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

Community treatment orders in New Zealand: regional variability and international comparisons

OBJECTIVES

Community treatment orders (CTOs) have been used in New Zealand since 1992 and are now used in most Commonwealth countries. There is little research on the rate of use of CTOs in New Zealand. This study compares the prevalence of CTO use across New Zealand's 20 health districts and makes comparisons with international prevalence rates.

METHODS

New Zealand Ministry of Health reports provided data on rates of CTO use in New Zealand between 2005 and 2011. International rates were obtained from published reports and academic literature on CTO use.

RESULTS

Rates of CTO use in New Zealand show marked and persistent regional variation over the period of data collection. National average rates increased from 58 per 100,000 in 2005 to 84 per 100,000 in 2011. Rates of use of CTOs are increasing internationally. New Zealand's CTO use is high by international comparisons.

CONCLUSIONS

New Zealand's high and increasing rate of CTO use by international standards raises questions about the delivery and functioning of mental health services, and about mental health service users' experience of mental health care. The high rate of CTO use needs to be addressed as a human rights issue as well as a clinical issue.

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.

Coercion and compulsion in mental healthcare-an international perspective

BACKGROUND

Coercion has always existed in psychiatry and is increasingly debated. The 'move into the community' in many countries over recent decades and the evolution of community services have substantially altered the locus of coercion. In many countries psychiatric services remain poorly funded and patchy. Substantial differences between regions and countries in the provision of services, the role of the family, and the wider economic and political climate are likely to lead to different sources and experiences of coercion.

DISCUSSION

This paper explores a number of factors that may affect the prevalence and type of coercion in psychiatric services and in society and their impact upon those with severe mental illnesses. Differences in service provision are explored and wider societal issues that may impact are considered along with relevant evidence.

CONCLUSIONS

Coercion is commonly experienced by those with severe mental illnesses but is poorly understood. The vast majority of research relates to High Income Group countries with developed community services and formal mental health legislation that adopt the so-called 'medical model'. Further research and collaboration is urgently required to increase our understanding of these issues, which are difficult to define and measure. An evidence base that is relevant worldwide, not just to a small group of countries, is needed to inform training and the care of all patients. A particular focus must be expanding our knowledge and understanding of coercion in cultures outside those where such research has traditionally taken place to date.

Medication Noncompliance and Criminal Responsibility: Is the Insanity Defense Legitimate?

Noncompliance with medication therapy and mental health care is prevalent among the mentally ill. Its multifactorial dynamics can include aspects of the illness itself, such as anosognosia. Noncompliance with medication can increase risk of violent or other criminal behavior, but the law currently does not recognize it as a factor in determining culpability. The legal test of insanity that focuses on a “defect of reason from disease of the mind” presumes that the disease was not self-induced. Noncompliance with medication and voluntary intoxication can both be seen as self-induced incapacities, but their adjudication is often quite different. A psychotic condition may be the basis of an excuse, whereas simple intoxication is not. The distinction is not only the obvious one of acts of omission (medication noncompliance) and acts of commission (voluntary intoxication). There are other complicating factors, such as the knowledge of the effects of noncompliance, the mental state prior to the noncompliance, and the presence of any conditions that would excuse or justify it. These and other considerations render the assignment of criminal responsibility for the noncompliant psychiatric offender complex. A possible solution to this would be the application of therapeutic jurisprudence to the noncompliant mentally ill offender.

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

OBJECTIVE

Some literature suggests that compulsory community treatment orders (CTOs) are effective in reducing hospitalizations in a subgroup of psychiatric patients with histories of repeated hospitalization, allowing them to be treated in the community under less restrictive measures. However, studies have yielded contradictory findings, in part because of methodological differences. Our study examines the effectiveness of CTOs in reducing hospitalizations and increasing community tenure of such patients.

METHOD

The sample included all psychiatric patients who had been given a CTO during a 9-year period at 2 of McGill University's hospitals. This is a naturalistic, observational, retrospective, before-and-after study where patients acted as their own control subjects. We examined variables, including the number, duration, and time to psychiatric admissions, comparing 4 time periods: early, pre-index, index (when the first CTO was in force), and post-index periods. The total study duration per subject encompasses the longest period of observation within existing studies in Canada.

RESULTS

Psychiatric patients with histories of frequent readmissions demonstrated a significant reduction in their number of hospitalizations as well as an increase in the median time to re-hospitalization, during the period when they were treated under a CTO. This effect of CTO was sustained even after the CTO had expired.

CONCLUSIONS

Our study suggests that CTOs are effective in assisting psychiatric patients with histories of repeated hospitalizations to live and be treated in the community, diminishing the occurrence of frequent hospitalization.

Arrest outcomes associated with outpatient commitment in New York State

OBJECTIVE

This study examined whether assisted outpatient treatment (AOT) under New York's "Kendra's Law" is associated with reduced arrests for violent and nonviolent offenses.

METHODS

Arrest records of 183 study participants attending outpatient clinics in New York City, 86 of whom were ever and 97 of whom were never assigned to AOT, were compiled to yield 16,890 months of observation. For each month the data indicated whether an arrest did or did not occur and whether a participant was or was not assigned to AOT. Generalized estimating equations and fixed-effects analyses were used to compare arrest rates within different periods (before, during or shortly after, and more than six months after) for those ever assigned and between the ever- and never-assigned groups.

RESULTS

For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment.

CONCLUSIONS

Outpatient commitment under Kendra's Law in New York State is associated with a reduced risk of arrest. The coercion necessitated by application of the law may forestall, at least for some people, the potentially more potent and consequential coercion they would have experienced in the criminal justice system.

The relationship between outpatient mental health treatment and subsequent mental health symptoms and disorders in young adults

The objective of this study was to evaluate community-based outpatient mental health services for young adults. Participants were interviewed at ages 21, 24, 27, and 30. Outcomes included: (1) symptoms of depression, generalized anxiety, social phobia, dysthymia and post traumatic stress individually and as a global scale; and (2) a dichotomous diagnosis variable inclusive of all above disorders. Treatment was indicated by an outpatient visit to a psychiatrist or other professional. Treatment did not reduce mental disorder or symptoms. Substance use, violence, poverty, community disorganization, and family history of antisocial behavior increased risks for negative outcomes, while social support was protective. The absence of positive findings associated with outpatient treatment is troubling given the empirically supported interventions for the conditions examined. Practitioners, agencies, and managed care organizations share a responsibility to implement effective and comprehensive interventions.