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Balcioglu YH, Ozdemir S, Oncu F, Turkcan A. Treatment adherence in forensic patients with schizophrenia spectrum disorders discharged on long-acting injectable antipsychotics: a comparative 3-year mirror-image study. Int Clin Psychopharmacol 2024; 39:267-275. [PMID: 37910435 DOI: 10.1097/yic.0000000000000519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
In this retrospective 3-year mirror-image study, 81 patients with schizophrenia spectrum disorders (SSD) were categorized according to whether they were prescribed long-acting injectable antipsychotics (LAI) or not upon discharge from the inpatient forensic psychiatric unit. Antipsychotic adherence, which was staged based on the 'proportion of days covered' method, as well as other clinical outcomes was compared between pre- and post-index mirror periods. In both Oral-only (n = 46) and Oral + LAI (n = 35) groups, the number of hospitalizations, convictions and months spent in the hospital were significantly lower in the post-index period than the pre-index period. Differences in these three variables between pre- and post-index periods were NS between the two groups. A mixed effect ordinal logistic regression model with random intercept showed that the odds ratio of obtaining a higher treatment adherence score in the post-index period was more pronounced in the Oral + LAI group than in the Oral-only group, considering adherence at baseline and the length of stay during the index hospitalization as potential confounders. Discharge with LAIs in a forensic psychiatric cohort of SSD was associated with a greater mid- to long-term improvement in antipsychotic medication adherence compared to discharge with oral-only antipsychotics.
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Affiliation(s)
- Yasin Hasan Balcioglu
- Forensic Psychiatry Unit, Department of Psychiatry, Bakirkoy Prof Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery, Istanbul, Turkey
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Kisely S, Zirnsak T, Corderoy A, Ryan CJ, Brophy L. The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses. Aust N Z J Psychiatry 2024; 58:555-570. [PMID: 38650311 PMCID: PMC11193324 DOI: 10.1177/00048674241246436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
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.
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Affiliation(s)
- Steve Kisely
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Services, Woolloongabba, QLD, Australia
- Griffith Criminology Institute (GCI), Griffith University, Mount Gravatt, QLD, Australia
- Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Tessa Zirnsak
- Social Work and Social Policy, Department of Community and Clinical Health, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia
| | - Amy Corderoy
- Discipline of Psychiatry & Mental Health, University of New South Wales, Sydney, NSW, Australia
| | - Christopher James Ryan
- Discipline of Psychiatry & Mental Health, University of New South Wales, Sydney, NSW, Australia
- Specialty of Psychiatry, University of Sydney, Sydney, NSW, Australia
- Department of Psychiatry, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Lisa Brophy
- Social Work and Social Policy, Department of Community and Clinical Health, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia
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Jiguet S, Michel T, Capdevielle D. Programme de soins psychiatriques : Etude de l’expérience de jeunes patients par une méthode qualitative: Psychiatric care program: A qualitative study of the experience of young patients. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2024:7067437241246589. [PMID: 38656192 DOI: 10.1177/07067437241246589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Ambulatory care without consent is widely used, but it is controversial, and its effectiveness has not yet been proven. The patient experience remains largely unstudied in France, particularly that of young patients, yet their adherence to care in the early stages of the disease is complex and has an impact on their prognoses. The aim of this study is to investigate the experience of young patients undergoing a program of care (POC) in order to suggest ways of optimizing their care and to enrich the debate on the use of POCs. METHOD Semi-structured interviews were conducted with 11 patients between ages 20 and 32, who were either undergoing a POC or had done so in the previous 5 years, followed by a semi-pragmatic phenomenological analysis of the resulting transcripts. RESULTS (1) The outpatient experience with restraints is contradictory, ranging from deprivation and intrusion to support and protection. (2) The POC is portrayed as a framework for developing awareness of disorders and acceptance of care. (3) Patients report a lack of information about care with restraints, even to the point of being unaware of its existence. Patient-psychiatrist interactions within the POC are complicated by the restraints, but remain perceived as a care relationship. (4) They report constraints in their daily lives in connection to the POC, which can complicate professional involvement. CONCLUSION The results support the importance of nurturing the therapeutic relationship within the POC and involving patients more in their care, starting with better information. They support the use of POCs as a temporary tool to be combined with work on adherence to treatment and support for social and professional reintegration. SPECIALTY Psychiatry.
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Affiliation(s)
- Sarah Jiguet
- Centre Hospitalier Leon Jean Gregory, Thuir, France
- Service Universitaire de Psychiatrie Adulte, CHU de Montpellier, Montpellier, France
| | - Thibault Michel
- Service Universitaire de Psychiatrie Adulte, CHU de Montpellier, Montpellier, France
| | - Delphine Capdevielle
- Service Universitaire de Psychiatrie Adulte, CHU de Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
- Fondation FondaMental, Paris, France
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4
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Ogilvie JM, Kisely S. Examining the health and criminal justice characteristics for young people on compulsory community treatment orders: An Australian birth cohort and data linkage study. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2022; 83:101813. [PMID: 35759935 DOI: 10.1016/j.ijlp.2022.101813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/27/2022] [Accepted: 06/13/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Most studies on the predictors and effectiveness of community treatment orders (CTOs) are restricted to health-related variables and do not consider forensic contacts as established by criminal justice databases or predictors from birth. We used linked administrative health and criminal justice data for a birth cohort in Queensland, Australia to investigate the characteristics and outcomes of people placed on CTOs. METHODS CTOs were identified from administrative data for hospital admissions and community mental health service contacts for a population cohort of 45,141 individuals born in Queensland in 1990. These data were linked with administrative court records, with individuals followed up to age 23/24 years. Logistic regression analyses were used to examine characteristics associated with CTO placement and Tobit regression analyses to examine factors predicting health and criminal justice outcomes in the following year. RESULTS There were 211 CTO cases by age 23/24 years, for whom it was possible to identify 413 controls on voluntary treatment. Non-affective psychoses [F20-F29] were the strongest predictors of CTO placement (ORadj = 4.07, 2.77-5.99) followed by a court appearance (ORadj = 1.99, 1.28-3.09). CTOs were associated with greater, not lower, subsequent psychiatric hospital admissions, inpatient bed-days and community mental health service contacts, although on sensitivity analyses psychiatric hospital admissions were the same as voluntary controls. CTOs were not associated with more subsequent court appearances despite higher rates of offending before CTO placement. CONCLUSIONS Both clinical and forensic variables can determine CTO placement and, on adjustment for these covariates, CTOs were not associated with reductions in psychiatric hospital admission, time spent as an inpatient, or subsequent court appearances. The latter finding might mean that CTOs reduce the risk of offending to that of voluntary controls.
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Affiliation(s)
- James M Ogilvie
- Griffith Criminology Institute, Griffith University, Australia
| | - Steve Kisely
- Griffith Criminology Institute, Griffith University, Australia; School of Medicine, The University of Queensland and Princess Alexandra Hospital, Woolloongabba, QLD, Australia; Metro South Health Service, Woolloongabba, QLD, Australia.
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Segal SP. Protecting Health and Safety with Needed-Treatment: the Effectiveness of Outpatient Commitment. Psychiatr Q 2022; 93:55-79. [PMID: 33404994 PMCID: PMC8257759 DOI: 10.1007/s11126-020-09876-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Steven P Segal
- University of Melbourne, Melbourne, Australia. .,Mental Health and Social Welfare Research Group, School of Social Welfare, University of California, 120 Haviland Hall (MC #7400), Berkeley, CA, 94720-7400, USA.
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Segal SP. Hospital Utilization Outcomes Following Assignment to Outpatient Commitment. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 48:942-961. [PMID: 33534072 PMCID: PMC8329100 DOI: 10.1007/s10488-021-01112-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Steven P Segal
- Department of Social Work, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.
- School of Social Welfare, University of California, Berkeley, 120 Haviland Hall (MC #7400), Berkeley, CA, 94720-7400, USA.
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Kisely S, Yu D, Maehashi S, Siskind D. A systematic review and meta-analysis of predictors and outcomes of community treatment orders in Australia and New Zealand. Aust N Z J Psychiatry 2021; 55:650-665. [PMID: 32921145 DOI: 10.1177/0004867420954286] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Australia and New Zealand have some of the highest rates of compulsory community treatment order use worldwide. There are also concerns that people from culturally and linguistically diverse backgrounds may have higher rates of community treatment orders. We therefore assessed the health service, clinical and psychosocial outcomes of compulsory community treatment and explored if culturally and linguistically diverse, indigenous status or other factors predicted community treatment orders. METHODS We searched the following databases from inception to January 2020: PubMed/Medline, Embase, CINAHL and PsycINFO. We included any study conducted in Australia or New Zealand that compared people on community treatment orders for severe mental illness with controls receiving voluntary psychiatric treatment. Two reviewers independently extracted data, assessing study quality using Joanna Briggs Institute scales. RESULTS A total of 31 publications from 12 studies met inclusion criteria, of which 24 publications could be included in a meta-analysis. Only one was from New Zealand. People who were male, single and not engaged in work, study or home duties were significantly more likely to be subject to a community treatment order. In addition, those from a culturally and linguistically diverse or migrant background were nearly 40% more likely to be on an order. Indigenous status was not associated with community treatment order use in Australia and there were no New Zealand data. Community treatment orders did not reduce readmission rates or bed-days at 12-month follow-up. There was evidence of increased benefit in the longer-term but only after a minimum of 2 years of use. Finally, people on community treatment orders had a lower mortality rate, possibly related to increased community contacts. CONCLUSION People from culturally and linguistically diverse or migrant backgrounds are more likely to be placed on a community treatment order. However, the evidence for effectiveness remains inconclusive and limited to orders of at least 2 years' duration. The restrictive nature of community treatment orders may not be outweighed by the inconclusive evidence for beneficial outcomes.
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Affiliation(s)
- Steve Kisely
- School of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.,Metro South Addiction and Mental Health Services, Metro South Health Service, Woolloongabba, QLD, Australia.,Griffith Criminology Institute (GCI), Griffith University, Mount Gravatt, QLD, Australia.,Departments of Psychiatry and Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Dong Yu
- School of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
| | - Saki Maehashi
- School of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
| | - Dan Siskind
- School of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.,Metro South Addiction and Mental Health Services, Metro South Health Service, Woolloongabba, QLD, Australia
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8
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Parker S, Arnautovska U, McKeon G, Kisely S. The association between discontinuation of community treatment orders and outcomes in the 12-months following discharge from residential mental health rehabilitation. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2021; 74:101664. [PMID: 33316696 DOI: 10.1016/j.ijlp.2020.101664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/29/2020] [Accepted: 11/26/2020] [Indexed: 06/12/2023]
Abstract
To compare the post-discharge outcomes of people admitted to community-based residential mental health rehabilitation facilities subject to a Community Treatment Order (CTO) who do and do not have this order discontinued prior to discharge. People subject to a CTO who were admitted across five Community Care Units (CCUs) in Queensland, Australia between 2005 and 2014 (N = 311), were grouped based on involuntary treatment status at the time of their discharge. Individuals whose status changed to voluntary (n = 63; CTO > VOL) were compared with those whose treatment remained involuntary (n = 248; CTO-CTO) on demographic, clinical and treatment-related characteristics. Group-level and individualised changes were assessed between the year pre-admission and the year post-discharge. The primary outcome measure was change in mental health and social functioning (Health of the Nation Outcome Scale). Secondary outcomes included disability (Life Skills Profile-16), service use, accommodation instability, and involuntary treatment. Logistic regression was completed to examine predictors of CTO discontinuation during CCU care. Potential predictors covered service-, consumer-, and treatment-related characteristics. Compared to the CTO-CTO group, the CTO > VOL group had significantly longer episodes of CCU care, more frequent primary diagnoses of schizophrenia spectrum disorders, and were more likely to be female. Following discharge, CTO > VOL subjects had more frequent reliable and clinically significant improvement in HoNOS scores, as well as more frequently demonstrated reliable improvement in hospital bed use and accommodation instability than the CTO-CTO subjects. CTO discontinuation was predicted by longer duration of CCU care, being a female, and having a smaller number of psychiatry-related bed use prior admission. Our findings suggest that CCU care of sufficient duration may lessen the need for subsequent compulsory treatment in the community.
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Affiliation(s)
- Stephen Parker
- Staff Specialist - Psychiatry Metro South Addiction and Mental Health Services (MSAMHS), Brisbane, Australia; Faculty of Medicine, University of Queensland, School of Public Health, Herston, Australia.
| | - Urska Arnautovska
- Senior Research Officer PA Foundation, Princess Alexandra Hospital, Brisbane, Australia
| | - Gemma McKeon
- Clinical Neuropsychologist and Clinical Psychologist Child and Youth Mental Health Group, QIMR Berghofer Medical Research Institute, Australia; Psychosis ACU, Metro South Addiction and Mental Health Services (MSAMHS), Brisbane, Australia
| | - Steve Kisely
- Faculty of Medicine, University of Queensland, School of Public Health, Herston, Australia
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Finding Common Ground for Diverging Policies for Persons with Severe Mental Illness. Psychiatr Q 2020; 91:1193-1208. [PMID: 32857286 DOI: 10.1007/s11126-020-09821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Two diametrically opposed positions predominate discourse for the care and treatment of persons with severe mental illness: anti-deinstitutionalization and anti-institutionalization. Both share the same goal of ensuring best quality of life for those with severe psychiatric disorders, but pathways to achieving this goal are very different and have resulted in much contention. Supporters of each position espouse a different belief system regarding people with psychiatric disorders and their presumed capabilities, placing varying emphasis on maximizing protection of the community versus protection of individual rights, and result in contrasting mental health policies and practice orientations. The authors delineate the history from which these positions evolved, consequent views, and policies and practices that emerged from these differing attitudes. The article culminates in a proposed practice approach that offers a more balanced approach to serving adults with mental illness -navigating risk management by preserving freedom and opportunities of risk while affording mutually satisfactory "risk control."
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10
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Abstract
Forensic psychiatry is an established medical specialty in England and Wales. Although its origins lie in the 19th century, the development of secure hospitals accelerated in the late 20th century. Services for mentally disordered offenders in the community have developed most recently and it is these services, which are the focus of this article. We have looked broadly at community services and have included criminal justice liaison and diversion services in our remit. We have also considered partnerships between health and justice agencies as well as mental health and criminal legislation. We consider the limited research evidence in relation to community forensic services and the discussion this has provoked.
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Frank D, Fan E, Georghiou A, Verter V. Community Treatment Order Outcomes in Quebec: A Unique Jurisdiction. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:484-491. [PMID: 31818137 PMCID: PMC7298585 DOI: 10.1177/0706743719892718] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Daniel Frank
- Jewish General Hospital, Montreal, Quebec, Canada.,McGill University, Montreal, Quebec, Canada
| | - E Fan
- McGill University, Montreal, Quebec, Canada
| | | | - Vedat Verter
- Michigan State University, East Lansing, MI, USA
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12
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Duncan C, Weich S, Moon G, Twigg L, Fenton SJ, Bhui K, Canaway A, Crepaz-Keay D, Keown P, Madan J, McBride O, Parsons H, Singh S. Moving beyond randomized controlled trials in the evaluation of compulsory community treatment. J Eval Clin Pract 2020; 26:812-818. [PMID: 31359526 DOI: 10.1111/jep.13245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
Abstract
Compulsory community treatment for people with severe mental illness remains controversial due to conflicting research evidence. Recently, there have been challenges to the conventional view that trial-based evidence should take precedence. This paper adds to these challenges in three ways. First, it emphasizes the need for critiques of trials to engage with conceptual and not just technical issues. Second, it develops a critique of trials centred on both how we can have knowledge and what it is we can have knowledge of. Third, it uses this critique to develop a research strategy that capitalizes on the information in large-scale datasets.
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Affiliation(s)
- Craig Duncan
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Scott Weich
- School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Graham Moon
- School of Geography and Environmental Science, University ofSouthampton, Southampton, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Sarah-Jane Fenton
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Queen Mary University of London, London, UK
| | | | | | - Patrick Keown
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Orla McBride
- School of Psychology, Ulster University, Coleraine, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Swaran Singh
- Warwick Medical School, University of Warwick, Coventry, UK
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13
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Segal SP. The utility of outpatient civil commitment: Investigating the evidence. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 70:101565. [PMID: 32482302 PMCID: PMC7394121 DOI: 10.1016/j.ijlp.2020.101565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Steven P Segal
- Professor, University of Melbourne, Australia; Professor of the Graduate Division and Director of the Mental Health and Social Welfare Research Group, University of California, Berkeley, USA.
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14
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Barkhuizen W, Cullen AE, Shetty H, Pritchard M, Stewart R, McGuire P, Patel R. Community treatment orders and associations with readmission rates and duration of psychiatric hospital admission: a controlled electronic case register study. BMJ Open 2020; 10:e035121. [PMID: 32139493 PMCID: PMC7059496 DOI: 10.1136/bmjopen-2019-035121] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Limited evidence is available regarding the effect of community treatment orders (CTOs) on mortality and readmission to psychiatric hospital. We compared clinical outcomes between patients placed on CTOs to a control group of patients discharged to voluntary community mental healthcare. DESIGN AND SETTING An observational study using deidentified electronic health record data from inpatients receiving mental healthcare in South London using the Clinical Record Interactive Search (CRIS) system. Data from patients discharged between November 2008 and May 2014 from compulsory inpatient treatment under the Mental Health Act were analysed. PARTICIPANTS 830 participants discharged on a CTO (mean age 40 years; 63% male) and 3659 control participants discharged without a CTO (mean age 42 years; 53% male). OUTCOME MEASURES The number of days spent in the community until readmission, the number of days spent in inpatient care in the 2 years prior to and the 2 years following the index admission and mortality. RESULTS The mean duration of a CTO was 3.2 years. Patients receiving care from forensic psychiatry services were five times more likely and patients receiving a long-acting injectable antipsychotic were twice as likely to be placed on a CTO. There was a significant association between CTO receipt and readmission in adjusted models (HR: 1.60, 95% CI 1.42 to 1.80, p<0.001). Compared with controls, patients on a CTO spent 17.3 additional days (95% CI 4.0 to 30.6, p=0.011) in a psychiatric hospital in the 2 years following index admission and had a lower mortality rate (HR: 0.66, 95% CI 0.50 to 0.88, p=0.004). CONCLUSIONS Many patients spent longer on CTOs than initially anticipated by policymakers. Those on CTOs are readmitted sooner, spend more time in hospital and have a lower mortality rate. These findings merit consideration in future amendments to the UK Mental Health Act.
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Affiliation(s)
- Wikus Barkhuizen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alexis E Cullen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Hitesh Shetty
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Megan Pritchard
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Robert Stewart
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
| | - Rashmi Patel
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
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15
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Weich S, Duncan C, Twigg L, McBride O, Parsons H, Moon G, Canaway A, Madan J, Crepaz-Keay D, Keown P, Singh S, Bhui K. Use of community treatment orders and their outcomes: an observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Scott Weich
- School of Health and Related Research, University of Sheffield, Sheffield, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Craig Duncan
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Orla McBride
- School of Psychology, Ulster University, Londonderry, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Graham Moon
- School of Geography and Environmental Science, University of Southampton, Southampton, UK
| | | | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Patrick Keown
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Swaran Singh
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Jager F, Perron A. The social utility of community treatment orders: Applying Girard's mimetic theory to community-based mandated mental health care. Nurs Philos 2019; 21:e12280. [PMID: 31441197 DOI: 10.1111/nup.12280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Fiona Jager
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Amélie Perron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
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Vine R, Tibble H, Pirkis J, Judd F, Spittal MJ. Does legislative change affect the use and duration of compulsory treatment orders? Aust N Z J Psychiatry 2019; 53:433-440. [PMID: 30449132 DOI: 10.1177/0004867418812683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Ruth Vine
- 1 NorthWestern Mental Health, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,2 Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Holly Tibble
- 3 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jane Pirkis
- 3 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Fiona Judd
- 2 Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia.,4 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Matthew J Spittal
- 3 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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18
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Lei H, Barnicot K, Maynard E, Etherington A, Zalewska K, Quirk A, Sanatinia R, Cooper SJ, Crawford MJ. Factors influencing use of community treatment orders and quality of care that people receive: results of a national survey in England and Wales. BJPsych Bull 2019; 43:227-235. [PMID: 30971324 DOI: 10.1192/bjb.2019.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Aims and methodWe conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive. RESULTS: Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive-behavioural therapy.Clinical implicationsCTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.Declaration of interestNone.
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19
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Harris A, Chen W, Jones S, Hulme M, Burgess P, Sara G. Community treatment orders increase community care and delay readmission while in force: Results from a large population-based study. Aust N Z J Psychiatry 2019; 53:228-235. [PMID: 29485289 DOI: 10.1177/0004867418758920] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Anthony Harris
- 1 Brain Dynamics Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, Australia.,2 Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Wendy Chen
- 3 InforMH, Mental Health and Drug and Alcohol Office, NSW Health, North Ryde, NSW, Australia
| | - Sharon Jones
- 3 InforMH, Mental Health and Drug and Alcohol Office, NSW Health, North Ryde, NSW, Australia
| | - Melissa Hulme
- 4 Department of Psychiatry, Westmead Hospital, Wentworthville, NSW, Australia
| | - Philip Burgess
- 5 School of Public Health, The University of Queensland, Herston, QLD, Australia
| | - Grant Sara
- 2 Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,3 InforMH, Mental Health and Drug and Alcohol Office, NSW Health, North Ryde, NSW, Australia
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20
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Abstract
OBJECTIVE: To question the status of the randomised controlled trial (RCT) in the hierarchy of evidence. CONCLUSIONS: The RCT provides important and clinically relevant information, particularly in psychopharmacology. However, and as with other methodologies, RCTs too are flawed and automatic abdication to their conclusions, especially in complex social interventions, is unwise. A clinical example with conflicting and polarising views, each with their evidence base, is described alongside a suggested clinical strategy for resolving differences of opinion.
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Affiliation(s)
- John D Little
- Consultant Psychiatrist, Kapiti Community Mental Health Team, Paraparaumu, New Zealand
| | - Lorraine Davison
- Consultant Psychiatrist, Mental Health, Addictions & Intellectual Disability Service, Wellington, New Zealand
| | - Robert D Little
- Medical Registrar, The Alfred Health, Melbourne, VIC, Australia
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21
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Bardell-Williams M, Eaton S, Downey L, Bowtell M, Thien K, Ratheesh A, Killackey E, McGorry P, O'Donoghue B. Rates, determinants and outcomes associated with the use of community treatment orders in young people experiencing first episode psychosis. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:85-89. [PMID: 30616858 DOI: 10.1016/j.ijlp.2018.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/31/2018] [Accepted: 11/24/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Community treatment orders (CTOs) are a controversial form of involuntary treatment for individuals affected by mental health disorders and yet little is known about the use of CTOs in first presentations. Therefore, this study aimed to determine the rates, determinants and outcomes associated with the use of CTOs in young people with a first episode of psychosis (FEP). METHODS This epidemiological cohort study included all individuals aged 15-24 who presented with a FEP to the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne between 01.01.2011 and 31.12.13. RESULTS A total of 544 young people presented with a FEP during the study period and of these, 93 (17.3%) were subject to a CTO during their episode of care. A total of 69.7% of CTOs were commenced after the first three months of treatment and the median duration of CTOs was 168.5 days. Males, a diagnosis of a schizophrenia spectrum disorder and a concurrent substance abuse disorder were associated with the use of CTOs. Additionally, young people with more severe positive psychotic symptoms were more likely to be subject to a CTO. At the time of discharge, only 38.7% of those subject to a CTO were in education or employment compared to 65.4% of those who had not been subject to a CTO. CONCLUSIONS The majority of CTOs are commenced after at least three months of treatment, however the optimal timing of CTO implementation needs to be determined. The poor functioning of young people on a CTO should be the focus of future interventional studies.
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Affiliation(s)
- Melissa Bardell-Williams
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia
| | - Scott Eaton
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia
| | - Linglee Downey
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia
| | - Meghan Bowtell
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia
| | - Kristen Thien
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia
| | - Aswin Ratheesh
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia; Orygen Youth Health, 35 Poplar Rd, Parkville, Melbourne, Australia
| | - Eoin Killackey
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia
| | - Patrick McGorry
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia
| | - Brian O'Donoghue
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Rd, Parkville, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, Australia; Orygen Youth Health, 35 Poplar Rd, Parkville, Melbourne, Australia.
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Moss K, Wyder M, Braddock V, Arroyo D, Kisely S. Compulsory community treatment and ethnicity: Findings from a culturally and linguistically diverse area of Queensland. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:154-159. [PMID: 30274852 DOI: 10.1016/j.ijlp.2018.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/31/2018] [Accepted: 09/19/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To compare the use of community treatment orders (CTOs) and forensic orders (FOs) in a culturally and linguistically diverse (CALD) population to that in a non-CALD population. METHODS We analysed the relationship between coming from a CALD background and the use of CTOs and FOs on discharge from hospital using merged data from the Metro South Addiction and Mental Health Service's Transitions of Care (ToC) and Consumer Integrated Mental Health Application (CIMHA) databases. RESULTS Nine hundred and seventy-six individual records were included in the data set, of whom eighty-six were from a CALD background (8.8%). Three hundred and eleven patients were on compulsory community treatment. Use of compulsory community treatment (CTOs and FOs) was similar for those born in Australasia, British Isles, North America and Europe but significantly higher for those born elsewhere even after adjusting for socio-demographic and clinical variables (Adj OR 2.19, 95% CI 1.36-3.52). The use of an interpreter significantly increased the likelihood of compulsory community treatment (Adj OR 2.76, 95% CI 1.20-6.35). Restricting the analyses to CTOs only did not alter these results. CONCLUSIONS Metro South residents from a CALD background outside of Europe were over-represented on compulsory community treatment orders. This could reflect the difficulties in accessing voluntary services, communication barriers, stigma associated with mental illness, discrimination, or issues related to accurately diagnosing mental illness cross-culturally. Clinicians need to be aware of the complexity of working with people from diverse cultures and apply these orders judiciously.
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Affiliation(s)
- Katherine Moss
- Metro South Addiction and Mental Health Services, University of Queensland, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Marianne Wyder
- Metro South Addiction and Mental Health Services, University of Queensland, Brisbane, QLD, Australia
| | - Vivienne Braddock
- Metro South Addiction and Mental Health Services, University of Queensland, Brisbane, QLD, Australia
| | - David Arroyo
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health Services, University of Queensland, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
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Barnett P, Matthews H, Lloyd-Evans B, Mackay E, Pilling S, Johnson S. 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. Lancet Psychiatry 2018; 5:1013-1022. [PMID: 30391280 PMCID: PMC6251967 DOI: 10.1016/s2215-0366(18)30382-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/07/2018] [Accepted: 09/17/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Phoebe Barnett
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK.
| | - Hannah Matthews
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK
| | | | - Euan Mackay
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness, Department of Clinical Educational and Health Psychology, University College London, London, UK; NIHR Policy Research Unit, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Policy Research Unit, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
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Weich S, Duncan C, Bhui K, Canaway A, Crepaz-Keay D, Keown P, Madan J, McBride O, Moon G, Parsons H, Singh S, Twigg L. Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study. BMJ Open 2018; 8:e024193. [PMID: 30341141 PMCID: PMC6196959 DOI: 10.1136/bmjopen-2018-024193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Scott Weich
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Craig Duncan
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Barts and The London School of Medicine & Dentist, University of London, London, UK
| | | | | | - Patrick Keown
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Jason Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Orla McBride
- School of Psychology, Ulster University, Londonderry, UK
| | - Graham Moon
- Geography and Environment, Ulster University, Southampton, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Swaran Singh
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
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Stomski NJ, Morrison P, Whitely M, Brennan P. Mental Health Consumers' Motives for Seeking Advocacy Support: A Qualitative Exploration. Community Ment Health J 2018; 54:607-615. [PMID: 29094230 DOI: 10.1007/s10597-017-0177-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/28/2017] [Indexed: 10/18/2022]
Abstract
Advocacy plays a vital role in ensuring that mental health consumers' rights are maintained. However, the primary issues for which consumers seek advocacy support remain unknown. Understanding these issues provides a sound basis from which advocacy organisations may develop a clear service delivery focus. This study addresses the literature gap through presenting a qualitative analysis of 60 records from an advocacy service. Four major themes emerged, across which two key issues were dominant: the sense of fearfulness and disempowerment. These issues accentuate the importance of advocates in enhancing the agency of mental health consumers.
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Affiliation(s)
- N J Stomski
- School of Health Professions, Murdoch University, 90 South St, Murdoch, WA, 6150, Australia.
| | - P Morrison
- School of Health Professions, Murdoch University, 90 South St, Murdoch, WA, 6150, Australia
| | - M Whitely
- Health Policy and Research, Health Consumers Council (WA), 40 Lord St, East Perth, 6004, Western Australia, Australia
| | - P Brennan
- Health Consumers Council (WA), 40 Lord St, East Perth, 6004, Western Australia, Australia
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Völlm BA, Clarke M, Herrando VT, Seppänen AO, Gosek P, Heitzman J, Bulten E. European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders. Eur Psychiatry 2018; 51:58-73. [PMID: 29571072 DOI: 10.1016/j.eurpsy.2017.12.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 01/15/2023] Open
Abstract
Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.
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Affiliation(s)
- Birgit A Völlm
- Section of Forensic Mental Health, Division of Psychiatry and Applied Psychology, University of Nottingham, Institute of Mental Health, Triumph Road, Nottingham NG7 2TU, United Kingdom.
| | - Martin Clarke
- Nottinghamshire Healthcare NHS Foundation Trust, Institute of Mental Health, Triumph Road, Nottingham NG7 2TU, United Kingdom.
| | - Vicenç Tort Herrando
- Unitat Polivalent de Psiquaitria Quatre Camins, Penitentiary Psychiatry, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, Barcelona, Spain
| | - Allan O Seppänen
- Helsinki University Hospital Psychoses and Forensic Psychiatry Vanha Valtatie 198, 04500 Kellokoski, Finland & Vanha Vaasa Hospital Vierinkiventie 1, 65380 Vaasa, Finland
| | - Paweł Gosek
- Department of Forensic Psychiatry, Institute of Psychiatry and Neurology, 9 Sobieskiego St., 02-957 Warsaw, Poland
| | - Janusz Heitzman
- Department of Forensic Psychiatry, Institute of Psychiatry and Neurology, 9 Sobieskiego St., 02-957 Warsaw, Poland
| | - Erik Bulten
- The Pompe Foundation, Forensic Psychiatric Centre Pompestichting, Nijmegen, Netherlands; Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, Netherlands
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Krieger E, Moritz S, Weil R, Nagel M. Patients' attitudes towards and acceptance of coercion in psychiatry. Psychiatry Res 2018; 260:478-485. [PMID: 29287276 DOI: 10.1016/j.psychres.2017.12.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 11/18/2022]
Abstract
Coercive interventions for psychiatric patients are controversial. Research on different preventive measures has increased over the last years. The present study examined patients' attitudes towards and understanding of previously experienced coercive measures as well as their preferences related to coercive measures and possible alternatives. In total, 213 patients who had experienced coercion and 51 patient controls (patients staying voluntarily on a closed ward with no coercive treatment) from three acute wards were examined via expert interviews and questionnaires in the framework of a naturalistic trial. Assessments included a new self-developed questionnaire as well as instruments measuring psychopathology. Patients who had experienced coercion differed from controls in both symptoms and insight into their illness. As expected, "noninvasive measures" (e.g., the use of a "soft room," observation in seclusion) were better accepted by patients than "invasive measures" (e.g., mechanical restraint, forced medication). Forced medication and mechanical restraint were less well accepted than involuntary hospitalization, seclusion, or video surveillance. The retrospective understanding of coercive measures increased over the course of treatment. In addition, patients rated a number of options for reducing coercion on the wards, particularly music or exercises. A large subgroup indicated they would like to discuss future admissions with the staff.
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Affiliation(s)
- Eva Krieger
- Department of Psychiatry and Psychotherapy, Asklepios Clinic Nord-Wandsbek, Jüthornstraße 71, 22043 Hamburg, Germany; University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
| | - Steffen Moritz
- University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
| | - Ricarda Weil
- University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
| | - Matthias Nagel
- Department of Psychiatry and Psychotherapy, Asklepios Clinic Nord-Wandsbek, Jüthornstraße 71, 22043 Hamburg, Germany.
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Abstract
OBJECTIVES To explore a contradiction between evidence suggesting community treatment order (CTO) ineffectiveness and clinical experience. CONCLUSIONS The literature pertaining to CTOs actually provides an evidence base for both positions. The headline that three randomised controlled trials and subsequent meta-analyses fail to demonstrate significant differences between groups reflects selection bias. A case may still be made for CTOs.
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Affiliation(s)
- John Little
- Consultant Psychiatrist, Kapiti Community Mental Health Team, Capital & Coast District Health Board, Wellington, New Zealand
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Abstract
SummaryIn the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.Learning Objectives• Gain an overview of the development and use of CTOs in the UK and internationally• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future
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Burns T, Kisely S, Rugkåsa J. Randomised controlled trials and outpatient commitment. Lancet Psychiatry 2017; 4:e31. [PMID: 29179942 DOI: 10.1016/s2215-0366(17)30442-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Tom Burns
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX, UK; University College London, London, UK.
| | - Steve Kisely
- Faculty of Medicine, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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Vergunst F, Rugkåsa J, Koshiaris C, Simon J, Burns T. Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study. Soc Psychiatry Psychiatr Epidemiol 2017; 52:1375-1384. [PMID: 28900690 DOI: 10.1007/s00127-017-1442-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 08/31/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients' social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients' long-term social outcomes. METHODS A sub-sample (n = 114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health. RESULTS No significant association was found between the duration of CTO intervention and social network size (IRR = 0.996, p = .63), objective social outcomes (B = -0.003, p = .77), health-related quality of life (B = 0.001, p = .77), and capabilities (B = 0.046, p = .41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SD = 5.9) contacts in their social networks, 42% of whom were relatives. CONCLUSIONS CTO duration was not associated with improvements in patients' social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.
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Affiliation(s)
- Francis Vergunst
- Research Unit On Children's Psychosocial Maladjustment, University of Montreal, 3175 Chemin de la Côte Ste-Catherine, Montreal, H3T 1C5, Canada. .,Department of Psychiatry, University of Oxford, Oxford, UK.
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University College of Southeast Norway, Notodden, Norway
| | | | - Judit Simon
- Department of Health Economics, Centre for Public Health, Medical University of Vienna, Vienna, Austria.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
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Sfetcu R, Musat S, Haaramo P, Ciutan M, Scintee G, Vladescu C, Wahlbeck K, Katschnig H. Overview of post-discharge predictors for psychiatric re-hospitalisations: a systematic review of the literature. BMC Psychiatry 2017; 17:227. [PMID: 28646857 PMCID: PMC5483311 DOI: 10.1186/s12888-017-1386-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND High levels of hospital readmission (rehospitalisation rates) is widely used as indicator of a poor quality of care. This is sometimes also referred to as recidivism or heavy utilization. Previous studies have examined a number of factors likely to influence readmission, although a systematic review of research on post-discharge factors and readmissions has not been conducted so far. The main objective of this review was to identify frequently reported post-discharge factors and their effects on readmission rates. METHODS Studies on the association between post-discharge variables and readmission after an index discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. Relevant articles published between January 1990 and June 2014 were included. A systematic approach was used to extract and organize in categories the information about post-discharge factors associated with readmission rates. RESULTS Of the 760 articles identified by the initial search, 80 were selected for this review which included a total number of 59 different predictors of psychiatric readmission. Subsequently these were grouped into four categories: 1) individual vulnerability factors, 2) aftercare related factors, 3) community care and service responsiveness, and 4) contextual factors and social support. Individual factors were addressed in 58 papers and were found to be significant in 37 of these, aftercare factors were significant in 30 out of the 45 papers, community care and social support factors were significant in 21 out of 31 papers addressing these while contextual factors and social support were significant in all seven papers which studied them. CONCLUSIONS This review represents a first attempt at providing an overview of post-discharge factors previously studied in association with readmission. Hence, by mapping out the current research in the area, it highlights the gaps in research and it provides guidance future studies in the area.
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Affiliation(s)
- R. Sfetcu
- National School of Public Health, Management and Professional Development, Bucharest, Romania ,grid.445726.6Psychology Department, Spiru Haret University, Bucharest, Romania
| | - S. Musat
- National School of Public Health, Management and Professional Development, Bucharest, Romania
| | - P. Haaramo
- National Institute for Health and Welfare, Mental Health Unit, Helsinki, Finland
| | - M. Ciutan
- National School of Public Health, Management and Professional Development, Bucharest, Romania
| | - G. Scintee
- National School of Public Health, Management and Professional Development, Bucharest, Romania
| | - C. Vladescu
- National School of Public Health, Management and Professional Development, Bucharest, Romania ,0000 0001 0504 4027grid.22248.3eVictor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - K. Wahlbeck
- National Institute for Health and Welfare, Mental Health Unit, Helsinki, Finland
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Morrison P, Stomski NJ, Whitely M, Brennan P. Understanding advocacy practice in mental health: a multidimensional scalogram analysis of case records. J Ment Health 2017; 27:127-134. [PMID: 28480771 DOI: 10.1080/09638237.2017.1322183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few studies have examined mental health consumers' motives for seeking advocacy assistance. AIMS This study aimed to identify factors that influenced mental health consumers' use of advocacy services. METHODS The analysis was based on 60 case records that were sourced from a community advocacy service. Each record was dichotomously coded across 11 variables to generate a series of categorical data profiles. The data set was then analysed using multidimensional scalogram analysis to reveal key relationships between subsets of variables. RESULTS The results indicated that mental health consumers commonly reported a sense of fear, which motivated them to contact the advocacy service in the hope that advocates could intervene on their behalf through effective communication with health professionals. Advocates often undertook such intervention either through attending meetings between the consumer and health professionals or contacting health professionals outside of meetings, which was typically successful in terms of achieving mental health consumers' desired outcome. The resolution of most concerns suggests that they were often legitimate and not the result of a lack of insight or illness symptoms. CONCLUSION Health professionals might consider exploring how they respond when consumers or carers raise concerns about the delivery of mental health care.
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Affiliation(s)
- Paul Morrison
- a School of Health Professions, Murdoch University , Murdoch , Western Australia , Australia
| | - Norman J Stomski
- a School of Health Professions, Murdoch University , Murdoch , Western Australia , Australia
| | - Martin Whitely
- b Health Policy and Research, Health Consumers Council (WA) , East Perth , Western Australia , Australia , and
| | - Pip Brennan
- c Health Consumers Council (WA) , East Perth , Western Australia , Australia
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Abstract
BACKGROUND In recent years, an increasing number of countries have introduced outpatient commitment orders (OC), which imply that patients can be subject to compulsory follow-up and treatment while living in the community. However, few studies on how OC is practised have been published. METHOD Retrospective case register study based on medical files of all patients receiving an OC order in 2008-2012. We used a pre/post design, recording the use of inpatient services three years before and three years after for those patients who received their first ever OC order in 2008 and 2009. RESULTS A total of 345 OC orders applying to 286 persons were identified in the study period 2008-2012. Incidence and prevalence rates were relatively stable, but decreased during the last years of the study period. For all the 54 patients receiving their first ever OC order in 2008 and 2009, need for treatment was the reason for imposing OC, and all received psychotropic medication. The number of inpatient admissions and inpatient days was greater, while the number of days for each admission was lower three years after the OC order than three years before. The first ever OC lasted under a year for 76% of the patients. Receiving depot medication and follow-up by psychiatrists predicted longer OC durations than such treatment and care by psychologists. Only nine patients were not hospitalized during the three-year follow-up after the first ever OC order. CONCLUSION Patients on first ever OC orders in Northern Norway used inpatient services more after OC orders than before. Further studies are needed to explore whether increased use of inpatient services by OC patients is beneficial or a failure of OC.
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What does being on a community treatment orders entail? A 3-year follow-up of the OCTET CTO cohort. Soc Psychiatry Psychiatr Epidemiol 2017; 52:465-472. [PMID: 27816998 DOI: 10.1007/s00127-016-1304-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Community Treatment Orders lack evidence of effectiveness. Very little is known about how they are used in practice and over time in terms of what it obliges patients to do and the judicial threshold for remaining on an order. AIMS To investigate CTO implementation in England in terms of the use of specified conditions, and judicial hearings; whether these change over time, and; the level of continued coercion. METHOD 36-month observational prospective study of patients on CTO in the OCTET follow-up study. RESULTS The number of CTO conditions remained stable over time but consolidated around medication adherence and remaining in contact with services. Ten percent of Mental Health Tribunal Hearings and only 1 percent of Hospital Managers Hearings resulted in discharge. Twenty-seven percent of patients experienced more than one CTO episode and eighteen percent remained under compulsion until the end of follow-up. CONCLUSIONS CTOs seem to be used primarily to oblige patients to take medication and stay in contact with services. There is agreement between clinical and legal judgements about their appropriateness and threshold for use. A pattern of continuous coercion for a significant group of patients raises concerns. If CTOs are to be continued to be imposed, their use should be carefully monitored with further cohort studies with long-term follow-up.
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Kisely SR, Campbell LA, O'Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2017; 3:CD004408. [PMID: 28303578 PMCID: PMC6464695 DOI: 10.1002/14651858.cd004408.pub5] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Steve R Kisely
- The University of QueenslandSchool of MedicinePrincess Alexandra HospitalIpswich RoadWoolloongabbaQueenslandAustraliaQLD 4102
| | - Leslie A Campbell
- Dalhousie UniversityDepartment of Community Health and EpidemiologyRoom 415, 5790 University AvenueHalifaxNSCanadaB3K 1V7
| | - Richard O'Reilly
- Western UniversityMental Health Building, Parkwood InstituteLondon, OntarioCanadaN6C 0A7
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Stomski N, Morrison P, Whitely M, Brennan P. Advocacy processes in mental health: a qualitative study. QUALITATIVE RESEARCH IN PSYCHOLOGY 2017. [DOI: 10.1080/14780887.2017.1282567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Norman Stomski
- Murdoch University, School of Health Professions, Murdoch, Australia
| | - Paul Morrison
- Murdoch University, School of Health Professions, Murdoch, Australia
| | | | - Pip Brennan
- Health Consumers Council, East Perth, Australia
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Light EM, Robertson MD, Boyce P, Carney T, Rosen A, Cleary M, Hunt GE, O'Connor N, Ryan CJ, Kerridge IH. How shortcomings in the mental health system affect the use of involuntary community treatment orders. AUST HEALTH REV 2017; 41:351-356. [DOI: 10.1071/ah16074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/03/2016] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n = 5), carers (n = 6), clinicians (n = 15) and members of the Mental Health Review Tribunal of NSW (n = 12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.
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Community Treatment Orders-A pause for thought. Asian J Psychiatr 2016; 24:1-4. [PMID: 27931888 DOI: 10.1016/j.ajp.2016.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 11/23/2022]
Abstract
Community Treatment Orders (CTO) have been available for several decades in some countries and are being progressively introduced worldwide, with significant uptake in Asian countries as they move more mental health care into the community. However the evidence for the effectiveness of CTOs is limited. The evidence from local audits and evaluations is conflicted with some studies showing clear benefit and others not. The same is the case for uncontrolled before and after studies. The higher levels of evidence such as randomised controlled trials, systematic reviews, and Cochrane reviews have consistently failed to demonstrate benefits from CTO use on key measures such as symptom levels, functioning, and healthcare use. Despite this they are increasingly available internationally and often greeted enthusiastically by clinicians and families who want to ensure care and follow up for the mentally ill. This article briefly discusses the evidence before describing potential alternatives to the use of compulsion that do have an evidence base, such as multidisciplinary community working, housing initiatives, and employment support.
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Burns T, Rugkåsa J, Yeeles K, Catty J. Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04210] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BackgroundCoercion 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.DesignThe 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.ParticipantsParticipants 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.OutcomesThe 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.ResultsCommunity 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.ConclusionsCommunity 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 registrationCurrent Controlled Trials ISRCTN73110773.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jorun Rugkåsa
- Department of Psychiatry, University of Oxford, Oxford, UK
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Ksenija Yeeles
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jocelyn Catty
- Department of Psychiatry, University of Oxford, Oxford, UK
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Recall of patients on community treatment orders over three years in the OCTET CTO cohort. BMC Psychiatry 2016; 16:392. [PMID: 27829396 PMCID: PMC5103421 DOI: 10.1186/s12888-016-1102-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Randomised studies consistently show that Community Treatment Orders (CTOs) do not have the intended effect of preventing relapse and readmissions of patients with severe and enduring mental illness. Critics suggest this in part can be explained by RCTs studying newly introduced CTO regimes and that patients therefore were not brought back to hospital for short-term observations ('recall') as frequently as intended. Our purpose was (i) to test the hypothesis that CTO practice as regards recall of patients to hospital in England and Wales was as rigorous under the OCTET trial period as in current routine use and (ii) to investigate the reasons for and outcomes of recalls and whether this changed over time. METHOD Thirty six-month observational prospective study of 198 patients in the OCTET Follow-up Study. RESULTS Forty percent of patients were recalled, 19 % more than once. This is in line with current national use. Deterioration in clinical condition was the most common reason for recalls (49 %), and 68 % of recalls resulted in revocation of the order (i.e., retention in hospital under compulsion). This pattern remained stable over time. CONCLUSION The use of recall cannot explain why RCTs have not confirmed any benefits from CTOs, and their continued use should be reconsidered. TRIAL REGISTRATION The OCTET Trial was retrospectively registered on 12 November 2009 ( ISRCTN73110773 ).
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Pai N, Vella SL. Are community treatment orders counterproductive? Asian J Psychiatr 2016; 23:125-127. [PMID: 27969069 DOI: 10.1016/j.ajp.2016.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/23/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Nagesh Pai
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Shae-Leigh Vella
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia.
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Løvsletten M, Haug E, Granerud A, Nordby K, Smaaberg T. Prevalence and management of patients with outpatient commitment in the mental health services. Nord J Psychiatry 2016; 70:401-6. [PMID: 26899039 DOI: 10.3109/08039488.2015.1137969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background People with mental health problems are mostly treated within the community. The law allows for the use of compulsory mental health care both in hospital and in the community. Various forms of outpatient commitment (OC) have been adopted in much European legislation. To be subjected to OC is a serious intervention in a person's life. Aim The purpose of this study is to gain knowledge about patients who undergo OC. The study explores the incidence and prevalence of OC in a geographical area, the central characteristics of the sample, and how the framework for follow-up treatment for patients to resolve OC works. Methods The data were collected from a review of electronic patient records. The statistical methods used in this study were descriptive analysis, with frequency analysis and cross-tabulation analysis. Results The main finding in the present study is that the use of OC has increased. An important finding is that most of the patients have a decision made for OC that is justified by the treatment criterion. The present study shows that there is insufficient documentation on statutory responsibilities for follow-up treatment of patients with an OC. Conclusions This study shows that the use of OC has increased. It should be considered whether implemented measures to reduce the use of coercion have the desired effect.
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Affiliation(s)
- Maria Løvsletten
- a Division of Mental Health Care , Innlandet Hospital Trust , Brumunddal , Norway
| | - Elisabeth Haug
- b Division of Mental Health Care , Innlandet Hospital Trust , Reinsvoll , Norway
| | - Arild Granerud
- c Faculty of Public Health , Hedmark University College , Elverum , Norway
| | - Kjell Nordby
- d Division of Mental Health Care , Innlandet Hospital Trust , Sanderud , Norway
| | - Toril Smaaberg
- e Occupational Therapist, Division of Mental Health Care , Innlandet Hospital Trust , Sanderud , Norway
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Burns T, Rugkåsa J. Hospitalisation and compulsion: the research agenda. Br J Psychiatry 2016; 209:97-8. [PMID: 27482036 DOI: 10.1192/bjp.bp.116.181297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 05/05/2016] [Indexed: 11/23/2022]
Abstract
Keown et al's paper highlights the complex nature of social determinants of hospital admission and compulsory care. We review here how research into compulsion in mental health has progressed beyond epidemiological studies of rates of admission. There is now a wider recognition of the range of compulsory and coercive processes used and how they are experienced by patients. The results of recent studies have confirmed the importance of confronting the complexity that Keown et al have presented. They have also produced unexpected and intriguing findings that set the direction for future research.
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Affiliation(s)
- Tom Burns
- Tom Burns, DSc, Department of Psychiatry, University of Oxford, Oxford, UK; Jorun Rugkåsa, PhD, Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway, and Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jorun Rugkåsa
- Tom Burns, DSc, Department of Psychiatry, University of Oxford, Oxford, UK; Jorun Rugkåsa, PhD, Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway, and Department of Psychiatry, University of Oxford, Oxford, UK
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Riley H, Lorem GF, Høyer G. Community treatment orders – what are the views of decision makers? J Ment Health 2016; 27:97-102. [DOI: 10.1080/09638237.2016.1207230] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Henriette Riley
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway,
- Department of Community Medicine, The Arctic University of Norway, Tromsø, Norway, and
| | - Geir Fagerjord Lorem
- Department of Health and Care Sciences, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
| | - Georg Høyer
- Department of Community Medicine, The Arctic University of Norway, Tromsø, Norway, and
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DeRidder R, Molodynski A, Manning C, McCusker P, Rugkåsa J. Community treatment orders in the UK 5 years on: a repeat national survey of psychiatrists. BJPsych Bull 2016; 40:119-23. [PMID: 27280030 PMCID: PMC4887727 DOI: 10.1192/pb.bp.115.050773] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 04/03/2015] [Accepted: 04/16/2015] [Indexed: 11/23/2022] Open
Abstract
Aims and method Community treatment orders (CTOs) are increasingly embedded into UK practice and their use continues to rise. However, they remain highly controversial. We surveyed psychiatrists to establish their experiences and current opinions of using CTOs and to compare findings with our previous survey conducted in 2010. Results The opinions of psychiatrists in the UK have not changed since 2010 in spite of recent evidence questioning the effectiveness of CTOs. Clinical factors (the need for engagement and treatment adherence, and the achievement of adherence and improved insight) remain the most important considerations in initiating and discharging a CTO. Clinical implications Given the accumulating evidence from research and clinical practice that CTOs do not improve outcomes, it is concerning that psychiatrists' opinions have not altered in response, particularly given the implications for patient care.
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Affiliation(s)
- Ritz DeRidder
- Berkshire Healthcare NHS Foundation Trust, Reading, UK
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Taylor M, Macpherson M, Macleod C, Lyons D. Community treatment orders and reduced time in hospital: a nationwide study, 2007-2012. BJPsych Bull 2016; 40:124-6. [PMID: 27280031 PMCID: PMC4887728 DOI: 10.1192/pb.bp.115.051045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims and method Community treatment orders (CTOs) were introduced in Scotland in 2005, but are controversial owing to a lack of supportive randomised evidence. The non-randomised studies provide mixed results on their efficacy and utility. We aimed to examine hospital bed day usage across Scotland both before and after CTOs were initiated in a national cohort of patients, spanning 5 years. Results In total, 1558 individuals who were subject to a CTO between 2007 and 2012, of whom 63% were male, were included. After CTO initiation the number of hospital bed days fell, on average, from 66 to 39 per annum per patient. Those with a longer psychiatric history appeared to benefit more from a CTO, in terms of reduced time in hospital. Clinical implications Our data offer cautious support for the use of CTOs in routine practice, in terms of reducing time spent in psychiatric hospital. This finding is balanced by the more rigorous randomised studies which do not find any benefit to CTOs.
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Affiliation(s)
- Mark Taylor
- Royal Edinburgh Hospital, UK; University of Edinburgh, UK; University of Queensland, Australia
| | | | | | - Donald Lyons
- Mental Welfare Commission for Scotland, Edinburgh, UK
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Heun R, Dave S, Rowlands P. Little evidence for community treatment orders - a battle fought with heavy weapons. BJPsych Bull 2016; 40:115-8. [PMID: 27280029 PMCID: PMC4887726 DOI: 10.1192/pb.bp.115.052373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Reinhard Heun
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Subodh Dave
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Paul Rowlands
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
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Vine R, Turner S, Pirkis J, Judd F, Spittal MJ. Mental health service utilisation after a Community Treatment Order: A comparison between three modes of termination. Aust N Z J Psychiatry 2016; 50:363-70. [PMID: 26304675 DOI: 10.1177/0004867415599847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ruth Vine
- NorthWestern Mental Health, Parkville, VIC, Australia Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | | | - Jane Pirkis
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Fiona Judd
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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