Compulsory community and involuntary outpatient treatment for people with severe mental disorders

Community Treatment Orders use Among Persons With a First Episode of Psychosis in Quebec

OBJECTIVES

Specialized early intervention for psychosis can reduce the duration of untreated psychosis and improve clinical and functional outcomes. However, poor adherence to treatment is frequent. The literature on community treatment orders (CTOs) use in first-episode psychosis (FEP) as a means to improve treatment adherence is limited. In the context of early intervention for psychosis services (EIS), this study aims to describe (1) the frequency of CTOs utilisation, (2) the trend of CTOs use over time, (3) the timing and reasons for requesting CTOs and (4) the baseline characteristics of FEP patients on CTOs compared to those who were not.

METHOD

A 5-year prospective longitudinal study describing the use of CTOs among persons with FEP admitted to two urban EIS in Montreal, Quebec, from 2005 to 2013. At admission, and then annually for 5 years, CTOs data were collected through chart review. Baseline characteristics, assessed by patient interviews, standardized questionnaires and chart review, included socio-demographic data, illness severity, functioning and alcohol and substance use. Descriptive analyses were performed, and FEP patients on CTOs during follow-up and those who were not were compared using analyses of variance, chi-square test and multivariate logistic regression.

RESULTS

Among 567 FEP patients, 19.2% were placed on CTOs. The main reasons for requesting CTOs were to prevent further deterioration in mental state, social functioning, harmful behaviours to self and others and homelessness. FEP patients on CTOs had poorer premorbid and baseline functioning, more severe symptoms and social dysfunction at admission, including legal problems and homelessness.

CONCLUSIONS

CTOs can be a tool to improve adherence to treatment, which is crucial for relapse prevention in FEP. However, since it is a coercive method that limits a person's fundamental rights, further research is warranted to assess its impact on patients' lives, clinical and functional outcomes, as well as patients' and carers' perception.

Utility and validity of the Brief Psychiatric Rating Scale (BPRS) as a transdiagnostic scale

The Brief Psychiatric Rating Scale (BPRS) was originally conceived to assess psychopathology in several psychiatric disorders, making it an appropriate candidate to be used as a transdiagnostic instrument. We analyzed the utility and validity of the BPRS in a diagnostically heterogeneous sample of 600 psychiatric inpatients. As a comparator, we chose the mini-ICF-APP, a scale used to measure functioning and impairment across the diagnostic spectrum. Both scales had good internal consistency. The BPRS and the mini-ICF-APP showed a moderate correlation, with good levels of agreement. We were able to identify general symptoms present across the diagnostic spectrum, influencing severity and a cluster of symptoms specific for each diagnosis. Our results show the utility and validity of the BPRS as a transdiagnostic assessment tool that could easily be introduced in routine clinical work.

Pharmacological treatment of violence in schizophrenia

Chronic aggression and violence in schizophrenia are rare, but receive disproportionate negative media coverage. This contributes to the stigma of mental illness and reduces accessibility to mental health services. Substance Use Disorders (SUD), antisocial behavior, non-adherence and recidivism are known risk factors for violence. Treatment with antipsychotic medication can reduce violence. Aside from clozapine, long-acting injectable antipsychotics (LAI) appear to be superior to oral antipsychotics for preventing violence, addressing adherence and recidivism. LAI also facilitate the implementation of functional skills training. For the high-risk recidivist target population with schizophrenia, better life skills have the potential to also reduce the risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others. High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in comorbid risk factors such as SUDs.

Mental Health Consumers' Motives for Seeking Advocacy Support: A Qualitative Exploration

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.

Compulsory psychiatric treatment checklist: Instrument development and clinical application

Instruments designed to evaluate the necessity of compulsory psychiatric treatment (CPT) are scarce to non-existent. We developed a 25-item Checklist (scoring 0 to 50) with four clusters (Legal, Danger, Historic and Cognitive), based on variables identified as relevant to compulsory treatment. The Compulsory Treatment Checklist (CTC) was filled with information on case (n=324) and control (n=251) subjects, evaluated under the Portuguese Mental Health Act (Law 36/98), in three hospitals. For internal validation, we used Confirmatory Factor Analysis (CFA), testing unidimensional and bifactor models. Multilevel logistic regression model (MLL) was used to predict the odds ratio (OR) for compulsory treatment based on the total scale score. Receiver Operating Characteristic analysis (ROC) was performed to predict compulsory treatment. CFA revealed the best fit indexes for the bifactor model, with all items loading on one General factor and the residual loading in the a priori predicted four specific factors. Reliability indexes were high for the General factor (88.4%), and low for specific factors (<5%), which demonstrate that CTC should not be performed in the subscales to access compulsory treatment. MLL reveals that for each item scored in the scale, it increases the OR by 1.26 for compulsory treatment (95%CI 1.21-1.31, p<0.001). Based on the total score, accuracy was 90%, and the best cut-off point of 23.5 detects compulsory treatment with a sensitivity of 75% and specificity of 93.6%. The CTC presents robust internal structure with a strong unidimensional characteristic, and a cut-off point for compulsory treatment of 23.5. The improved 20-item version of the CTC could represent an important instrument to improve clinical decision regarding CPT, and ultimately to improve mental health care of patients with severe psychiatric disorders.

Understanding advocacy practice in mental health: a multidimensional scalogram analysis of case records

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.

Effects of assisted outpatient treatment and health care services on psychotic symptoms

RATIONALE

An ongoing debate concerns acceptability, benefits, and shortcomings of coercive treatment such as assisted outpatient treatment (AOT). The hypothesis that involuntary commitment to outpatient treatment may lead to a better clinical outcome for a subgroup of persons with severe mental illness (SMI) is controversial. Nonetheless, positive effects of AOT may be mediated by an increased availability of healthcare resources or increased service use.

OBJECTIVE

The purpose of the present study is to evaluate the course of delusions, hallucinations, and negative symptoms among patients with SMI receiving AOT compared to patients receiving non-compulsory treatment (NCT). Moreover, we assessed if the effects of AOT on psychotic symptoms were mediated by increased healthcare service use.

METHODS

This study used a quasi-experimental design to examine the effect of AOT and the use of healthcare services on psychotic symptoms. In total, 76 (41.3%) participants with SMI received AOT, and 108 (58.7%) received NCT. The participants were interviewed at baseline every 3 months up to 1 year. Propensity score matching was used to control for group differences.

RESULTS

In the basic model, AOT was associated with lower severity of psychotic symptoms over all follow-up points. In the model including healthcare service use, the frequency of case manager visits predicted a reduction in severity of all psychotic symptoms. The frequency of visits to the outpatient clinics, frequency of emergency room, and psychiatrist visits were independently associated with lower levels of delusional symptoms. Psychiatrist visits were related to a decrease in negative symptoms.

CONCLUSION

Results indicate that the treatment benefits of AOT are enhanced with the increased use of mental healthcare services, suggesting that the positive effect of AOT on psychotic symptoms is related to the availability of mental healthcare service use. Coercive outpatient treatment might be more effective through greater use of intensive services.

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

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