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Sharwood LN, Waller M, Draper B, Shand F. Exploring community mental health service use following hospital-treated intentional self-harm among older Australians: a survival analysis. Int Psychogeriatr 2024; 36:405-414. [PMID: 37960921 DOI: 10.1017/s1041610223000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
OBJECTIVES This study aimed to examine the impact of community mental health (CMH) care following index hospital-treated intentional self-harm (ISH) on all-cause mortality. A secondary aim was to describe patterns of CMH care surrounding index hospital-treated ISH. DESIGN A longitudinal whole-of-population record linkage study was conducted (2014-2019), with index ISH hospitalization (Emergency Department and/or hospital admissions) linked to all available hospital, deaths/cause of death, and CMH data. SETTING Australia's most populous state, New South Wales (NSW) comprised approximately 7.7 million people during the study period. CMH services are provided statewide, to assess and treat non-admitted patients, including post-discharge review. PARTICIPANTS Individuals with an index hospital presentation in NSW of ISH during the study period, aged 45 years or older. INTERVENTION CMH care within 14 days from index, versus not. MEASUREMENTS Cox-proportionate hazards regression analysis evaluated all-cause mortality risk, adjusted for relevant covariates. RESULTS Totally, 24,544 persons aged 45 years or older experienced a nonfatal hospital-treated ISH diagnosis between 2014 and 2019. CMH care was received by 56% within 14 days from index. Survival analysis demonstrated this was associated with 34% lower risk of death, adjusted for age, sex, marital status, index diagnosis, and 14-day hospital readmission (HR 0.66, 95% CI 0.58, 0.74, p < 0.001). Older males and chronic injury conveyed significantly greater risk of death overall. CONCLUSIONS CMH care within 14 days of index presentation for self-harm may reduce the risk of all-cause mortality. Greater effort is needed to engage older males presenting for self-harm in ongoing community mental health care.
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Affiliation(s)
- Lisa N Sharwood
- Black Dog Institute, University of New South Wales, Sydney, Kensington, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- School of Engineering, University of Technology Sydney, Sydney, NSW, Australia
- School of Population Health, University of NSW, Sydney
| | | | - Brian Draper
- Eastern Suburbs Older Persons' Mental Health Service, Randwick, NSW, 2031, Australia
- Discipline of Psychiatry and Mental Health, University of New South Wales,Sydney, NSW, Australia
| | - Fiona Shand
- Black Dog Institute, University of New South Wales, Sydney, Kensington, NSW, 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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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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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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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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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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Rugkåsa J. Effectiveness of Community Treatment Orders: The International Evidence. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:15-24. [PMID: 27582449 PMCID: PMC4756604 DOI: 10.1177/0706743715620415] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Social Psychiatry Group, Lørenskog, Norway Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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