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

Stakeholder experiences with compulsory treatment at home: A focus-group study

BACKGROUND

Since 2020, Dutch mental health legislation has provided scope for compulsory treatment at home (CTH). Unlike compulsory community treatment (CCT), CTH allows for the use of compulsion in a patient's home, and thus not only in hospital.

AIM

To examine several stakeholders' experiences and views regarding CTH and its implementation.

METHODS

Four focus-groups were performed: one with patients, one with significant others, one with psychiatrists, and one with a mixed group of stakeholders. The transcripts were analyzed thematically.

RESULTS

We identified three themes and 16 subthemes. The first theme concerned the potential benefits of CTH, one of which was avoiding admission to hospital. The second theme focused on preconditions for the delivery of CTH, mainly on communication between mental health workers, patients, and significant others; and the importance of a dialogue well in advance of any compulsory care. With regard to the third theme, considerations regarding the delivery of CTH, all stakeholder groups believed that CTH would be most suitable for patients who had a longer history with their treatment team: between them, they would be able to draw up a plan for compulsory care.

CONCLUSION

Stakeholders felt that CTH can work for patients with a longer treatment history whose home situation allows for treatment at home. They regard an advance dialogue and jointly drawing up a crisis plan as important preconditions. Overall, CTH can be regarded as an extra option for enabling an individually tailored approach.

Interventions for the unhoused individual with schizophrenia: a civilized plan

This article provides an overview of individuals with schizophrenia who become unhoused and explores current approaches to managing this severe illness in those who often do not want care or believe they need it. Individuals with schizophrenia and who are unhoused face numerous adverse consequences including premature mortality and increased rates of suicide. There is a dearth of research evidence demonstrating efficacy of the Housing First (HF) model and harm reduction approach in decreasing psychotic symptoms in individuals with schizophrenia. Ensuring medication adherence in individuals with psychosis, both housed and unhoused, is important to prevent delays in untreated psychosis and chronic deterioration.

Changes in inpatient mental health treatment and related costs before and after flexible assertive community treatment: a naturalistic observational cohort study

BACKGROUND

Flexible Assertive Community Treatment (FACT) is currently implemented in Norwegian mental health services, aiming to ensure comprehensive and rights-based services for persons with severe mental illness and complex needs, but also motivated by assumed cost-effectiveness. We need knowledge about the consequences of this service innovation. The aim of this study was to investigate changes in total and involuntary inpatient mental health treatment and associated changes in costs of inpatient days before and after enrolment into FACT for persons with severe mental illness and complex needs in Norway.

METHODS

In this naturalistic observational cohort study of 397 patients in eight Norwegian FACT teams, we compared total and involuntary admissions, total and involuntary inpatient days, and the costs of total and involuntary inpatient days, for two periods: 24 months before and 24 months after enrolment in FACT. We used paired t-test.

RESULTS

There was a significant reduction in involuntary admissions, involuntary inpatient days, and total inpatient days after enrolment in FACT. We found a slight but non-significant reduction in total admissions to inpatient mental health treatment. There was a significant reduction in the costs of total inpatient days and involuntary inpatient days.

CONCLUSION

Patients in FACT were admitted to inpatient treatment as frequently as before enrolment in FACT, but involuntary admissions were less frequent. Furthermore, the duration of involuntary and total inpatient treatment was reduced, with a corresponding reduction in costs as expected. Results suggest that targeted and well-timed interventions from FACT may reduce the need for prolonged involuntary inpatient treatment, implying reduced disadvantages for the individual and more efficient allocation of health service funding.

Compulsory treatment at home: an interview study exploring the experiences of an early group of patients, relatives and mental-health workers

BACKGROUND

When introduced in 2020, the Netherlands' Compulsory Mental Healthcare Act included provisions for compulsory community treatment (CCT) and compulsory treatment in patients' homes (CTH). Although CCT has been incorporated into mental health care in many countries, its effectiveness is debated. We know of no other countries in which CTH has been adopted. The aim of this study is to evaluate how an early group of participants experienced CTH. They were drawn from three stakeholder groups: patients, relatives and mental-health workers.

METHODS

In total, 17 open interviews were conducted with six patients, five relatives and six mental-health workers. All had experience with CTH. Thematic analysis was used to analyze the interviews.

RESULTS

Five themes were identified: 1). Reasons for applying for a court order with options for CTH. The reasons included preventing harm, avoiding hospitalization, and providing a safety net. 2.) Participants' experiences with CTH in practice. The four most noteworthy experiences were related to the process of applying for a court order; compulsory home visits and the compulsory use of medication; the involvement of relatives during treatment; and the influence of CTH on the relationship between patients and relatives.  3.) The advantages and disadvantages of CTH. The most important advantages were avoiding hospitalization; improving medication adherence; facilitating easy access to care; early signaling of deterioration; early intervention; and regained autonomy. The most important disadvantages were restricted autonomy; fewer options for monitoring compared to hospitalization; and problems regarding control of patient behavior. 4.) Participants' preferences. All preferred CTH to hospitalization. 5.) Participants' suggestions for improving CTH. These included the need not only to provide patients with better information, but also to improve the involvement of relatives during treatment.

CONCLUSION

The interviewees found that CTH might help to avoid hospitalization by providing stakeholders with more options for arranging effective care at home. Although this suggests that initial experiences of CTH under the new Dutch mental health law were positive, it is still uncertain whether CTH as currently implemented really differs from CCT.

The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses

AIMS

Community treatment orders have been introduced in many jurisdictions with increasing use over time. We conducted a rapid umbrella review to synthesise the quantitative and qualitative evidence from systematic reviews and/or meta-analyses of their potential harms and benefits.

METHODS

A systematic search of Medline, PubMed, Embase and PsycINFO for relevant systematic reviews and/or meta-analyses. Where available, participants on community treatment orders were compared with controls receiving voluntary psychiatric treatment. This review is registered with PROSPERO (CRD42023398767) and the Open Science Framework (https://osf.io/zeq35).

RESULTS

In all, 17 publications from 14 studies met the inclusion criteria. Quantitative synthesis of data from different systematic reviews was not possible. There were mixed findings on the effects of community treatment orders on health service use, and clinical, psychosocial or forensic outcomes. Whereas uncontrolled evidence suggested benefits, results were more equivocal from controlled studies and randomised controlled trials showed no effect. Any changes in health service use took several years to become apparent. There was evidence that better targeting of community treatment order use led to improved outcomes. Although there were other benefits, such as in mortality, findings were mostly rated as suggestive using predetermined and standardised criteria. Qualitative findings suggested that family members and clinicians were generally positive about the effect of community treatment orders but those subjected to them were more ambivalent. Any possible harms were under-researched, particularly in quantitative designs.

CONCLUSIONS

The evidence for the benefits of community treatment orders remains inconclusive. At the very least, use should be better targeted to people most likely to benefit. More quantitative research on harms is indicated.

Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review

In mental health and psychiatric care, the use of involuntary psychiatric treatment for people with mental disorders is still a central and contentious issue. The main objective of this scoping review was to map and systematize the literature on ethical issues in clinical decision-making about involuntary psychiatric treatment. Five databases (Embase, PsycINFO, CINAHL, Medline, and Scopus) were searched for articles on this topic. Out of a total of 342 articles found, 35 studies from 14 countries were included based on the selection criteria. The articles were analyzed using the inductive content analysis approach. The following main categories were identified: (1) ethical foundations that guide clinical decision-making; (2) criteria for involuntary psychiatric treatment; (3) gaps, barriers, and risks associated with involuntary psychiatric treatment; (4) strategies used to reduce, replace, and improve the negative impact of involuntary treatment; and (5) evidence-based recommendations. Most of the selected articles discuss the logic underlying involuntary treatment of the mentally ill, exploring ethical principles such as autonomy, beneficence, non-maleficence, or justice, as well as how these should be properly balanced. During the process of involuntary psychiatric admission, there was a notable absence of effective communication and a significant power imbalance that disenfranchised those seeking services. This disparity was further intensified by professionals who often use coercive measures without a clear decision-making rationale and by family members who strongly depend on hospital admission. Due to the pluralistic and polarized nature of opinions regarding legal capacity and the complexity and nuance of involuntary admission, further studies should be context-specific and based on co-production and participatory research.