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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Variation in the use of compulsory community treatment orders between district health boards in New Zealand

OBJECTIVE

To report rates of Compulsory Community Treatment Order (CTO) use by District Health Boards (DHBs) in New Zealand and analyse whether socio-demographic factors explain any variability.

METHODS

The annualised rate of CTO use per 100,000 population was calculated for the years 2009-2018 using national databases. Rates were adjusted for age, gender, ethnicity, and deprivation and are reported according to DHBs to allow comparisons between regions.

RESULTS

The annualised rate of CTO use for New Zealand was 95.5 per 100,000 population. CTO use varied between DHBs from 53 to 184 per 100,000 population. Standardising for demographic variables and deprivation made little difference to this variation. CTO use was higher in males and young adults. Rates for Māori were more than three times that of Caucasian people. CTO use increased as deprivation became more severe.

CONCLUSIONS

CTO use increases with Maori ethnicity, young adulthood, and deprivation. Adjusting for socio-demographic factors does not explain the wide variation in CTO use between DHBs in New Zealand. Other regional factors appear to be the major driver of variation in CTO use.

The association between Compulsory Community Treatment Order status and mortality in New Zealand

BACKGROUND

Compulsory Community Treatment Orders (CTOs) enable psychiatric medication without the need for consent. Careful scrutiny of outcomes including mortality is required to ensure compulsory treatment is evidence-based and ethical.

AIMS

To report mortality for patients placed on CTOs and analyse data according to CTO status, mortality cause and diagnosis.

METHOD

Data for all patients placed under CTOs between 1 January 2009 and 31 December 2018 was provided by the Ministry of Health, New Zealand. Data included diagnostic and demographic information, dates of CTOs, and any dates and causes of death. Deaths were categorised into suicides, accidents and assaults, and medical causes. Mortality data are reported according to CTO status and diagnosis.

RESULTS

A total of 14 726 patients were placed on CTOs over the study period, during which there were 1328 deaths. The mortality rate was 2.97 on and 2.31 off CTOs (rate ratio 1.29, 95% CI 1.14-1.45; P < 0.01). The mortality rate for accidents and assaults was 0.44 on and 0.25 off CTOs (rate ratio 1.73, 95% CI 1.23-2.42; P < 0.01). The mortality rate for medical causes was 2.33 on and 1.90 off CTOs (rate ratio 1.22, 95% CI 1.07-1.40; P < 0.01). The suicide rate was 0.20 on and 0.15 off of CTOs (rate ratio 1.33, 95% CI 0.81-2.12; P = 0.22).

CONCLUSIONS

Increased care and medication provided during compulsory treatment does not the modify the course of illness sufficiently to reduce mortality during CTOs. Higher mortality rates during CTO periods compared with non-CTO periods may reflect greater unwellness during CTOs.

Imprisonment following discharge from mental health units: A developing trend in New Zealand

INTRODUCTION

Contemporary models of care for people with mental disorders continue to shift to community-based care, requiring fewer inpatient mental health beds, shorter inpatient lengths of stay, and less use of coercion. It has been suggested that some mentally unwell people, whose behavior can no longer be safely contained in overstretched mental health units where seclusion and restraint are discouraged, are now left to the criminal justice system to manage. It is unclear whether the risk of imprisonment following discharge from a mental health unit has increased over recent years.

METHODS

A quantitative, retrospective cohort study design was used to investigate any association between an acute inpatient mental health service admission in Aotearoa (New Zealand), and referral to a prison mental health team within 28 days of hospital discharge, from 2012 to 2020. Data were extracted from the national mental health dataset managed by the Ministry of Health.

RESULTS

Risk of imprisonment within 28 days of inpatient discharge increased over the study period. People experiencing this outcome were more likely to be younger, male, of Mâori or Pacific ethnicity, presenting with substance use and psychotic disorders who were aggressive or overactive, and were subject to coercive interventions such as seclusion and compulsory treatment during their admission.

DISCUSSION

We concluded that contemporary models of less coercive predominantly community based mental health care may be increasingly reliant on the criminal justice system to manage aggressive and violent behavior driven by mental illness. It is argued from a human rights perspective that mental health inpatient units should retain the capacity to safely manage this type of clinical presentation.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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