Assessing the outcome of compulsory treatment orders on management of psychiatric patients at 2 McGill University-associated hospitals

Study on covert administration of medications practices among persons with severe mental illness: A cross-sectional study

BACKGROUND

Covert administration of medication (CoAdM) by caregivers to persons with severe mental illness (SMI) is a commonly observed medication delivery practice in India.

AIMS

This study aims to examine different medication delivery practices adopted by caregivers to provide care to SMI at times of medication refusal.

METHOD

This study was conducted at the outpatient department between April 2019 and November 2019. A semi-structured questionnaire was used to interview the caregivers of persons with SMI to assess medication delivery practices.

RESULTS

A total of 300 caregivers were interviewed. CoAdM was practiced in 96 (32.0%) persons with SMI at least once during their lifetime, and other strategies used were pleading (n = 105, 35.0%), lying (n = 10, 3.3%), and threatening (n = 154, 51.4%). Logistic regression showed that male gender (OR 4.75; CI 1.37-16.46), absent insight (OR 10.0; CI 2.01-47.56), and poor adherence to medication (OR 4.75; CI 1.31-16.92) were significantly associated with CoAdM in the last 1 year. Caregivers perceived significant improvement in self-care (Z = -4.37, p < .01), interpersonal (Z = -7.61, p < .01), work (Z = -5.9, p < .01), family functioning (Z = -7.82, p < .01) difficult behavior (Z = -8.27, p < .01), and dependency (Z = -6.34, p < .01) in persons with SMI with use of CoAdM.

CONCLUSIONS

CoAdM was given to one in three persons with SMI at some point in their lives. Male gender, absent insight and poor adherence were predictive of CoAdM in the last 1 year. Caregiver perceived improvements in self-care, work, interpersonal, family functioning, problem behaviors, and dependency after CoAdM. Policies need to be evolved to serve all stakeholders while keeping these practices in mind.

The Significance of Intracranial Pressure Monitoring for Reducing Mortality in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Background

Despite guidelines provided by the Brain Trauma Foundation (BTF) for treating patients with TBI, including advice to monitor intracranial pressure (ICP), the clinical application of ICP monitoring is far from universal. This laxity has been attributed to the relationship between mortality in TBI patients and ICP monitoring.

Objective

This systematic review and meta-analysis was aimed at determining the effect of intracranial pressure (ICP) monitoring on the mortality of patients with traumatic brain injury (TBI).

Method

A systematic search for articles was conducted on PubMed, Scopus, Cochrane Central Register of Control Trials (CENTRAL), and APA PsycNet for articles published from 1 January 2000 to 1 August 2022. Manager 5.4 was used to carry out statistical analysis.

Results

Article search yielded 1421 articles, but only 23 cohort studies were included in the systematic review and meta-analysis. The total number of study participants is 80,058. Seventeen studies reported unadjusted odds ratios (OR), and only 8 reported the adjusted odds ratio (OR). Nine out of seventeen studies reported an unadjusted OR of less than 1, and five out of eight studies reported an adjusted OR of less than 1. From this paper's analysis, the OR for in-hospital mortality was 1.01 [95% CI, 0.80, 1.28], with a p value of 0.92. OR for ICU mortality was 0.84 [95% CI, 0.52, 1.35], with a p value of 0.47.

Conclusion

But due to conflicting results, as evident above, it is unsatisfyingly challenging to draw any substantial conclusions from them. This paper thus calls for more research on this particular paper.

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.

Community Treatment Order Outcomes in Quebec: A Unique Jurisdiction

OBJECTIVE

We study compulsory community treatment orders (CTOs) for patients with severe and persistent mental illness (SPMI). Focusing on a unique jurisdiction in Canada that allows for long duration CTOs with strict enforcement procedures, our objectives are to determine whether extended duration CTOs are effective and to determine whether associated hospitalization costs are reduced.

METHOD

A mirror image, naturalistic design was employed using patients as their own controls to enhance external validity. No inclusive or exclusive criteria were employed for the 367 SPMI clinic patients who were studied over a 5-year period. Detailed documentation of the dates of all CTOs, long-acting antipsychotic injections (LAIs), emergency visits, hospitalizations, duration of hospitalizations, crimes and/or police involvement were collected. To study the relation between CTO and injection adherence, we use a mixed-effect linear regression model. To study the effect of injection adherence and hospitalization, we use survival analysis via Kaplan-Meier and Cox survival models.

RESULTS

CTO and non-CTO patients did not differ with respect to demographics, but CTO patients were significantly more severely ill. Following a CTO, adherence to LAIs increased over time (P < 0.001). The average time the patients spent in the community, that is, outside the hospital, was significantly longer under a CTO, and the duration of hospitalizations was decreased.

CONCLUSIONS

LAI adherence and outpatient office visits were enhanced by extended duration CTOs, as was time out of the hospital. The shorter duration of hospital stays implies cost savings. These must be weighed against their undesirable coercive nature.

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.

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.

Service Users' Knowledge and Views on Outpatients' Compulsory Community Treatment Orders: A Cross-Sectional Matched Comparison Study

OBJECTIVE

Community treatment orders (CTOs) have been used in the treatment of some individuals with serious mental illness who fail to adhere to their psychiatric treatment, leading to frequent hospitalization. This article examines perceptions and knowledge of CTOs amongst outpatient service users in Toronto, Canada.

METHOD

Service users under a CTO were matched to a comparison control group of voluntary outpatients (n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at assessing instead of evaluating their knowledge and perceptions of CTOs, as well as understanding their views about the utility and impact of CTOs in the treatment of individuals with mental health issues.

RESULTS

Participants in the CTO group knew significantly more about CTO processes, restrictions, and procedural protections than the control group. Both groups thought that a CTO could improve certain individuals' mental health. The control group felt more strongly that a CTO could improve a service user's physical health by providing better access to care and closer monitoring (P = 0.019) while a significant proportion of the CTO group thought that being on a CTO was better than being in the hospital (P = 0.001) and that service users should be able to contest their CTO (P = 0.001). In addition, CTO group participants were significantly more optimistic about the potential positive impact of CTOs on other service users' quality of life (P = 0.008) and mental health (P = 0.023) compared to themselves.

CONCLUSIONS

In general, both groups viewed CTOs as potentially capable of positively affecting treatment and lives of some individuals with mental illness.

The social utility of community treatment orders: Applying Girard's mimetic theory to community-based mandated mental health care

Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non-compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.

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.

Coercion in Outpatients under Community Treatment Orders: A Matched Comparison Study

OBJECTIVE

Since the deinstitutionalization of psychiatric services around the world, the scope of outpatient psychiatric care has also increased to better support treatment access and adherence. For those with serious mental illness who may lack insight into their own illness, available interventions include coercive community practices such as mandated community treatment orders (CTOs). This paper examines the perceptions of coercion among service users treated with a CTO.

METHOD

We used a cross-sectional comparative design where service users treated under a CTO were matched to a comparison group of voluntary psychiatric outpatients. Both groups were receiving intensive community mental health services (n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at evaluating their perceptions of coercion and other aspects of the psychiatric treatment.

RESULTS

The level of coercion reported by service users treated under a CTO was significantly higher than that in the comparison group. However, in adjusted analyses, service users' perception of coercion, irrespective of their CTO status, was directly correlated with their previous experience with probation and inversely correlated with the sense of procedural justice in their treatment.

CONCLUSIONS

Evaluation of psychiatric service users' experiences of coercion should consider their past and current involvement with other types of coercive measures, particularly history of probation. Clinicians may be able to minimize these experiences of coercion by incorporating procedural justice principles into their practice.

Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study

INTRODUCTION

Supervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form of community treatment orders (CTOs). CTOs have been used more than expected, with significant variations between people and places. There is conflicting evidence about the effectiveness of SCT; studies based on randomised controlled trials (RCTs) have suggested few positive impacts, while those employing observational designs have been more favourable. Robust population-based studies are needed, because of the ethical challenges of undertaking further RCTs and because variation across previous studies may reflect the effects of sociospatial context on SCT outcomes. We aim to examine spatial and temporal variation in the use, effectiveness and cost of CTOs in England through the analysis of routine administrative data.

METHODS AND ANALYSIS

Four years of data from the Mental Health Services Dataset (MHSDS) will be analysed using multilevel models. Models based on all patients eligible for CTOs will be used to explore variation in their use. A subset of CTO-eligible patients comprising a treatment group (CTO patients) and a matched control group (non-CTO patients) will be used to examine variation in the association between CTO use and study outcomes. Primary outcome will be total time in hospital. Secondary outcomes will include time to first readmission and mortality. Outputs from these models will be used to populate predictive models of healthcare resource use.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the National Health Service Data Access and Advisory Group and Warwick University. To ensure patient confidentiality and to meet data governance requirements, analyses will be carried out in a secure microdata laboratory using de-identified data. Study findings will be disseminated through academic channels and shared with mental health policy-makers and other stakeholders.

Exploring experiences with compulsory psychiatric community treatment: A qualitative multi-perspective pilot study in an urban Canadian context

As medical, ethical and clinical effectiveness debates about the use of compulsory psychiatric treatment continues, it is important to further explore the actual experiences and perspectives of all relevant stakeholders in community treatment orders (CTOs). This qualitative pilot study engaged a total of twenty-seven clients, their family members, and care providers in Toronto, Canada. Semi-structured, one-on-one interviews were conducted between February and July 2013 and analyzed using thematic analysis. Top key themes from all the participants identified include, among others: 1) clients' experiences of coercion while treated under CTO, but a preference for CTOs compared to involuntary hospitalization, nevertheless; 2) limited real opportunities for collaboration in treatment decisions expressed by clients and family members; 3) acceptance of the potential for clinical recovery on CTOs while debating the role of CTO in a broader recovery journey by all stakeholders; 4) general preservation of therapeutic relationships between clients and care providers, while acknowledging the tension of taking on an "enforcer" role by providers; and 5) existence of different avenues for asserting agency by clients. The findings of this research illuminate the nuanced, complex, and adaptive perspectives held by different stakeholders, point to the importance of preserving and enhancing procedural justice in their use, and alert the field to incorporate recovery-based approaches in this controversial practice that is a widely and commonly used clinical tool across many jurisdictions.

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.

Are community treatment orders counterproductive?

OBJECTIVE

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

CONCLUSIONS

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

Little evidence for community treatment orders - a battle fought with heavy weapons

This editorial discusses the pros and cons of community treatment orders (CTOs) from the perspective of community general adult psychiatry. There is little scientific evidence supporting the application of CTOs. Preconditions of a CTO to work are likely to be met by few patients. The time for the application of a CTO may be better spent for patient-centred care until there is sufficient new and robust evidence that identifies the patients that might profit.

Effectiveness of Community Treatment Orders: The International Evidence

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Canadian Studies on the Effectiveness of Community Treatment Orders

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Residence Conditions on Community Treatment Orders

OBJECTIVE

To identify the clinical reasons and legal authority for including a residential placement condition in a community treatment order (CTO).

METHOD

We describe the clinical reasons for imposing a residence condition and discuss how this is authorized by the laws of the Canadian provinces (using Ontario as the main example).

RESULTS

A residence condition can facilitate numerous benefits, including: regular access to a person by a clinical team; continuing therapeutic relations; supervision of medication; provision of general medical care; and reduction in substance use, risks of victimization, and other unintended harm. A resident condition can be lawfully imposed when it clearly fits the purposes of the CTO legislation and stops short of authorizing detention in a community facility.

CONCLUSIONS

In certain circumstances, a residence condition is clinically justified and a lawful aspect of a CTO.

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.

Community treatment orders in a Swedish county--applied as intended?

BACKGROUND

Community treatment orders (CTOs) were legally implemented in psychiatry in Sweden in 2008, both in general psychiatry and in forensic psychiatric care. A main aim with the reform was to replace long leaves from compulsory psychiatric inpatient care with CTOs. The aims of the present study were to examine the use of compulsory psychiatric care before and after the reform and if this intention of the law reform was fulfilled.

METHODS

The study was based on register data from the computerized patient administrative system of Örebro County Council. Two periods of time, two years before (I) and two years after (II) the legal change, were compared. The Swedish civic registration number was used to connect unique individuals to continuous treatment episodes comprising different forms of legal status and to identify individuals treated during both time periods.

RESULTS

The number of involuntarily admitted patients was 524 in period I and 514 in period II. CTOs were in period II used on relatively more patients in forensic psychiatric care than in general psychiatry. In all, there was a 9% decrease from period I to period II in hospital days of compulsory psychiatric care, while days on leave decreased with 60%. The number of days on leave plus days under CTOs was 26% higher in period II than the number of days on leave in period I. Among patients treated in both periods, this increase was 43%. The total number of days under any form of compulsory care (in hospital, on leave, and under CTOs) increased with five percent. Patients with the longest leaves before the reform had more days on CTOs after the reform than other patients.

CONCLUSIONS

The results indicate that the main intention of the legislator with introducing CTOs was fulfilled in the first two years after the reform in the studied county. At the same time the use of coercive psychiatric care outside hospital, and to some extent the total use of coercive in- and outpatient psychiatric care, increased. Adding an additional legal coercive instrument in psychiatry may increase the total use of coercion.

Fatores associados à formação da aliança terapêutica na psicoterapia obrigatória

O objetivo deste estudo foi identificar de que forma se estabelece a aliança terapêutica (AT) em pacientes encaminhados de forma obrigatória para a psicoterapia, em comparação aos pacientes que buscam atendimento psicoterapêutico voluntariamente, verificando-se também as características das representações de objeto, mecanismos de defesa, percepção de coerção, e gravidade dos sintomas. Participaram da pesquisa 51 sujeitos, sendo 15 casos em psicoterapia obrigatória e 36 casos em tratamento voluntário. Ambos os grupos foram selecionados em uma instituição pública de saúde que oferece psicoterapia para funcionários públicos municipais. Os resultados apontaram que apesar dos pacientes obrigatórios apresentarem sintomas mais graves, foi possível o estabelecimento da AT. Além disso, o status de paciente obrigatório não influenciou o estabelecimento da AT e sim a percepção de coerção na procura de atendimento.

CTOs: what is the state of the evidence?

PURPOSE

Community Treatment Orders (CTOs) require outpatients to adhere to treatment and permit rapid hospitalisation when necessary. They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence. In this article, we appraise the current literature on CTOs from the viewpoint of Evidence-Based Medicine and discuss the way forward for using and researching CTOs.

RESULTS

Non-randomised outcome studies show conflicting results, but their lack of standardisation of methods and measures makes it difficult to draw conclusions. In contrast, all three randomised controlled trials (RCTs) conducted concur in their findings that CTOs do not impact on hospital outcomes. No systematic review or meta-analysis has identified any clear clinical advantage to CTOs.

CONCLUSION

The evidence-base does not support the use of CTOs in their current form. Involuntary clinical interventions must conform to the highest standard of evidence-based care. To enable clinicians to take an evidence-based approach and to settle remaining uncertainties about the current evidence, high-quality RCTs should be designed and undertaken, using standardised outcome measures.

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.

A retrospective study of psychotropic drug use among individuals with mental illness issued a community treatment order

BACKGROUND

Community treatment orders (CTOs) are legal orders which require individuals with mental illness to accept treatment in the community. Previous studies report that long-acting injectable (LAI) antipsychotics are associated with CTOs, however, little is known about the specific treatment plans prescribed in CTOs. The objective of this study was to describe the patterns of psychotropic drugs prescribed to individuals issued a CTO, focusing on LAI antipsychotics, antipsychotic polypharmacy and high-dose antipsychotics.

METHODS

This was a retrospective cross-sectional study of 378 individuals randomly selected from a sample of 1317 individuals with a CTO expiry date up to and including 30 April 2010, taken from all 2856 individuals issued a CTO by the New South Wales Mental Health Review Tribunal, Australia, in 2009. De-identified information relating to individuals' treatment plans, demographic and clinical details were systematically extracted.

RESULTS

A total of 377 (99.7%) individuals were prescribed at least one antipsychotic. Of these, 310 (82%) were prescribed a LAI antipsychotic, either alone (45%), or in combination with, an oral antipsychotic (37%). Risperidone was the most prevalent antipsychotic, prescribed to 164 (43%) individuals. Antipsychotic polypharmacy was prescribed to 121 (32%) individuals and between 20% and 27% of individuals were prescribed high-dose antipsychotics. Antipsychotic polypharmacy accounted for 74-80% of individuals prescribed high-dose antipsychotics.

CONCLUSIONS

The results from this study confirm that LAI antipsychotics are commonly prescribed in CTOs. Antipsychotic polypharmacy was also common, and accounted for the majority of individuals prescribed high-dose antipsychotics. Further research is needed to determine the potential outcomes and implications of the patterns observed.