and other persons with SMI would be treated. Although community treatment was effective for many, there was a large minority who did not adapt successfully and who presented challenges in treatment. Consequently, some of these individuals' mental condition and behavior brought them to the attention of law enforcement personnel, whereupon they would be subsequently arrested and incarcerated. The failure of the mental health system to provide a sufficient range of treatment interventions, including an adequate number of psychiatric inpatient beds, has contributed greatly to persons with SMI entering the criminal justice system. A discussion of the many issues and factors related to the criminalization of persons with SMI as well as how the mental health and criminal justice systems are developing strategies and programs to address them is presented.

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

Background

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

Objectives

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

Design

Secondary analysis using multilevel statistical modelling.

Setting

England, including 61 NHS mental health provider trusts.

Participants

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

Main outcome measures

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

Data sources

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

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

Funding

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

Innovation and Its Discontents: Pathways and Barriers in the Diffusion of Assertive Community Treatment

Policy Points Widespread diffusion of policy innovation is the exception rather than the rule, depending as it does on the convergence of a variety of intellectual, political, economic, and organizational forces. The history of Assertive Community Treatment (ACT) provides a compelling case study of this process while also showing how conditions may shift over time, altering the scenarios for continued program expansion. Diffusion of a program like ACT challenges government to play a nuanced role in which public endorsement and resources are used to strengthen a worthwhile service, but without suppressing flexibility and ongoing experimentation as core program values. Acceptance as a proven form of "evidence-based practice" is a critical element in the validation of ACT and other community mental health interventions that combine clinical and social features in novel ways. However, the use of conventional evidence-based research as a singular gold standard of program value narrows the range of stakeholder input, as well as the evaluation methodologies and forms of data deemed worthy of attention.

CONTEXT

Originating at the county level in Wisconsin in the early 1970s, Assertive Community Treatment is one of the most influential mental health programs ever developed. The subject of hundreds of research studies and recipient of enthusiastic backing from private advocacy organizations and government agencies, the program has spread widely across the United States and internationally as a package of resources and management techniques for supporting individuals with severe and chronic mental illness in the community. Today, however, ACT is associated with a rising tide of criticism challenging the program's practices and philosophy while alternative service models are advancing.

METHODS

To trace the history of the Assertive Community Treatment movement, a diffusion-of-innovation framework was applied based on relevant concepts from public policy analysis, organizational behavior, implementation science, and other fields. In-depth review of the literature on ACT design, management, and performance also provided insight into the program's creation and subsequent evolution across different settings.

FINDINGS

A number of factors have functioned to fuel and to constrain ACT diffusion. The former category includes policy learning through research; the role of policy entrepreneurs; ACT's acceptance as a normative standard; and a thriving international epistemic community. The latter category includes cost concerns, fidelity demands, shifting norms, research contradictions and gaps, and a multifactorial context affecting program adoption. Currently, the program stands at a crossroads, strained by the principle of adherence to a long-standing operational framework, on the one hand, and calls to adjust to an environment of changing demands and opportunities, on the other.

CONCLUSIONS

For nearly 50 years, Assertive Community Treatment has been a mainstay of community mental health programming in the United States and other parts of the world. This presence will continue, but not in any static sense. A growing number of hybrid and competing versions of the program are likely to develop to serve specialized clientele groups and to respond to consumer demands and the recovery paradigm in behavioral health care.

Community Treatment Orders and Other Forms of Mandatory Outpatient Treatment

This position paper has been substantially revised by the Canadian Psychiatric Association's Professional Standards and Practice Committee and approved for republication by the CPA's Board of Directors on July 26, 2018. The original position paper¹ was first approved by the Board of Directors on January 25, 2003. It was subsequently reviewed and approved for republication with minor revisions on June 2, 2009.

Does legislative change affect the use and duration of compulsory treatment orders?

OBJECTIVE

Victoria, Australia, introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimisation of the use and duration of compulsory orders. This paper compares service utilisation and legal status after being on a community treatment order under the Mental Health Act 1986 (Vic) with that under the Mental Health Act 2014 (Vic).

METHODS

We obtained two distinct data sets of persons who had been on a community treatment order for at least 3 months and their subsequent treatment episodes over 2 years under the Mental Health Act and/or as an inpatient for the periods 2008-2010 (Mental Health Act 1986) and 2014-2016 (Mental Health Act 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over 2 years. We also considered the mode of discharge - whether by the treating psychiatrist, external body or through expiry.

RESULTS

Compared with the Mental Health Act 1986, under the Mental Health Act 2014, index community treatment orders were shorter (mean 227 days compared with 335 days); there was a reduction in the mean number of community treatment orders in the 2 years following the index discharge - 1.1 compared with 1.5 (incidence rate ratio (IRR) = 0.71, 95% confidence interval = [0.63, 0.80]) - and a 51% reduction in days on an order over 2 years. There was a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist under the Mental Health Act 2014 compared to those under the Mental Health Act 1986. The number of orders which were varied to an inpatient order by the authorised psychiatrist was notably greater under the Mental Health Act 2014.

CONCLUSION

The reformed Mental Health Act has been successful in its intent to reduce the use and duration of compulsory orders in the community. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.

Community, Public Policy, and Recovery from Mental Illness: Emerging Research and Initiatives

This commentary examines the roles that communities and public policies play in the definition and processes of recovery for adults with mental illness. Policy, clinical, and consumer definitions of recovery are reviewed, which highlight the importance of communities and policies for recovery. This commentary then presents a framework for the relationships between community-level factors, policies, and downstream mental health outcomes, focusing on macroeconomic, housing, and health care policies; adverse exposures such as crime victimization; and neighborhood characteristics such as social capital. Initiatives that address community contexts to improve mental health outcomes are currently under way. Common characteristics of such initiatives and select examples are discussed. This commentary concludes with a discussion of providers', consumers', and other stakeholders' roles in shaping policy reform and community change to facilitate recovery.

Community treatment orders increase community care and delay readmission while in force: Results from a large population-based study

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.

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

BACKGROUND

Compulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence.

METHODS

For this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232.

FINDINGS

Of 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53-1·08; I²=94·74), use of community services (0·83, 0·46-1·21; I²=87·26), and treatment adherence (2·12, 1·69-2·55; I²=0), and a medium effect on inpatient bed-days (0·66, 0·46-0·85; I²=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19-0·58; I²=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants.

INTERPRETATION

We found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality.

FUNDING

National Institute for Health Research.

Medication-Assisted Treatment for Alcohol-Dependent Adults With Serious Mental Illness and Criminal Justice Involvement: Effects on Treatment Utilization and Outcomes

OBJECTIVE

Adults with serious mental illness and comorbid alcohol dependence are at high risk for both high utilization of crisis-driven health care services and criminal justice involvement. Evidence-based medication-assisted treatment (MAT) for alcohol dependence may reduce both crisis service utilization and criminal recidivism. The authors estimated the effect of MAT on behavioral health treatment utilization and criminal justice outcomes for this population.

METHOD

Relevant administrative data were merged from several public agencies in Connecticut for 5,743 adults ≥18 years old who had schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder comorbid with moderate to severe alcohol dependence and who were incarcerated for at least one night during the study window (2002-2009). Longitudinal multivariable regression models were used to estimate the effect of MAT compared with other outpatient substance abuse treatments on inpatient mental health and substance abuse hospitalizations, emergency department visits, criminal convictions, and incarcerations.

RESULTS

MAT was associated with significant improvements in clinical outcomes in the 12 months following initiation compared with non-MAT comparison treatment, including greater reductions in mental health hospitalization and emergency department visits and greater improvements in psychotropic medication adherence. No benefits of MAT were found for most criminal justice outcomes, except for significant reductions in felony convictions among adults with bipolar disorder.

CONCLUSIONS

MAT is underused for treating alcohol dependence, especially among adults with serious mental illness. These results suggest that MAT can have important benefits for clinical outcomes in this population. More research is needed to improve its use in this patient population as well as to address barriers to its availability.

Correlates of offense recidivism in patients with schizophrenia

INTRODUCTION

Schizophrenia increases the risk of offending. Recidivism rates are significant. Literature doesn't provide recidivism risk factors specific to patients with schizophrenia independently of the offenses' types.

OBJECTIVE

Identifying recidivism risk factors in schizophrenia patients independently of the offenses' types.

METHODS

We conducted a case-control study. All included patients were admitted, at least once, to the forensic psychiatry unit in Razi Hospital between January 1st, 1985 and December 31st, 2014 after a decision of irresponsibility by reason of insanity. All those who reoffended during this period were considered as cases. Univariate and multivariate analyses were performed to identify recidivism risk factors.

RESULTS

We included 25 cases and 38 controls. Eight recidivism risk factors were identified. Living in poor urban neighborhoods (P = 0.023; OR = 4.86), having been unemployed (P = 0.042; OR = 2.18) and not having lived with the family (P = 0.039; OR = 1.36) after discharge were considered as risk factors. The same applied to alcohol (P = 0.026; OR = 4.89) and cannabis use disorders (P = 0.018; OR = 6.01). A hospitalization shorter than 6 months multiplied the risk by 1.79 (P = 0.046). A combination of conventional antipsychotics (P = 0.023; OR = 4.81) and a poor adherence to treatment (P = 0.001; OR = 10.42) were considered as recidivism risk factors too.

CONCLUSIONS

All eight recidivism risk factors are dynamic. This makes recidivism prevention conceivable. Measures involving the patient, the health care system, patients' families, society and the government should be undertaken.

Responsibilities with conflicting priorities: a qualitative study of ACT providers' experiences with community treatment orders

Background

Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.

Methods

The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.

Results

The main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.

Conclusions

Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3097-7) contains supplementary material, which is available to authorized users.

Associations between pharmacotherapy for opioid dependence and clinical and criminal justice outcomes among adults with co-occurring serious mental illness

Adults suffering from a serious mental illness (SMI) and a substance use disorder are at especially high risk for poor clinical outcomes and also arrest and incarceration. Pharmacotherapies for treating opioid dependence could be a particularly important mode of treatment for opioid-dependent adults with SMI to lower their risk for overdose, high-cost hospitalizations, repeated emergency department visits, and incarceration, given relapse rates are very high following detoxification in the absence of one of the three FDA-approved pharmacotherapies. This study estimates the effects of methadone, buprenorphine, and oral naltrexone on clinical and justice-related outcomes in a sample of justice-involved adults with SMI, opioid dependence, and criminal justice involvement. Administrative data were merged from several public agencies in Connecticut for 8736 adults 18years of age or older with schizophrenia spectrum disorder, bipolar disorder, or major depression; co-occurring moderate to severe opioid dependence; and who also had at least one night in jail during 2002-2009. Longitudinal multivariable regression models estimated the effect of opioid-dependence pharmacotherapy as compared to outpatient substance abuse treatment without opioid-dependence pharmacotherapy on inpatient substance abuse or mental health treatment, emergency department visits, criminal convictions, and incarcerations, analyzing instances of each outcome 12months before and after an index treatment episode. Several baseline differences between the study groups (opioid-dependence pharmacotherapy group versus outpatient treatment without opioid-dependence pharmacotherapy) were adjusted for in the regression models. All three opioid-dependence pharmacotherapies were associated with reductions in inpatient substance abuse treatment, and among the oral naltrexone subgroup, also reductions in inpatient mental health treatment, as well as improved adherence to SMI medications. Overall, the opioid-dependence pharmacotherapy group had higher rates of arrest and incarceration in the follow-up period than the comparison group; but those using oral naltrexone had lower rates of arrest (including felonies). The analysis of observational administrative data provides useful population-level estimates but also has important limitations that preclude conclusive causal inferences. Large reductions in crisis-driven service utilization associated with opioid-dependence pharmacotherapy in this study suggest that evidence-based medications for treating opioid dependence can be used successfully in adults with SMI and should be considered more systematically during assessments of treatment needs for this population.

Key international themes in coercion

Coercion remains a dominant theme in mental healthcare and a source of major concern. While the presence of coercion is ubiquitous internationally, it varies significantly in nature and degree in different countries and is influenced by a variety of factors. Recent reports have raised concerns about physical restraint and the increasing use of legislation in high-income countries. At the same time, a recent Human Rights Watch report on pasung (the practice of tying or restricting movement more generally) in Indonesia has served to highlight the plight of many in middle- and lower-income countries who are subject to degrading and dehumanising ‘treatment’.

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.

Are Randomized Control Trials the Best Method to Assess the Effectiveness of Community Treatment Orders?

Many jurisdictions have enacted community treatment order (CTO) legislation that requires a person, who suffers from a severe mental disorder, to follow a treatment plan when living in the community. CTOs have been a source of debate because of controversies on whether evidence of effectiveness should only be considered from randomized controlled trials (RCTs). RCTs are considered the "gold standard" method to evaluate effectiveness of simple therapeutic interventions such as medication, but they are problematic for evaluation of complex interventions because valid attribution of causation in complex interventions is not guaranteed with RCTs. CTOs are complex interventions that require the interaction of many individuals and organizations to achieve their effects and effectiveness research must measure these complexities of delivery and outcomes. This paper examines conceptual, methodological and analytical challenges of CTO research within the context of RCTs and other research designs. It also discusses the current state of knowledge on effectiveness of CTOs. Finally, we suggest a way forward by presenting alternative causal inference approaches and potential models for evaluation complex interventions, such as CTOs. We propose that these approaches should be used alongside other research designs in a nuanced approach that may involve using findings from initial studies to refine the intervention and/or its implementation.

Jail-to-community treatment continuum for adults with co-occurring substance use and mental disorders: study protocol for a pilot randomized controlled trial

BACKGROUND

Adults with co-occurring mental and substance use disorders (CODs) are overrepresented in jails. In-custody barriers to treatment, including a lack of evidence-based treatment options and the often short periods of incarceration, and limited communication between jails and community-based treatment agencies that can hinder immediate enrollment into community care once released have contributed to a cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among this vulnerable and high-risk population. This paper describes a study that will develop research and communication protocols and adapt two evidence-based treatments, dual-diagnosis motivational interviewing (DDMI) and integrated group therapy (IGT), for delivery to adults with CODs across a jail-to-community treatment continuum.

METHODS/DESIGN

Adaptations to DDMI and IGT were guided by the Risk-Need-Responsivity model and the National Institute of Corrections' implementation competencies; the development of the implementation framework and communication protocols were guided by the Evidence-Based Interagency Implementation Model for community corrections and the Inter-organizational Relationship model, respectively. Implementation and evaluation of the protocols and adapted interventions will occur via an open trial and a pilot randomized trial. The clinical intervention consists of two in-jail DDMI sessions and 12 in-community IGT sessions. Twelve adults with CODs and four clinicians will participate in the open trial to evaluate the acceptability and feasibility of, and fidelity to, the interventions and research and communication protocols. The pilot controlled trial will be conducted with 60 inmates who will be randomized to either DDMI-IGT or treatment as usual. A baseline assessment will be conducted in jail, and four community-based assessments will be conducted during a 6-month follow-up period. Implementation, clinical, public health, and treatment preference outcomes will be evaluated.

DISCUSSION

Findings have the potential to improve both jail- and community-based treatment services for adults with CODs as well as inform methods for conducting rigorous pilot implementation and evaluation research in correctional settings and as inmates re-enter the community. Findings will contribute to a growing area of work focused on interrupting the cycle of limited treatment engagement, unaddressed criminogenic risks, and (re)arrest among adults with CODs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02214667 . Registered on 10 August 2014.

Understanding and Treating Offenders with Serious Mental Illness in Public Sector Mental Health

This article begins with the history of the rise and fall of the state hospitals and subsequent criminalization of persons with serious mental illness (SMI). Currently, there is a belief among many that incarceration has not been as successful as hoped in reducing crime and drug use, both for those with and those without SMI. Moreover, overcrowding in correctional facilities has become a serious problem necessitating a solution. Consequently, persons with SMI in the criminal justice system are now being released in large numbers to the community and hopefully treated by public sector mental health. The issues to consider when releasing incarcerated persons with SMI into the community are as follows: diversion and mental health courts; the expectation that the mental health system will assume responsibility; providing asylum and sanctuary; the capabilities, limitations, and realistic treatment goals of community outpatient psychiatric treatment for offenders with SMI; the need for structure; the use of involuntary commitments, including assisted outpatient treatment, conservatorship and guardianship; liaison between treatment and criminal justice personnel; appropriately structured, monitored, and supportive housing; management of violence; and 24-hour structured in-patient care. Copyright © 2017 John Wiley & Sons, Ltd.

Coercion or Caring: The Fundamental Paradox for Adherence Interventions for HIV+ People with Mental Illness

To determine if an escalating HIV treatment adherence intervention would be considered by participants from a caring or coercive perspective, perceived coercion was examined in 238 community-based dually diagnosed individuals (HIV+ and a serious mental illness) randomized to a treatment-as-usual (TAU) control group or preventing AIDS through health for HIV+ persons (PATH+) Intervention that increased intervention intensity when adherence fell below 80 %. Minor differences were observed in perceived coercion between the PATH+ Intervention and Control groups with perceived coercion marginally higher in the PATH+ group. Latent growth curve analyses indicate that perceived coercion was not related to duration of the intervention for either the PATH+ or Control group. The experience of coercion by HIV+ individuals receiving community-based mental health services was not related to the intensity or duration of delivered services.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Involuntary Outpatient Commitment and the Elusive Pursuit of Violence Prevention

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care

Background

Coercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.

Design

The programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.

Participants

Participants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.

Outcomes

The OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.

Results

Community treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.

Conclusions

Community Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.

Trial registration

Current Controlled Trials ISRCTN73110773.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Do intensive services obviate the need for CTOs?

OBJECTIVE

Opponents of community treatment orders (CTOs) argue that they would be unnecessary if sufficient community services such as assertive community treatment (ACT) teams were available. This study was designed to determine the frequency of CTO use for patients on ACT teams; reasons why patients receiving ACT services are placed on CTOs; and views of stakeholders on use of CTOs on ACT teams.

METHODS

We identified all patients on a CTO while being served by ACT teams in London, Ontario, between 2000 and 2013. Data were collected using chart review, questionnaires completed by psychiatrists and focus groups for patients, their relatives and non-psychiatrist clinicians.

RESULTS

During the study period, 190 patients were on a CTO while receiving ACT services. In December 2013, 17% of London's ACT team patients had an active CTO. ACT alone had been tried for 57% of patients before a CTO was introduced. Psychiatrists cited refusal of treatment and unavailability for follow-up as the primary reasons why ACT alone was ineffective. Patients were ambivalent about CTOs: describing them as coercive while simultaneously noting benefits. Relatives and non-psychiatrist clinicians were more clearly positive about the use of CTOs.

CONCLUSIONS

The availability of intensive services does not ensure that patients will engage with those services.

CLINICAL IMPLICATIONS

Community legislation requiring some patients to adhere to treatment is needed in addition to intensive clinical services.

LIMITATIONS

This study conducted in a single location may not generalize to other regions. Many patients were not approached to participate in the focus groups which call into question the representativeness of patient opinions.

Mental health service utilisation after a Community Treatment Order: A comparison between three modes of termination

OBJECTIVE

Little work has examined Community Treatment Order processes, including mode of termination. This paper aimed to examine service utilisation and legal status following the Community Treatment Order termination by a review board, treating psychiatrist or expiry of order.

METHOD

Data-linkage study following the service utilisation of those discharged from a Community Treatment Order of at least 3-month duration for the subsequent 2 years. We used the state-wide database of all contacts with state-funded mental health services in Victoria, Australia.

RESULTS

Of the 1478 patients who were discharged, 5% were discharged by the review board, 88% were discharged by the treating psychiatrist and in 7% the order expired. Logistic regression indicated that those discharged by the treating service were less likely to be subsequently placed under an involuntary order than those discharged by the Mental Health Review Board or those whose order had expired (odds ratio = 0.61).

CONCLUSION

Poorly planned discharge as a result of expiry of the Community Treatment Order or abrupt discharge by the review board may be associated with a more severe relapse and subsequent need for compulsory treatment. The likelihood of being readmitted as an involuntary patient is greater for younger adults and those living in urban settings. In order to minimise the risk of major relapse, strong community engagement with treating services should be supported.

A Specialized Treatment Court for Veterans with Trauma Exposure: Implications for the Field

This study examines the efficacy of providing a Veterans Treatment Court specialized docket to trauma-affected veterans. Eighty-Six veterans enrolled in a jail diversion and trauma recovery Veterans Treatment Court program. Veteran participants were interviewed at baseline, 6- and 12-months to determine if the program led to improvements in jail recidivism, psychiatric symptoms, quality of life, and recovery. The results suggest that veteran's involved in the Veterans Treatment Court programs experienced significant improvement in PTSD, depression, substance abuse, overall functioning, emotional wellbeing, relationships with others, recovery status, social connectedness, family functioning, and sleep.

Effectiveness of Community Treatment Orders: The International Evidence

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Effect of increased compulsion on readmission to hospital or disengagement from community services for patients with psychosis: follow-up of a cohort from the OCTET trial

BACKGROUND

Community treatment orders (CTOs) have not been shown in randomised trials to reduce readmission to hospital in patients with psychosis, but these trials have been short (11-12 months). We previously investigated the effect of CTOs on readmission rates over 12 months in a randomised trial (OCTET). Here, we present follow-up data for a cohort of individuals recruited to our original trial to examine the long-term effect of CTOs on readmissions and the risk of patients disengaging from mental health services temporarily or enduringly.

METHODS

For OCTET, an open-label, parallel, randomised controlled trial, we recruited patients aged 18-65 years involuntarily admitted to mental health hospitals in 32 trusts in England, with a diagnosis of psychosis and deemed suitable for CTOs by their clinicians. Between Nov 10, 2008, and Feb 22, 2011, we recruited and randomly assigned 336 eligible patients (1:1) to be discharged on either a CTO (n=167) or to voluntary status via Section 17 leave (control group; n=169). For the analysis presented in this report, we assessed data at 36 months for 330 of these patients. We tested rates of readmission to hospital, time to first readmission, number of readmissions, and duration of readmission in patients assigned to CTO versus those assigned to control, and in all patients with CTO experience at any time in the 36 months versus those without. We also tested whether duration of CTO affected readmission outcomes in patients with CTO experience. We examined discontinuation (≥60 days between clinical contacts) and disengagement from services (no clinical contact for ≥90 days with no return to contact) in the whole cohort. OCTET is registered with isrctn.com, number ISRCTN73110773.

FINDINGS

We obtained data for 330 patients in the relevant period between Nov 10, 2008 and Feb 22, 2014 (36 months after the last patient was randomly assigned to OCTET). We identified no difference between the randomised groups in the numbers of patients readmitted (100 [61%] of 165 CTOs vs 113 [68%] of 165 controls; relative risk 0·88 [95% CI 0·75-1·03]), number of readmissions (mean 2·4 readmissions [SD 1·91] vs 2·2 [1·43]; incident density ratio [IDR] 0·97 [95% CI 0·76-1·24]), duration of readmissions (median 117·5 days [IQR 63-303] vs 139·5 days [63·0-309·5]; IDR 0·84 [95% CI 0·51-1·38]), or time to first readmission (median 601·0 days [95% CI 387·0-777·0] vs 420·0 days [352·0-548·0]; hazard ratio [HR] 0·81 [95% CI 0·62-1·06]). The CTO experience group had significantly more readmissions than the group without (IDR 1·39 [95% CI 1·07-1·79]) and we noted no significant difference between groups in readmission rates, duration of readmission, or time to first readmission. We did not identify a linear relationship between readmission outcomes and duration of CTO. 19 (6%) patients disengaged from services (12 [7%] of 165 CTOs vs 7 [4%] of 165 controls). Longer duration of compulsion was associated with later disengagement (HR 0·946 [95% CI 0·90-0·99, p=0·023). 187 (57%) experienced no discontinuities, and we noted no significant difference between the CTO and control groups for time to disengagement or number of discontinuities. Levels of discontinuity were associated with compulsion (IDR 0·973 [95% CI 0·96-0·99, p<0·0001]. We identified no effect of baseline characteristics on the associations between compulsion and disengagement.

INTERPRETATION

We identified no evidence that increased compulsion leads to improved readmission outcomes or to disengagement from services in patients with psychosis over 36 months. The level of persisting clinical follow-up was much higher than expected, irrespective of CTO status, and could partly account for the absence of CTO effect. The findings from our 36-month follow-up support our original findings that CTOs do not provide patient benefits, and the continued high level of their use should be reviewed.

FUNDING

National Institute for Health Research.

Increased influence and collaboration: a qualitative study of patients' experiences of community treatment orders within an assertive community treatment setting

Background

Since 2009, 14 assertive community treatment (ACT) teams have started up in Norway. Over 30 % of the patients treated by the ACT teams were subject to community treatment orders (CTOs) at intake. CTOs are legal mechanisms to secure treatment adherence for patients with severe mental illness. Little is known about patients’ views and experiences of CTOs within an ACT context.

Methods

The study was based on qualitative in depth interviews with 15 patients that were followed up by ACT teams and that were currently subjected to CTOs. The data were analyzed by using a modified grounded theory approach.

Results

While some participants experienced the CTO as a security net and as an important factor for staying well, others described the CTO as a social control mechanism and as a violation of their autonomy. Although experiencing difficulties and tensions, many participants described the ACT team as a different mental health arena from what they had known before, with another frame of interaction. Despite being legally compelled to receive treatment, many participants talked about how the ACT teams focused on addressing unmet needs, the management of future crises, and finding solutions to daily life problems. Assistance with housing and finances, reduced social isolation, and being able to seek help voluntarily were positive outcomes emphasized by many patients.

Discussion

The participants had different views of being on a CTO within an ACT setting. While some remained clearly negative to the CTO, others described a gradual transition toward regarding the CTO as an acceptablesolution as they gained experience of ACT. Many of the participants valued the supportive relationship withthe ACT team, and communication with the care providers and the care providers’ attitudes could make a significant difference. The study shows that the perception of coercion is context dependent, and that the relationship between care providers and patients is of importance to how patients interpret the providers’ behavior and the restrictive interventions.

Conclusions

Although some patients focused on loss of autonomy and being compelled to take medications, other patients emphasised the supportive relationships they had with the ACT teams and that they had received help with housing, finances, and other daily life problems. Thus, being on mandated community treatment could be acceptable in the opinion of several of the patients, provided that they received other services that they found beneficial.

How Health Reform is Recasting Public Psychiatry

This article reviews the fiscal, programmatic, clinical, and cultural forces of health care reform that are transforming the work of public psychiatrists. Areas of rapid change and issues of concern are discussed. A proposed health care reform agenda for public psychiatric leadership emphasizes (1) access to quality mental health care, (2) promotion of recovery practices in primary care, (3) promotion of public psychiatry values within general psychiatry, (4) engagement in national policy formulation and implementation, and (5) further development of psychiatric leadership focused on public and community mental health.

Impact of involuntary out-patient commitment on reducing hospital services: 2-year follow-up

Aims and method To evaluate whether involuntary out-patient commitment (OPC) in patients with severe mental disorder reduces their use of hospital services. This is a retrospective case-control study comparing a group of patients on OPC (n = 75) and a control group (n = 75) which was composed of patients whose sociodemographic variables and clinical characteristics were similar to those of the OPC group. Each control case is paired with an OPC case, so the control case must have an involuntary admission in the month that the index OPC case admission occurred. Emergency room visits, admissions and average length of hospital stay over a 2-year follow-up after the initiation of OPC were compared. Results No statistically significant evidence was found in the use of mental healthcare services between the two groups. Different reasons for admission found between the groups limit similarity when comparing the two. Clinical implications The findings cast doubt over the effectiveness of this legal measure to reduce emergency visits, the number of admissions and the length of stay in the hospital.