Family perspective on community treatment orders: a New Zealand study

Community treatment orders: A qualitative study of stakeholder perspectives

INTRODUCTION

For people with a serious mental disorder, a community treatment order (CTO) is a legal response that requires them to undergo psychiatric treatment unwillingly under certain conditions. Qualitative studies have explored the perspectives of individuals involved in CTOs, including persons with lived experiences of a CTO, family members and mental health care providers, who are directly involved in these procedures. However, few studies have integrated their different perspectives.

METHOD

This descriptive and qualitative study aimed to explore the experience associated with a CTO in hospital and community settings among individuals with a history of CTO, relatives, and mental health care providers. Using a participatory research approach, individual semi-structured interviews were conducted with 35 participants. The data were reviewed using content analysis.

RESULTS

Three themes and seven sub-themes were identified: 1) differential positions as a function of meaning conferred to CTOs; 2) a risk management tool; and 3) coping strategies used to deal with CTOs. Overall, relatives' and mental health care providers' perspectives tended to be in opposition to those who went under a CTO.

CONCLUSIONS

In a context of recovery-oriented care, more research is needed to reconcile the seemingly contradictory positions of individual with experiential knowledge and the legal leverage that deprives them of their fundamental right to autonomy.

'He was a brilliant student but became mad like his grandfather': an exploratory investigation on the social perception and stigma against individuals living with mental health problems in Bangladesh

BACKGROUND

Worldwide, mental health issues constitute a substantial threat to people's social, economic, and mental well-being and contribute significantly to many fatalities each year. In Bangladesh, people with mental health issues typically delay contacting health professionals because they prefer traditional or religious healers. Moreover, the situation is exacerbated by a lack of awareness, social stigma, and negative perception of sufferers of mental health issues on the part of families and the community. Therefore, this paper investigates the social perception and stigmatization of individuals living with mental health problems and their caregivers in Khulna, Bangladesh.

METHODS

Data were collected from university students with concurring mental health issues as well as their closest caregivers, who had in-depth knowledge of the problem and a willingness to take care of the individuals with mental health issues. Following the criteria for data collection, eight individuals living with mental health problems and five caregivers were purposively selected for this research. A semi-structured in-depth interview guide was used for the confidential data collection process, which took place in November and December 2021, and each interview lasted 40-50 min on average.

RESULTS

This study used thematic analysis to present the results; the findings showed that: individuals afflicted with mental health problems sought both medical and spiritual support to recover. Those with mental health issues who received positive family support recovered relatively faster than those who did not. However, negative social perception and stigmatization were the key impediments for individuals suffering from mental health problems and their families, as they found it difficult to discuss their issues with relatives and communities when attempting to access support or seek remedies. Moreover, the commonality of social stigmas, such as labeling mental health problems as equal to 'madness,' hindered disclosure to family members, peers, and the community.

CONCLUSION AND RECOMMENDATIONS

In Bangladesh, the majority of individuals living with mental health problems are stigmatized and do not receive emotional support. Hence, we suggest nationwide community-based awareness-building programs to promote more positive perceptions of the fight against mental health disorders. Furthermore, counseling and awareness-building programs for effective discouragement of non-scientific remedies such as spiritual healing, as well as diagnosis and medication at the primary stage of sickness, are recommended for early detection and better medical assistance.

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

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.

Community treatment orders in New Zealand

Many legal mechanisms can be used to authorise compulsory community mental healthcare: leave or conditional discharge for compulsory in-patients; adult guardianship (or incapacity) legislation; treatment as a condition of a community-based criminal sentence, like probation, or of parole from imprisonment; or a full-fledged community treatment order (CTO) scheme. It is the specific mix of mechanisms employed in a particular jurisdiction that will characterise how that legal system manages the delivery of compulsory (or quasi-consensual) community psychiatric care.

Carer involvement in compulsory out-patient psychiatric care in England

BACKGROUND

There is an expectation in current heath care policy that family carers are involved in service delivery. This is also the case with compulsory outpatient mental health care, Community Treatment Orders (CTOs) that were introduced in England in 2008. No study has systematically investigated family involvement through the CTO process.

METHOD

We conducted qualitative interviews with 24 family carers to ascertain their views and experiences of involvement in CTOs. The transcripts were subjected to thematic analysis that incorporated both deductive and inductive elements.

RESULTS

We found significant variation in both the type and extent of family carer involvement throughout the CTO process (initiation, recall to hospital, renewal, tribunal hearings, discharge). Some were satisfied with their level of involvement while others felt (at least partly) excluded or that they wanted to be more involved. Some wanted less involvement than what they had. From the interviews we identified key factors shaping carers' involvement. These included: perceptions of patient preference; concern over the relationship to the patient; carers' knowledge of the CTO and of the potential for carer involvement; access to and relationships with health professionals; issues of patient confidentiality; opportunities for private discussions, and; health professionals limiting involvement. These factors show that health professionals have many opportunities to facilitate, or hinder, carer involvement. The various roles attributed to carers, such 'proxy' for patient decision, 'gatekeeper' to services, 'mother' or 'expert carer', however, conflict with one another and make the overall role unclear.

CONCLUSIONS

There is a need for clarification of the expectations of carers in individual care situations, for carers to be equipped with the information they need to in order to be involved, and for services to find flexible and innovative ways of ensuring continuous, open communication. The introduction of CTOs in England has not been successful in its ambition for carer involvement.

Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care

Background

Coercion 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.

Design

The 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.

Participants

Participants 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.

Outcomes

The 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.

Results

Community 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.

Conclusions

Community 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 registration

Current Controlled Trials ISRCTN73110773.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Care planning for consumers on community treatment orders: an integrative literature review

BACKGROUND

Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders' perspectives and experiences of care planning for consumers' on CTOs.

METHODS

An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management.

RESULTS

Forty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions.

CONCLUSIONS

Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the 'control and care' dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.

Community treatment orders: exploring the paradox of personalisation under compulsion

The introduction of supervised community treatment, delivered through community treatment orders (CTOs) in England and Wales, contrasts with the policy of personalisation, which aims to provide service users autonomy and choice over services. This article draws upon findings from a primarily qualitative study which included 72 semi-structured interviews (conducted between January and December 2012) with practitioners, service users and nearest relatives situated within a particular NHS Trust. The article also refers to a follow-on study in which 30 Approved Mental Health Practitioners were interviewed. The studies aimed to develop a better understanding of how compulsory powers are being used in the community, within a policy context that emphasises personalisation and person-centred care in service delivery. Findings from the interview data (which were analysed thematically) suggest that service users were often inadequately informed about the CTO and their legal rights. Furthermore, they tended to be offered little, or no, opportunity to make choices and have involvement in the making of the CTO and setting of conditions. Retrospectively, however, restrictions were often felt beneficial to recovery, and service users reported greater involvement in decisions at review stage. Areas of good practice are identified through which person-centred care can be better incorporated into the making of CTOs.

Effectiveness of Community Treatment Orders: The International Evidence

OBJECTIVE

Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness.

METHOD

The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies.

RESULTS

The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion.

CONCLUSION

There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs.

'Responsible, but Still not a Real Treatment Partner': A Qualitative Study of the Experiences of Relatives of Patients on Outpatient Commitment Orders

The aim of this study was to explore relatives' experiences when their family member is under an outpatient commitment order. A descriptive and exploratory approach was used based on qualitative interviews with 11 relatives. The relatives felt they had responsibility for the patient, but experienced a lack of recognition for their contribution to the treatment. Relatives paid little attention to coercion, but were more concerned about whether the follow-up care improved the patient's social functioning. They further reported an unmet need for information and guidance from healthcare staff to improve cooperation in the patient's care and treatment.

Carer experience of Community Treatment Orders: implications for rights based/recovery-oriented mental health legislation

OBJECTIVE

Our aim was to determine the views and experiences of carers of people with severe mental illness in regard to Community Treatment Orders (CTOs).

METHOD

Questionnaires were posted using the mailing lists of two well-established carer support organisations in Victoria. The questionnaires included information about the person with a mental illness, the carer and their experience of care (ECI) and knowledge of recovery (RKI).

RESULTS

In total, 278 questionnaires were sent and 63 returned, of which 62 provided valid data. Those who responded were predominantly female (90%) and older (mean age 63 years), and were the carer of a person with a severe and recurrent mental illness. Some 60% had experience of caring for a person on a CTO. Most felt the CTO had been of benefit, and in 89% the person relapsed and needed further treatment when the CTO was stopped.

CONCLUSION

Mental health legislation is shifting to bring a greater focus on rights, individual choice and autonomy in line with recovery-oriented care. This study describes the impact of severe mental illness and decisions in relation to CTOs on carers.

Patient, psychiatrist and family carer experiences of community treatment orders: qualitative study

PURPOSE

Current literature on personal experiences of community treatment orders (CTO) is limited. This paper examines participants' experiences of the mechanisms via which the CTO was designed to work: the conditions that form part of the order and the power of recall. We also report an emergent dimension, legal clout and participants' impressions of CTO effectiveness. This paper will contribute to a fuller picture of how the law is implemented and how CTOs operate in practice.

METHODS

In-depth qualitative interviews were conducted with a purposive sample of 26 patients, 25 psychiatrists and 24 family carers about their experiences and views of CTOs. Data were analysed using the constant comparative method.

RESULTS

All three sample groups perceived the chief purpose of CTOs to be medication enforcement and that its legal clout was central to achieving medication adherence. Understanding of how the inbuilt mechanisms of the CTO work varied considerably: participants expressed uncertainty regarding the enforceability of discretionary conditions and the criteria for recall. We found mixed evidence regarding whether recall simplified responses to relapse or risk. The range of experiences and views identified within each group suggests that there is no single definitive experience or view of CTOs.

CONCLUSIONS

The (perceived) focus of the CTO on medication adherence combined with the variations in understanding within and across groups might not only have consequences for how CTOs are viewed and subsequently experienced, but also for broader goals in patient care and patient and carer involvement.

CTOs: what is the state of the evidence?

PURPOSE

Community Treatment Orders (CTOs) require outpatients to adhere to treatment and permit rapid hospitalisation when necessary. They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence. In this article, we appraise the current literature on CTOs from the viewpoint of Evidence-Based Medicine and discuss the way forward for using and researching CTOs.

RESULTS

Non-randomised outcome studies show conflicting results, but their lack of standardisation of methods and measures makes it difficult to draw conclusions. In contrast, all three randomised controlled trials (RCTs) conducted concur in their findings that CTOs do not impact on hospital outcomes. No systematic review or meta-analysis has identified any clear clinical advantage to CTOs.

CONCLUSION

The evidence-base does not support the use of CTOs in their current form. Involuntary clinical interventions must conform to the highest standard of evidence-based care. To enable clinicians to take an evidence-based approach and to settle remaining uncertainties about the current evidence, high-quality RCTs should be designed and undertaken, using standardised outcome measures.

Community treatment orders and the experiences of ethnic minority individuals diagnosed with serious mental illness in the Canadian mental health system

Introduction

The prevalence of Community Treatment Orders (CTOs) in the Western world has generated considerable discussion regarding best practices in the outpatient treatment of the seriously mentally ill. Although problems encountered by ethnic minority communities in the various health care systems have been studied to some degree, there is an acute dearth of information on the effects of CTOs on minority individuals. This paper presents findings from research on the lived experiences of individuals from ethnic minority backgrounds who have been the subjects of CTOs in Toronto, Canada, and their perceptions of its impact on their lives.

Methods

Using a qualitative phenomenological approach, in-depth semi-structured interviews were conducted with individuals who have experienced CTOs. Purposive sampling was used to recruit participants (n = 24) from ethnic minority background in Toronto, Canada.

Results

Participants perceived both positive and negative impacts of CTOs. The positives included affirmation of experiences with the mental health system; improved rapport with the case management and clinical team, increased medication compliance and feelings of empowerment. The negative feedback included feelings of being coerced and the stigma associated with it.

Conclusions

The findings of this study suggest that although CTOs are not a panacea for every mental health problem, they can be effective with a specific group who choose to follow through with the expectations of the treatment. The author, however argues that for these individuals to be on a CTO before getting better treatment, brings to the fore a number of issues with the mental health system. This is particularly concerning as it pertains to individuals of ethnic minority background.

The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers

OBJECTIVE

To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers.

METHOD

We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies.

RESULTS

The lived experiences were characterised by 'access' concerns, 'isolation', 'loss and trauma', 'resistance and resignation' and 'vulnerability and distress'. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes.

CONCLUSIONS

The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.

Liberty or dignity: community treatment orders and rights

The use of community treatment orders (CTOs) remains controversial despite their widespread use in a number of different countries. The focus of a CTO should be on individuals with severe and enduring mental disorders, typically requiring adherence with recommended outpatient treatment in the community and requiring that they allow access to members of the clinical team for the purpose of assessment. There is no current provision for CTOs under Irish mental health legislation, although patients who are involuntarily detained under the MHA 2001 (Ireland) can be granted approved leave from hospital. This provision allows for the patient to be managed in the community setting, though, while technically on leave, they remain as inpatients detained under the MHA 2001 (Ireland). This article describes the use of CTOs and considerations relating to their implementation. There is discussion of the ethical grounds and evidence base for their use. Ethical considerations such as balancing autonomy against health needs and the utilisation of capacity principles need to be weighed by clinicians considering the use of CTOs. Though qualitative research provides some support for the use of CTOs, there remains a clear lack of robust evidence based findings to support their use in terms of hospitalisation rates, duration of illness remission and improved social functioning.

Coercion and compulsion in community mental health care

There is ongoing debate in the UK as to the place of coercion and compulsion in community mental health care. Recent changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community. This has intensified the debate revealing fault lines in the psychiatric and legal professions. Despite powerful arguments from all sides there is little empirical evidence to inform this debate at a clinical or a theoretical level. This review utilizes evidence from articles in peer reviewed journals. Papers were identified from electronic databases, the authors' databases of relevant literature and personal correspondence with experts in the field. The evidence base is relatively small but is expanding. It has been demonstrated that informal coercion is common in USA mental health services and can be experienced negatively by patients. There is evidence that powers of compulsion in community mental health care are used frequently when available and their availability is generally seen as positive by clinicians when practice becomes embedded. The evidence for the effectiveness of compulsion in community mental health care is patchy and conflicting, with randomized or other trials failing to show significant benefits overall even if secondary analyses may suggest positive outcomes in some subgroups. There are widespread regional and international differences in the use of community compulsion. Research examining treatment pressures (or 'leverage') and the subjective patient experience of them appears to be expanding and is increasing our awareness and understanding of these complex issues. There is an urgent need for evidence regarding the usefulness and acceptability of compulsion in the community now that powers have been made available. Trials of the effectiveness of compulsion are needed as is qualitative work examining the experiences of those involved in the use of such orders. These are needed to help clinicians utilize the powers available to them in an informed and judicious fashion and to ensure adequate training.

Stigma towards people with mental illness in developing countries in Asia

BACKGROUND

There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996-2006.

METHOD

Medline search focusing on English-speaking literature.

RESULTS

Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing.

CONCLUSION

This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization-beliefs about causes of and attitudes towards mental illness, consequences for help-seeking-have more commonalities than differences to Western countries.