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Cossu G, Kalcev G, Sancassiani F, Primavera D, Gyppaz D, Zreik T, Carta MG. The long-term adherence following the end of Community Treatment Order: A systematic review. Acta Psychiatr Scand 2024; 150:78-90. [PMID: 38796307 DOI: 10.1111/acps.13709] [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] [Received: 02/13/2024] [Revised: 04/16/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND The community treatment order (CTO) is designed to deliver mental healthcare in the community and has been introduced in around 75 jurisdictions worldwide. It constitutes a legal obligation in which individuals with severe mental illness must adhere to out-of-hospital treatment plans. Despite intense criticism and the debated nature of published evidence, it has emerged as a clinical and policy response to frequent hospital readmissions and to enhance adherence in cases where there is refusal of pharmacological treatments. This systematic review outlines findings on CTO long-term adherence, after mandatory outpatient treatment has ended, in studies that include people with psychiatric disorders. METHOD Following PRISMA guidelines, we performed a review of published articles from PubMed, PsycINFO, EMBASE, and CINAHL up to January 15, 2023. We included studies that assessed adherence after CTO ends. The study is registered with PROSPERO number CRD42022360879. RESULTS Six independent studies analyzing the main indicators of long adherence: engagement with services and medication adherence, were included. The average methodological quality of the studies included is fair. Long-term adherence was assessed over a period ranging from 11 to 28 months. Only two studies reported a statistically significant improvement. Regarding the remaining studies, no positive correlation was observed, except for certain subgroup samples, while in one study, medication adherence decreased. CONCLUSION Scientific evidence supporting the hypothesis that CTO has a positive role on long-term adherence post-obligation is currently not sufficient. Given the importance of modern recovery-oriented approaches and the coercive nature of compulsory outpatient treatment, it is necessary that future studies ensure the role of CTO in effectively promoting adherence.
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Affiliation(s)
- Giulia Cossu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Goce Kalcev
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Federica Sancassiani
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Diego Primavera
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Davide Gyppaz
- Department of Neuroscience, University of Turin, Turin, Italy
| | | | - Mauro Giovanni Carta
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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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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Aragonés-Calleja M, Sánchez-Martínez V. Evidence synthesis on coercion in mental health: An umbrella review. Int J Ment Health Nurs 2024; 33:259-280. [PMID: 37908175 DOI: 10.1111/inm.13248] [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] [Received: 12/11/2022] [Revised: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023]
Abstract
Coercion in mental healthcare is ubiquitous and affects the physical health, recovery and psychological and emotional well-being of those who experience it. Numerous studies have explored different issues related to coercion, and the present umbrella review aims to gather, evaluate and synthesise the evidence found across systematic reviews. The protocol, registered in the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42020196713), included 46 systematic reviews and meta-analyses of primary studies whose main theme was coercion and which were obtained from databases (Medline/PubMed, PsycINFO, EMBASE and CINAHL) and repositories of systematic reviews following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. All the reviews were subjected to independent assessment of quality and risk of bias and were grouped in two categories: (1) evidence on specific coercive measures (including Community Treatment Orders, forced treatment, involuntary admissions, seclusion and restriction and informal coercion), taking into account their prevalence, related factors, effectiveness, harmful effects and alternatives to reduce their use; and (2) experiences, perceptions and attitudes concerning coercion of professionals, mental health service users and their caregivers or relatives. This umbrella review can be useful to professionals and users in addressing the wide variety of aspects encompassed by coercion and the implications for professionals' daily clinical practice in mental health units. This research received funding from two competitive calls.
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Affiliation(s)
- Miriam Aragonés-Calleja
- Mental Health Department, Hospital Padre Jofre, Valencia, Spain
- Department of Nursing, Faculty of Nursing and Chiropody, University of Valencia, Valencia, Spain
| | - Vanessa Sánchez-Martínez
- Department of Nursing, Faculty of Nursing and Chiropody, University of Valencia, Valencia, Spain
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Nguyen MT, Sicotte R, Pires De Oliveira Padilha P, Abdel-Baki A. Community Treatment Orders use Among Persons With a First Episode of Psychosis in Quebec. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2023; 68:119-129. [PMID: 36135936 PMCID: PMC9923137 DOI: 10.1177/07067437221125284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Minh Thi Nguyen
- Department of Psychiatry and Addiction, Faculty of Medicine, 5622University of Montréal, Montréal, Québec, Canada
| | - Roxanne Sicotte
- Department of Psychiatry and Addiction, Faculty of Medicine, 5622University of Montréal, Montréal, Québec, Canada
| | | | - Amal Abdel-Baki
- Department of Psychiatry and Addiction, Faculty of Medicine, 5622University of Montréal, Montréal, Québec, Canada.,Neurosciences axis, 177460Research Center Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada
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Practitioner Perspectives About Managing Community Treatment Orders (CTOs) in England and the Importance of Social Influences. Community Ment Health J 2022; 58:1584-1591. [PMID: 35445909 DOI: 10.1007/s10597-022-00974-2] [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: 09/21/2021] [Accepted: 04/04/2022] [Indexed: 01/27/2023]
Abstract
Previous research in England has suggested a medical acceptance of Community Treatment Order (CTO) coercion, but none have explored the importance of social influences on practitioner decision making. A sample of 181 practitioners with Mental Health Act responsibilities completed an online survey. They recorded their perspectives about the influence of medical and social items. Sixteen questionnaire items were subdivided into three operational aspects: discharge, renewal, and recall. Medical item averages scored significantly higher as influences than social items (medical items mean = 4.43; social items mean = 3.58; t = - 19.38, p = 0.001). The influence of separate medical and social factors was evidenced by exploratory factor analysis when related to discharge and renewal, but not for recall, where items divided into factors that resembled 'risk' and 'disengagement'. Participants' scores showed no statistically significant difference for a practitioner's professional allegiance. The findings demonstrate that social influences are a homogeneous influence on managing CTOs, in addition to the higher scoring influence of medical factors.
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Wergeland NC, Fause Å, Weber AK, Fause ABO, Riley H. Health professionals' experience of treatment of patients whose community treatment order was revoked under new capacity-based mental health legislation in Norway: qualitative study. BJPsych Open 2022; 8:e183. [PMID: 36217299 PMCID: PMC9634590 DOI: 10.1192/bjo.2022.592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Norway introduced capacity-based legislation in mental healthcare on 1 September 2017 with the aim of increasing patient autonomy and legal protection and reducing the use of coercion. The new legislation was expected to be particularly important for patients under community treatment orders (CTOs). AIMS To explore health professionals' experiences of how capacity-based legislation affects healthcare services for patients whose compulsory treatment order was revoked as a result of being assessed as having capacity to consent. METHOD Nine health professionals responsible for treatment and care of patients whose CTO was revoked owing to the new legislation were interviewed in depth from September 2019 to March 2020. We used a hermeneutic approach to the interviews and analysis of the transcripts. RESULTS The participants found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They also felt a need for more frequent assessments of patients' condition and capacity to consent and more flexibility between levels of care. CONCLUSIONS The study shows that health professionals found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They sought closer dialogue with patients, providing information and advice, and more frequently assessing patients' condition to adjust treatment and care to enable them to retain their capacity to consent. This could be challenging and required competence, continuity and close collaboration between personnel in different healthcare services at primary and specialist level.
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Affiliation(s)
- Nina Camilla Wergeland
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway; and Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Åshild Fause
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Astrid Karine Weber
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway
| | | | - Henriette Riley
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway; and Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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7
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Martinho SM, Santa-Rosa B, Silvestre M. Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry. BMC Med Ethics 2022; 23:77. [PMID: 35879800 PMCID: PMC9309603 DOI: 10.1186/s12910-022-00814-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. Main body The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002–2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. Conclusion Ross Upshur’s principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.
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Affiliation(s)
- Sérgio M Martinho
- Bioethics Institute, Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal.
| | - Bárbara Santa-Rosa
- Bioethics Institute, Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal.,National Institute of Legal Medicine and Forensic Sciences, North Branch, Porto, Portugal
| | - Margarida Silvestre
- Bioethics Institute, Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal.,Reproductive Medicine Department, Coimbra Hospital and University Centre, Coimbra, Portugal
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8
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Suetani S, Kisely S, Parker S, Waterreus A, Morgan VA, Siskind D. Characteristics of people on community treatment orders in Australia: Data from the 2010 National Survey of High Impact Psychosis. Aust N Z J Psychiatry 2022; 56:788-799. [PMID: 34340594 DOI: 10.1177/00048674211036032] [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: 11/16/2022]
Abstract
OBJECTIVE Existing evidence on factors associated with community treatment order placement is largely restricted to administrative data. We utilised the data from a large nationally representative sample to compare the demographic, clinical, social functioning, substance use and service utilisation profiles of people living with psychosis under community treatment orders with those who were not. METHODS Participants were grouped based on whether they had been subject to a community treatment order in the past 12 months or not. We conducted logistic regressions to examine demographic, clinical, social functioning, substance use and service utilisation profiles associated with the two groups. RESULTS People who had recently been subject to community treatment orders were more likely to be treated with long-acting injectable antipsychotics and lacked insight but were less likely to report suicidal ideation. They also had higher psychiatric inpatient admission rates but a lower frequency of general practitioner visits. CONCLUSION People on community treatment orders in Australia may differ from those who are not under a community treatment order in their treatment needs. Resources and care provision must match the needs of this particularly vulnerable group.
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Affiliation(s)
- Shuichi Suetani
- The University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Wacol, QLD, Australia.,Metro South Addiction and Mental Health Services, Woolloongabba, QLD, Australia.,School of Medicine, Griffith University, Nathan, QLD, Australia
| | - Steve Kisely
- The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Services, Woolloongabba, QLD, Australia
| | - Stephen Parker
- The University of Queensland, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Nathan, QLD, Australia.,The Prince Charles Hospital, Chermside, QLD, Australia
| | - Anna Waterreus
- Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Perth, WA, Australia.,Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, The University of Western Australia, Perth, WA, Australia
| | - Vera A Morgan
- Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Perth, WA, Australia.,Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, The University of Western Australia, Perth, WA, Australia
| | - Dan Siskind
- The University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Wacol, QLD, Australia.,Metro South Addiction and Mental Health Services, Woolloongabba, QLD, Australia
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Storrier K, Ouliaris C, George D. New injectable antiretroviral therapy for HIV facilitates novel treatment pathways for persons without capacity to consent to medical treatment. Australas Psychiatry 2022; 30:375-378. [PMID: 35285293 DOI: 10.1177/10398562221077892] [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: 11/15/2022]
Abstract
OBJECTIVE The development of new injectable antiretroviral therapy facilitates treatment for Human immunodeficiency virus (HIV) positive individuals who lack capacity to consent, posing a safety risk to both themselves and the wider community. We consider pathways to enforce treatment and propose an algorithm to determine the most appropriate legal instrument for application. CONCLUSION Legislative safeguards in mental health and guardianship legislation provide oversight and protection for those who suffer from illness and require coercive treatment. These frameworks have utility in the treatment of HIV patients who lack capacity to consent to treatment.
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Affiliation(s)
| | - Calina Ouliaris
- 522555Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Duncan George
- School of Psychiatry, Faculty of Medicine, 3960University of New South Wales, Australia; School of Rural Health, Faculty of Medicine and Health, University of Sydney, Australia; Consultation Liaison Psychiatry, The Albion Centre & Prince of Wales Hospital, NSW, Australia; and Dubbo Base Hospital, Dubbo, NSW, Australia
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10
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Cheung D. Control in the community: A qualitative analysis of the experience of persons on conditional discharge in Hong Kong. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2022; 82:101791. [PMID: 35367916 DOI: 10.1016/j.ijlp.2022.101791] [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: 01/24/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 06/14/2023]
Abstract
Mandatory outpatient treatment schemes such as community treatment orders remain controversial despite being commonly used around the world. Given concerns about patient autonomy and civil liberties, such schemes need to be closely scrutinised. Though Hong Kong's mandatory outpatient treatment scheme, the conditional discharge (CD) regime, has a number of significant legal concerns, empirical research on how it operates on the ground remains limited, and data on the subjective experience of relevant stakeholders is limited to healthcare professionals. This two-part cross-sectional study, the first on the service user perspective in Hong Kong, rectifies this gap. Data was collected through a self-reported survey and semi-structured interviews. Results demonstrated that, while similar themes to those in the literature were raised, such as powerlessness, a lack of understanding about the regime and in particular their rights thereunder, concerns about restrictive aspects of the regime and poor attitudes of healthcare professionals, and in some cases positive sentiments about beneficial aspects, the Hong Kong experience differs in the significant extent to which many of these concerns are demonstrated. The insights which this data provides in relation to how the implementation of the CD regime can be improved prior to legal reform is discussed, and suggestions for the way forward are proposed.
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Affiliation(s)
- Daisy Cheung
- Centre for Medical Ethics and Law, Faculty of Law, University of Hong Kong, Hong Kong, China.
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11
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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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12
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Paradis-Gagné E, Holmes D. Gilles Deleuze's societies of control: Implications for mental health nursing and coercive community care. Nurs Philos 2021; 23:e12375. [PMID: 34724314 DOI: 10.1111/nup.12375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/14/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
Since the era of deinstitutionalisation, many clinical approaches have emerged to enable the care and treatment of people suffering from mental illness. In recent years, the use of coercive approaches in the community (e.g., outpatient commitment or community treatment orders) has also increased internationally. Although nurses' role regarding these coercive approaches is central and significant, few empirical and theoretical writings have tackled this controversial nursing practice. The purpose of this paper is to analyse coercive nursing care through the lens of French philosopher Gilles Deleuze's concept of 'societies of control'. Taking up Michel Foucault's work on disciplinary power, Deleuze explores how the move from the striated spaces of closed institutions to the smooth spaces of societies of control took place since the middle of the 20th century. According to Deleuze, the overall objective of 'societies of control' is no longer simply to govern deviant behaviour in closed environments (e.g., psychiatric hospitals and prisons) but to ensure a regime of unrelentless surveillance in the open spaces of our communities.
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Affiliation(s)
| | - Dave Holmes
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
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13
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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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Lamberti JS, Katsetos V, Jacobowitz DB, Weisman RL. Psychosis, Mania and Criminal Recidivism: Associations and Implications for Prevention. Harv Rev Psychiatry 2021; 28:179-202. [PMID: 32251070 DOI: 10.1097/hrp.0000000000000251] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
People with mental illness are overrepresented throughout the criminal justice system, including jail, prison, probation, and parole populations. Yet much disagreement remains about why this problem exists and how best to address it. This article specifically examines empirical evidence regarding the question of whether psychosis and mania are associated with criminal recidivism, and whether this association is predictive or causal in nature. Review of the current literature suggests that psychotic and manic symptoms are associated with increased likelihood of arrest and incarceration. In addition, current evidence shows that pharmacotherapy can reduce criminal recidivism among justice-involved adults with psychosis or mania. However, the extent to which the association between psychosis, mania, and criminal justice system involvement is causal remains uncertain. Also, the literature suggests that most crimes committed by people with schizophrenia spectrum disorders or bipolar I disorder may be driven by factors other than their psychotic or manic symptoms. These established "criminogenic needs" are more common among people with severe mental disorders than in the general population. For optimal prevention, those who serve justice-involved adults with psychosis or mania in community settings should consider addressing the full range of factors that potentially drive their criminal justice system involvement.
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Affiliation(s)
- J Steven Lamberti
- From the Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
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15
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Hofstad T, Rugkåsa J, Ose SO, Nyttingnes O, Husum TL. Measuring the level of compulsory hospitalisation in mental health care: The performance of different measures across areas and over time. Int J Methods Psychiatr Res 2021; 30:e1881. [PMID: 34033189 PMCID: PMC8412230 DOI: 10.1002/mpr.1881] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/24/2021] [Accepted: 05/07/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE A variety of measures are used for reporting levels of compulsory psychiatric hospitalisation. This complicates comparisons between studies and makes it hard to establish the extent of geographic variation. We aimed to investigate how measures based on events, individuals and duration portray geographical variation differently and perform over time, how they correlate and how well they predict future ranked levels of compulsory hospitalisation. METHODS Small-area analysis, correlation analysis and linear regressions of data from a Norwegian health registry containing whole population data from 2014 to 2018. RESULTS The average compulsory hospitalisation rate per 100,000 inhabitant was 5.6 times higher in the highest area, compared to the lowest, while the difference for the compulsory inpatient rate was 3.2. Population rates based on inpatients correlate strongly with rates of compulsory hospitalisations (r = 0.88) and duration (r = 0.78). 68%-81% of ranked compulsory hospitalisation rates could be explained by each area's rank the previous year. CONCLUSION There are stable differences in service delivery between catchment areas in Norway. In future research, multiple measures of the level of compulsory hospitalisation should ideally be included when investigating geographical variation. It is important that researchers describe accurately the measure upon which their results are based.
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Affiliation(s)
- Tore Hofstad
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
| | | | - Olav Nyttingnes
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,R&D Department, Division of Mental Health, Akershus University Hospital, Lørenskog, Norway
| | - Tonje L Husum
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
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16
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Chatzisimeonidis S, Stylianidis S, Tzeferakos G, Giannoulis G. Insights into involuntary hospital admission procedures for psychiatric patients: A 3-year retrospective analysis of police records. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2021; 78:101732. [PMID: 34411888 DOI: 10.1016/j.ijlp.2021.101732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/25/2021] [Accepted: 08/08/2021] [Indexed: 06/13/2023]
Abstract
The procedure of involuntary hospitalization has been an ongoing subject of study. Its implementation requires the systematic co-ordination between the Justice and Health Care systems around the globe. In the case of Greece, the procedure under discussion is regulated by Law 2071/1992, which designates the Police as the agent that links the aforementioned systems together. The present study aims to shed light upon the procedure of involuntary hospitalizations, regarding the preparatory stage and the Police involvement up to the individuals' admission to the on-call hospital for a mental health assessment (MHA). The entry data of two police stations in Athens was recorded by the respective Duty Officer responsible for each case. The police records were retrospectively inspected and information on socio-demographic, clinical and parametric characteristics was extracted. The data collection took place between March and July 2020 and included 324 cases, 80.3% of which referred to involuntary hospitalizations; 17.6% of sample cases did not meet the criteria of the procedure, as opposed to 1.9% of the cases in which the patients eventually ended up being voluntarily admitted and afterwards hospitalized for treatment. There was a statistically comparison of socio-demographic, clinical and parametric variables in relation to the status of hospitalization groups (involuntary, voluntary and no hospitalization). Additionally, statistical comparisons were made between parametric and clinical variables in relation to the type of prosecution order (written: standard route, oral: emergency route). Acute mental health deterioration accounted for around 45% of the total data and it has been identified as the main factor for informing the Hearings Prosecutor office mainly by the patient's family and subsequently proceeding to the issuance of an order (in either written or oral form) to the Police. This enables the Police to escort the individuals and lead them to a psychiatric unit for mental health assessment (MHA) and based on this, for involuntary hospitalization if deemed necessary. In 87.9% of the cases, the individual was transported by police vehicles over a time span ranging from the very same day to 22 days. In total, the written prosecution orders (63.6%) outnumbered the oral ones (36.7%). The findings of the present study demonstrate that the Prosecution order type varies significantly depending on the causes that instigated the involuntary hospitalization procedure. The psychiatric decision whether there should be hospitalization or outpatient therapy also significantly varies depending on the diagnosis. Lastly, the results point out that the need for improvement and further clarification of the aforementioned Greek Law is absolutely essential.
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Affiliation(s)
| | - Stelios Stylianidis
- Panteion University of Social and Political Sciences, Athens, Greece; Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
| | - Georgios Tzeferakos
- Integrated Addiction Treatment Units, OKANA - Attikon University Hospital, Athens, Greece
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17
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Dawson S, Muir-Cochrane E, Simpson A, Lawn S. Community treatment orders and care planning: How is engagement and decision-making enacted? Health Expect 2021; 24:1859-1867. [PMID: 34382300 PMCID: PMC8483198 DOI: 10.1111/hex.13329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 01/07/2023] Open
Abstract
Background In many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery‐focussed. Key components in the care planning process include engagement and decision‐making about a person's support needs and care options, with trust being an essential component of care planning relationships. Objective This study examines how these components were enacted during service care contacts for individuals on community treatment orders. Methods The study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day‐to‐day care interactions. Results Care planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of ‘knowing’, with consumers assumed to have less knowledge than clinicians. Conclusions Services and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision‐making. Patient or Public Contribution This study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.
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Affiliation(s)
- Suzanne Dawson
- School of Allied Health Science and Practice, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.,Mental Health Directorate, Central Adelaide Local Health Network, Adelaide, Australia
| | - Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Alan Simpson
- Health Service and Population Research Department, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Sharon Lawn
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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18
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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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19
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Simon J, Mayer S, Łaszewska A, Rugkåsa J, Yeeles K, Burns T, Gray A. Cost and quality-of-life impacts of community treatment orders (CTOs) for patients with psychosis: economic evaluation of the OCTET trial. Soc Psychiatry Psychiatr Epidemiol 2021; 56:85-95. [PMID: 32719905 PMCID: PMC7847440 DOI: 10.1007/s00127-020-01919-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 07/02/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE Current RCT and meta-analyses have not found any effect of community treatment orders (CTOs) on hospital or social outcomes. Assumed positive impacts of CTOs on quality-of-life outcomes and reduced hospital costs are potentially in conflict with patient autonomy. Therefore, an analysis of the cost and quality-of-life consequences of CTOs was conducted within the OCTET trial. METHODS The economic evaluation was carried out comparing patients (n = 328) with psychosis discharged from involuntary hospitalisation either to treatment under a CTO (CTO group) or voluntary status via Section 17 leave (non-CTO group) from the health and social care and broader societal perspectives (including cost implication of informal family care and legal procedures). Differences in costs and outcomes defined as quality-adjusted life years (QALYs) based on the EQ-5D-3L or capability-weighted life years (CWLYs) based on the OxCAP-MH were assessed over 12 months (£, 2012/13 tariffs). RESULTS Mean total costs from the health and social care perspective [CTO: £35,595 (SD: £44,886); non-CTO: £36,003 (SD: £41,406)] were not statistically significantly different in any of the analyses or cost categories. Mental health hospitalisation costs contributed to more than 85% of annual health and social care costs. Informal care costs were significantly higher in the CTO group, in which there were also significantly more manager hearings and tribunals. No difference in health-related quality of life or capability wellbeing was found between the groups. CONCLUSION CTOs are unlikely to be cost-effective. No evidence supports the hypothesis that CTOs decrease hospitalisation costs or improve quality of life. Future decisions should consider impacts outside the healthcare sector such as higher informal care costs and legal procedure burden of CTOs.
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Affiliation(s)
- Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria. .,Department of Psychiatry, Warneford Hospital, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK. .,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK.
| | - Susanne Mayer
- grid.22937.3d0000 0000 9259 8492Department of Health Economics, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090 Vienna, Austria
| | - Agata Łaszewska
- grid.22937.3d0000 0000 9259 8492Department of Health Economics, Center for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090 Vienna, Austria
| | - Jorun Rugkåsa
- grid.411279.80000 0000 9637 455XHealth Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway ,grid.463530.70000 0004 7417 509XCentre for Care Research, University of South-Eastern Norway, 3900 Porsgrunn, Norway
| | - Ksenija Yeeles
- grid.451190.80000 0004 0573 576XDepartment of Psychiatry, Warneford Hospital, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, OX3 7JX UK
| | - Tom Burns
- grid.451190.80000 0004 0573 576XDepartment of Psychiatry, Warneford Hospital, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, OX3 7JX UK
| | - Alastair Gray
- grid.4991.50000 0004 1936 8948Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF UK
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20
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Macgregor A. Meaningful participation or tokenism for individuals on community based compulsory treatment orders? Views and experiences of the mental health tribunal in Scotland. J Ment Health 2020; 31:158-165. [PMID: 32955380 DOI: 10.1080/09638237.2020.1818708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Mental Health (Care and Treatment) (Scotland) Act 2003 was considered as world leading when it was enacted due to its rights-based approach. Changes were made to encourage participation and enhance autonomy, including the Mental Health Tribunal for Scotland (the tribunal) replacing the Sheriff Court in making decisions about compulsory treatment. AIMS To explore the views of individuals on community based compulsory treatment orders (CCTOs) and independent advocates to assess whether participation in the tribunal is perceived as meaningful in practice. METHOD A qualitative research design was adopted and semi-structured interviews were undertaken with 19 people with experience of being on a CCTO and eight mental health advocates in Scotland. The data were thematically analysed and explored using ethics of care principles. RESULTS Individuals faced barriers to participation, including mental distress, medication, and inaccessible communication, and both the tribunal process and outcome were important in shaping perceptions of fairness. A perceived unsuccessful outcome was found to undermine an ostensibly participatory process, and unequal power dynamics resulted in feelings of powerlessness. CONCLUSIONS The findings suggest that participation is often experienced as tokenistic in practice and that cultural change is required if people are to be meaningfully involved in tribunal proceedings.
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Affiliation(s)
- Aisha Macgregor
- Strathclyde Centre for Disability Research, School of Social and Political Sciences, University of Glasgow, Glasgow, UK
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21
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McDermott BE, Ventura MI, Juranek ID, Scott CL. Role of Mandated Community Treatment for Justice-Involved Individuals With Serious Mental Illness. Psychiatr Serv 2020; 71:656-662. [PMID: 32212909 DOI: 10.1176/appi.ps.201900456] [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: 11/30/2022]
Abstract
OBJECTIVE Research has suggested that increased length of mandated community treatment for individuals with a serious mental disorder leads to better outcomes, but few studies have described whether these outcomes are maintained after treatment ends. The goal of this study was to evaluate the impact of court-mandated treatment on outcomes for individuals found not guilty by reason of insanity (NGRI) and released to the community. METHODS Ninety-three patients who were found to be NGRI participated in this study. Rearrest rates were compared for three groups: patients released to the community with court-mandated treatment (conditional release), patients who were conditionally released but later "restored to sanity" with no further court supervision, and patients released from the hospital to the community by the court with no court-imposed conditions. Patients were followed for an average of 4.83 years after discharge. RESULTS Nearly half (43.8%) of the patients released to the community without court-mandated supervision were arrested for another offense in the study period, compared with 8.2% of patients released under the supervision of the conditional release program. In contrast, those who were restored to sanity and ultimately released unconditionally had higher arrest rates (25%). CONCLUSIONS This study suggests that court oversight on an ongoing basis may be necessary to help justice-involved individuals with a serious mental disorder avoid the criminal justice system and remain engaged in community treatment. More research is needed to determine whether these findings can be extrapolated to civil commitment procedures.
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Affiliation(s)
- Barbara E McDermott
- Department of Psychiatry, University of California (UC), Davis, School of Medicine (all authors); California Department of State Hospitals-Napa (DSH-NAPA) (McDermott, Juranek)
| | - Maria I Ventura
- Department of Psychiatry, University of California (UC), Davis, School of Medicine (all authors); California Department of State Hospitals-Napa (DSH-NAPA) (McDermott, Juranek)
| | - Isah Dualan Juranek
- Department of Psychiatry, University of California (UC), Davis, School of Medicine (all authors); California Department of State Hospitals-Napa (DSH-NAPA) (McDermott, Juranek)
| | - Charles L Scott
- Department of Psychiatry, University of California (UC), Davis, School of Medicine (all authors); California Department of State Hospitals-Napa (DSH-NAPA) (McDermott, Juranek)
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22
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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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23
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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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24
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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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25
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Løvsletten M, Husum TL, Granerud A, Haug E. Outpatient commitment in mental health services from a municipal view. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 69:101550. [PMID: 32241457 DOI: 10.1016/j.ijlp.2020.101550] [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: 10/02/2019] [Revised: 02/01/2020] [Accepted: 02/05/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Outpatient commitment (OC) is a legal decision for compulsory mental health care when the patient stays in his or her own home. Municipal health-care workers have a key role for patients with OC decision, but little is known about how the legislation system with OC works from the municipality's point of view. METHOD The present study has a quantitative descriptive design using an electronic questionnaire sent to health-care workers in the municipalities that participated. The study included health-care workers from the mental health services in two counties in Norway who have experience with psychosis and OC decisions. RESULTS There were 230 people who received the questionnaire. The sample consisted of various health professionals from both small and large municipalities.The results show which tasks they have in follow-up of patients in the municipalities. CONCLUSION From the municipality's point of view, there are no significant differences in follow-up for patients with or without an OC decision, apart from conversations about medication. An individual plan is rarely used to facilitate follow-up, although this is the statutory right of patients with OC decisions. The health-care workers lack knowledge and education about the OC scheme. The cooperation between municipalities and the specialist health-care services is not clearly defined.
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Affiliation(s)
- Maria Løvsletten
- Innlandet Hospital Trust, Division Psykisk Helsevern, Postboks 104, NO-2381 Brumunddal, Norway; Faculty of Public Health, Inland Norway University of Applied Science, Elverum, Norway; Helsam, Universitet I, Oslo, Norway.
| | - Tonje Lossius Husum
- Centre for Medical Ethics, Institute for Health & Society, University of Oslo, Norway
| | - Arild Granerud
- Faculty of Public Health, Inland Norway University of Applied Science, Elverum, Norway
| | - Elisabeth Haug
- Division of Mental Health Care, Innlandet Hospital Trust, 2840 Reinsvoll, Norway
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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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Segal S. Different Patient Group Responses To Community Treatment Orders Suggest Alternative Approaches. PROFESSIONAL DEVELOPMENT (PHILADELPHIA, PA.) 2020; 23:61-71. [PMID: 34025111 PMCID: PMC8136251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Community treatment orders (CTOs) help people with severe mental illness survive through potentially harmful crises posing imminent threats to health and safety by providing needed treatment when possible as a less restrictive alternative (LRA) to involuntary hospitalization. This review considers how differing patient subgroups have responded to differing CTO implementation approaches. Though recent trends have favored restricting psychiatric discretion, patients selected by psychiatrists as eligible for brief CTO assignment and assigned randomly to either brief or fixed-longer-term CTOs were no different in adverse outcomes other than in the duration of supervised time. Though emphasis has been on dangerousness to others, a study excluding such patients found lesser amounts of victimization among CTO-assigned vs. non-CTO patients. Though the trend has been focused on shortening CTO-duration, studies of extended six-month CTO assignment found that such patients experienced reduced inpatient days. Though emphasis has been on using CTOs with patients who have repeatedly failed in voluntary community care, studies of early intervention CTO use yielded positive results. Finally, CTO diversion has received limited use but when used had positive outcomes. Average evidence rankings for all subgroup study areas were 3.58 of 5 with 1 being the best rank. These studies, while low in evidence ranking, suggest alternative approaches may improve CTO-use outcomes for different patient subgroups.
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Affiliation(s)
- Steven Segal
- Professor at University of Melbourne, and a Professor of the Graduate Division and Director of the Mental Health and Social Welfare Research Group at University of California, Berkeley
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Pelto-Piri V, Kjellin L, Hylén U, Valenti E, Priebe S. Different forms of informal coercion in psychiatry: a qualitative study. BMC Res Notes 2019; 12:787. [PMID: 31791408 PMCID: PMC6889621 DOI: 10.1186/s13104-019-4823-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/24/2019] [Indexed: 11/20/2022] Open
Abstract
Objectives The objective of the study was to investigate how mental health professionals describe and reflect upon different forms of informal coercion. Results In a deductive qualitative content analysis of focus group interviews, several examples of persuasion, interpersonal leverage, inducements, and threats were found. Persuasion was sometimes described as being more like a negotiation. Some participants worried about that the use of interpersonal leverage and inducements risked to pass into blackmail in some situations. In a following inductive analysis, three more categories of informal coercion was found: cheating, using a disciplinary style and referring to rules and routines. Participants also described situations of coercion from other stakeholders: relatives and other authorities than psychiatry. The results indicate that informal coercion includes forms that are not obviously arranged in a hierarchy, and that its use is complex with a variety of pathways between different forms before treatment is accepted by the patient or compulsion is imposed.
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Affiliation(s)
- Veikko Pelto-Piri
- University Health Care Research Center (UFC), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, House S, 701 85, Örebro, Sweden.
| | - Lars Kjellin
- University Health Care Research Center (UFC), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, House S, 701 85, Örebro, Sweden
| | - Ulrika Hylén
- University Health Care Research Center (UFC), Faculty of Medicine and Health, Örebro University Hospital, Örebro University, House S, 701 85, Örebro, Sweden
| | - Emanuele Valenti
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, UK
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Silva B, Golay P, Boubaker K, Bonsack C, Morandi S. Community treatment orders in Western Switzerland: A retrospective epidemiological study. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 67:101509. [PMID: 31785725 DOI: 10.1016/j.ijlp.2019.101509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 06/10/2023]
Abstract
PURPOSE Community treatment orders (CTOs) are legal procedures that authorise compulsory community mental health care to people affected by severe mental disorders. Nowadays, CTOs are regulated in 75 countries, with important variations in terms of legal criteria and practices. In Switzerland CTOs were introduced on the 1st January 2013, following the amendment of the Swiss Civil Code. The aim of this study was to provide a first understanding of the use of CTOs in Western Switzerland in terms of incidence and prevalence rates, population profile, orders duration and reasons for discharge. METHODS Incidence and prevalence rates of CTOs between 2013 and 2017 were estimated. Survival analysis was used to investigate time to CTO discharge and associated factors. Logistic regression was performed to identify factors associated with CTOs' success as reason for discharge. RESULTS CTOs' incidence rates per 100'000 inhabitants ranged between 4.8 for 2013 and 9.6 for 2017, while their prevalence raised from 4.8 to 19.5. People placed under CTO were mainly male, in their forties, of Swiss origin, single and living independently. Primarily affected by Schizophrenia, schizotypal and delusional disorders (F20-F29), they frequently presented substance use problems, and severe danger for themselves. CTOs were mainly ordered by the guardianship authority as a form of conditional release. The estimated mean time to discharge was almost three years. Not being of Swiss origin and being prescribed to take a medication were associated with longer CTO while living in hospital, as a consequence of a long-lasting hospitalisation, and having a non-medical professional in charge of the order were associated with shorter time to discharge. Neither clinical factors nor legal criteria predicted time to discharge. Moreover, spending more days under CTO increased the likelihood of success at discharge, whereas not being of Swiss origin reduced it. CONCLUSIONS To the best of our knowledge, no previous studies have examined the CTOs' implementation in Switzerland. CTOs prevalence increased rapidly despite the lack of evidence on positive outcomes. Our results suggested that once under CTO, it takes a long time for a patient to be released, in case of both positive and negative outcomes.
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Affiliation(s)
- Benedetta Silva
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Place Chauderon 18, 1003 Lausanne, Switzerland; Cantonal Medical Office, Public Health Service of Canton Vaud, Department of Health and Social Action (DSAS), Avenue des Casernes 2, 1014 Lausanne, Switzerland.
| | - Philippe Golay
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Place Chauderon 18, 1003 Lausanne, Switzerland
| | - Karim Boubaker
- Cantonal Medical Office, Public Health Service of Canton Vaud, Department of Health and Social Action (DSAS), Avenue des Casernes 2, 1014 Lausanne, Switzerland
| | - Charles Bonsack
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Place Chauderon 18, 1003 Lausanne, Switzerland
| | - Stéphane Morandi
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Place Chauderon 18, 1003 Lausanne, Switzerland; Cantonal Medical Office, Public Health Service of Canton Vaud, Department of Health and Social Action (DSAS), Avenue des Casernes 2, 1014 Lausanne, Switzerland
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30
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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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31
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Gowda GS, Telang A, Sharath CR, Issac TG, Haripriya C, Ramu PS, Math SB. Use of newer technologies with existing service for family reintegration of unknown psychiatric patients: A case series. Asian J Psychiatr 2019; 43:205-207. [PMID: 29129550 DOI: 10.1016/j.ajp.2017.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/22/2017] [Indexed: 10/18/2022]
Abstract
Homeless Mentally Ill (HMI) patients pose a challenge in treatment, management and rehabilitation services. HMI patients are often difficult to engage in treatment, and associated with relapse and rehospitalization, even after recovery. Family plays an important role in treatment engagement and care of the mentally ill person in India. Here, we report two unknown psychiatric patients who were reintegrated to their families using newer technologies with existing service. Newer technologies have helped in early identification of HMI families and reintegration into them. The early reintegration reduced the unnecessary detention of HMI patients inside the hospital after recovery.
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Affiliation(s)
- Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India.
| | - Ashay Telang
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
| | - Chandra Reddy Sharath
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
| | - Thomas Gregor Issac
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
| | - Chintala Haripriya
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
| | - Praveen Shivalli Ramu
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
| | - Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, 560029, India
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32
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O'Reilly RL, Hastings T, Chaimowitz GA, Neilson GE, Brooks SA, Freeland A. Community Treatment Orders and Other Forms of Mandatory Outpatient Treatment. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2019; 64:356-374. [PMID: 31095435 PMCID: PMC6591887 DOI: 10.1177/0706743719845906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This position paper has been substantially revised by the Canadian Psychiatric Association's Professional Standards and Practice Committee and approved for republication by the CPA's Board of Directors on July 26, 2018. The original position paper1 was first approved by the Board of Directors on January 25, 2003. It was subsequently reviewed and approved for republication with minor revisions on June 2, 2009.
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Affiliation(s)
- Richard L O'Reilly
- 1 Professor, Department of Psychiatry, Western University, London, Ontario, and Northern Ontario School of Medicine
| | - Thomas Hastings
- 2 Associate Clinical Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario; Lecturer, Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Gary A Chaimowitz
- 3 Head of Service, Forensic Psychiatry, St Joseph's Healthcare, Hamilton, Ontario; Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - Grainne E Neilson
- 4 Staff Forensic Psychiatrist, East Coast Forensic Hospital, Halifax, Nova Scotia; Assistant Professor, Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia
| | | | - Alison Freeland
- 6 Vice-President, Quality, Education and Patient Relations, Trillium Health Partners, Mississauga, Ontario; Associate Dean, Medical Education (Regional), Faculty of Medicine, University of Toronto; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario
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Light E. Rates of use of community treatment orders in Australia. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 64:83-87. [PMID: 31122644 DOI: 10.1016/j.ijlp.2019.02.006] [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: 09/04/2018] [Revised: 12/05/2018] [Accepted: 02/20/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The variable and changing rates of use of involuntary community treatment orders (CTOs) in the treatment of people living with mental illness are not well-documented or well understood. This new study sought to determine contemporary rates of use in Australia, where local jurisdictions were previously shown to have varied and shifting rates of use that were high by world standards. METHODS Australian state and territory mental health review tribunals, health departments, and/or offices of the chief psychiatrist were surveyed for the most recent published annual data on the total number of individual people placed on a CTO and/or the total number of CTOs made. FINDINGS Contemporary rates of CTO use in Australia range from 40.0 per 100,000 population (in Western Australia) to 112.5 per 100,000 (in South Australia). Since the last national survey, the rates of people subject to CTOs fell into in two jurisdictions (Victoria and Western Australia). However, rates of CTOs made were higher than previous figures in all jurisdictions reporting data. Use of CTOs in Australia varies considerably within and between jurisdictions. CONCLUSIONS Australian jurisdictions continue to use CTOs at high and varying rates, despite unresolved questions about their role and impact. Transparency and accountability around their use would be improved by regular and nationally uniform public reporting of CTO data. Further research into how and why CTOs are used may also provide opportunities to respond to factors driving their use and thereby reduce the use of coercion in mental health care.
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Affiliation(s)
- Edwina Light
- Sydney Health Ethics, University of Sydney, Sydney, Australia.
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Edan V, Brophy L, Weller PJ, Fossey E, Meadows G. The experience of the use of Community Treatment Orders following recovery-oriented practice training. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 64:178-183. [PMID: 31122627 DOI: 10.1016/j.ijlp.2019.04.001] [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: 08/20/2018] [Revised: 02/22/2019] [Accepted: 04/02/2019] [Indexed: 06/09/2023]
Abstract
States across Australia are changing and adapting policy and laws to deliver mental health services using principles of personal recovery. Yet, the use of Community Treatment Orders (CTOs) remains high in apparent contradiction with this change. As part of the PULSAR trial investigating the outcomes of recovery oriented practice (ROP) training in primary and secondary care services within Metropolitan Melbourne, Victoria, a qualitative study was undertaken to explore the intersection between implementing ROP and working with consumers on CTOs. In-depth interviews were undertaken with consumers with experience being on CTOs and staff of secondary care services, and inductively analysed to identify themes. For consumers, being on a CTO meant lacking choice and control, an emphasis on medication, fear of the threat of hospitalisation, an absence of recovery oriented practice, and staying supported. For staff, recovery oriented practice in the presence of CTOs is challenging, with CTOs being seen to be a primary way to manage risk. Staff supported recovery as a practice, but identified a lack of organisational 'buy in' by services. The findings of this small scale study, embedded in a much larger study about ROP, support other literature that identifies implementing ROP in services that use CTOs as potentially problematic; and that ROP can enhance both consumers and staff experiences of services but, without systemic change, there may not be a significant shift in the use of CTOs, while CTOs also inhibit uptake of ROP.
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Affiliation(s)
- Vrinda Edan
- Southern Synergy, Department of Psychiatry, Monash University, 126 Cleeland St, Dandenong, VIC, Australia; Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia.
| | - Lisa Brophy
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia; Mind Australia, Heidelberg, VIC, Australia; School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia
| | | | - Ellie Fossey
- School of Primary and Allied Health Care, Monash University Peninsula Campus, Frankston, VIC, Australia
| | - Graham Meadows
- Southern Synergy, Department of Psychiatry, Monash University, 126 Cleeland St, Dandenong, VIC, Australia; Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia; Monash Health, Melbourne, VIC, Australia
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Abstract
India enacted the Mental Healthcare Act, 2017 (MHCA 2017) on April 7, 2017 to align and harmonize with United Nations Convention on Persons with Disabilities and the principles of prioritizing human rights protection. While MHCA 2017 is oriented toward the rights of the patients, the rights of the family members and professionals delivering treatment, care, and support to persons with severe mental disorder (SMD) often suffer. MHCA 2017 mandates discharge planning in consultation with the patients for admitted patients and makes the service providers responsible for ensuring continuity of care in the community. The concerns surrounding the chances of relapse and recurrence when a person with a SMD stops medications continue to remain largely unaddressed. The rights-based MHCA 2017 makes it difficult for the prevailing practices of surreptitious treatment by the family/caregiver and proxy consultations on behalf of the patients. This will, in turn, lead to increased chances of relapse, risk of violence, homelessness, stigma, and suicide in persons with SMDs in the community, largely due to noncompliance to treatment. This will also result in increased caregiver burden and burnouts and may also cause disruptions in the family and the community. To strike a balance over the current MHCA 2017, there is a need to amend or bring-forth a new law rooted in the principles of community treatment order.
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Affiliation(s)
- Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Arun Enara
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | | | - Mahesh Gowda
- Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
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Rugkåsa J, Nyttingnes O, Simonsen TB, Benth JŠ, Lau B, Riley H, Løvsletten M, Christensen TB, Austegard ATA, Høyer G. The use of outpatient commitment in Norway: Who are the patients and what does it involve? INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:7-15. [PMID: 30616856 DOI: 10.1016/j.ijlp.2018.11.001] [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: 08/28/2018] [Revised: 10/04/2018] [Accepted: 11/01/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE Despite one of the longest histories of using Outpatient Commitment (OC), little is known about the use in the Norwegian context. Reporting from the Norwegian Outpatient Commitment Study, this article aims to: establish the profile of the OC population in Norway; ascertain the legal justification for the use of OC and what OC involves for patients; investigate possible associations between selected patient and service characteristics and duration of OC, and; explore potential differences based on gender or rurality. METHODS A retrospective multi-site study, extracting data from the medical records of all patients on OC in six large regional hospitals in 2008-12, with detailed investigation over 36 months of the subsample of patients on first ever OC-order in 2008-09. We use descriptive statistics to establish the profile of the OC population and the legal justification for and the content of OC, and logistic regression to examine factors associated with duration of OC over 36 months. RESULTS 1414 patients were on OC over the 5 years, and 274 had their first OC in 2008-09. The sample included more men than woman, and three-quarters were diagnosed with schizophrenia. They had long service histories, including involuntary admissions. The legal justification for all OC-orders was the need for treatment, and 18% were additionally justified by dangerousness. The option to initiate OC directly from the community was not used in any of the 274 first ever OC-orders. While 98% of patients were prescribed psychotropic medication, under half had an Involuntary Treatment Order, which under the Norwegian OC regime is required in addition to the OC-order to oblige patients to accept treatment (usually medication). 60% of patients had ≥2 clinical contacts monthly. There were some gender differences in descriptive analyses with men generally being worse off, but no clear pattern in terms of rurality. Patients in the sample had been on OC between one week and 20 years. The median duration of OC over 36 months was 365 days. Three factors contributed to longer duration: the use of the dangerousness criterion; a diagnosis of schizophrenia disorder, and; considerable problems with substance abuse. CONCLUSION The characteristics of the OC population in Norway are very similar to that reported in other jurisdictions. Medication seems to be the central focus of OC, yet additional Involuntary Treatment Orders are imposed for less than half of patients. While all OC-orders were justified by the need to ensure treatment, risk seems to be a concern for a subgroup of patients who are kept on for longer. How the 2017 amendment to the mental health act, which precludes compulsion for competent patients unless danger is present, will affect OC use, remains to be seen. Further studies should specifically focus on variation in the use of OC, including at the level of individual clinicians.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway; Centre for Care Research, University of South-Eastern Norway, 3900 Porsgrunn, Norway.
| | - Olav Nyttingnes
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway; R&D Department Mental Health, Akershus University Hospital, 1478 Lørenskog, Norway.
| | - Tone Breines Simonsen
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, 0318 Blindern, Norway; Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Bjørn Lau
- Lovisenberg Diaconal Hospital, Norway
| | - Henriette Riley
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway
| | - Maria Løvsletten
- Division of Mental Health Care, Innlandet Hospital Trust, Postboks 104, NO-2381 Brumunddal, Norway
| | | | | | - Georg Høyer
- Institute of Community Medicine, UiT-Norway's Arctic University, 9037 Tromsø, Norway
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Jobling H. The legal oversight of community treatment orders: A qualitative analysis of tribunal decision-making. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:95-103. [PMID: 30616860 DOI: 10.1016/j.ijlp.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/19/2018] [Accepted: 12/05/2018] [Indexed: 06/09/2023]
Abstract
Community treatment orders (CTOs) have been in place in various jurisdictions for over three decades, and yet are still a controversial aspect of mental health provision. One of the ethical concerns CTOs may engender is how difficult it can be to secure discharge from them, which in some jurisdictions can result in service users being subject to compulsion in the community indefinitely. Given the questions that can therefore be raised about the discharge process, it is important to understand the role of the mental health tribunal as a key safeguard in the management of CTOs. However, whilst a substantial body of literature exists on CTOs and on various aspects of tribunal practice in inpatient settings respectively, relatively little has been written about the role of the tribunal in the oversight of CTO discharge decisions. This article presents the results of an eight month ethnographic investigation into CTO use in England, focusing on the factors which contribute to tribunal decisions. A total of 62 participants were involved in the study, including 18 service users on CTOs, 36 mental health practitioners and 8 tribunal chairs. A combination of interviews, observations and documentary analysis are drawn upon to illustrate tribunal decision-making practice on CTOs. The key themes reported on are: the mediating influence of participant presentation and interaction in tribunals; tribunal framing and interpretation of insight and risk; and the importance of timing to tribunals, both in terms of the perceived stability of a service user's social circumstances, and the length of the CTO. The findings highlight the cumulative and interrelated effect of such factors on tribunal decision-making, and point to how tribunal judgements are heavily weighted towards upholding CTOs, with the implications that holds for individual rights.
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Affiliation(s)
- Hannah Jobling
- Department of Social Policy and Social Work, University of York, York YO10 5DD, UK.
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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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Abstract
PURPOSE OF REVIEW Assisted outpatient treatment (AOT) is an outpatient court-ordered treatment for people with severe mental illness (SMI) whose care needs are often unmet in the community due, in part, to treatment non-adherence. AOT is controversial, and the goal of this review is to provide an update on recent research, the status of AOT in the United States, and future directions for research and implementation. RECENT FINDINGS Several recent studies have demonstrated that it is not just a lack of access to appropriately intensive care that prevents some individuals with SMI from engaging in and benefiting from treatment and that AOT can improve engagement and patient outcomes over and above the provision of care. The future of AOT in the United States is still somewhat uncertain and will largely depend on the effectiveness and sustainability of the SAMHSA AOT grant programs. Future research efforts should investigate the conditions under which and for whom AOT can be most effective, to help avoid poor outcomes for this vulnerable population.
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Affiliation(s)
- Stephanie N Cripps
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Marvin S Swartz
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, 27710, USA.
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Stuen HK, Landheim A, Rugkåsa J, Wynn R. How clinicians make decisions about CTOs in ACT: a qualitative study. Int J Ment Health Syst 2018; 12:51. [PMID: 30258490 PMCID: PMC6151000 DOI: 10.1186/s13033-018-0230-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/16/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams' first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting. METHODS Semi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach. RESULTS The participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians' legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others. CONCLUSIONS According to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients' need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.
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Affiliation(s)
- Hanne Kilen Stuen
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anne Landheim
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- Divison of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway
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Guta A, Voronka J, Gagnon M. Resisting the Digital Medicine Panopticon: Toward a Bioethics of the Oppressed. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:62-64. [PMID: 30235095 DOI: 10.1080/15265161.2018.1498936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Kisely S, Xiao J. Cultural and linguistic diversity increases the likelihood of compulsory community treatment. Schizophr Res 2018; 197:104-108. [PMID: 29249560 DOI: 10.1016/j.schres.2017.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 11/29/2017] [Accepted: 12/11/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND People from culturally and linguistically diverse (CALD) backgrounds are over-represented in compulsory admissions to hospital but little is known about whether this also applies to community treatment orders (CTOs). AIMS We investigated any differences between Australian- and foreign-born patients in the likelihood of CTO placement using state-wide databases from Western Australia. METHODS Cases and controls from administrative health data were matched on age, sex, diagnosis and time of hospital discharge (the index date). Logistic regression was then used to identify potential predictors of a CTO. We also assessed if any differences in CTO placement between Australian- and foreign-born patients had effects on bed-days or community contacts in the subsequent year. RESULTS We identified 2958 CTO cases and controls from November 1997 to December 2008 (total n=5916). Of these, 74% had schizophrenia or other non-affective psychoses. Patients who were born in New Zealand, the United Kingdom or Ireland had very similar rates of CTO placement compared to those who were Australian-born. By contrast, there was a gradient of increasing risk of CTO placement for people born in Continental Europe (ORadj=1.36; 95% CI=1.07-1.71, p=0.01) and then the Rest of the World (ORadj=1.61; 95% CI=1.31-1.97, p<0.001). However, there was no evidence of additional benefit in terms of health service use in the following year. CONCLUSIONS In common with other coercive treatments, people from culturally and linguistically diverse (CALD) backgrounds are more likely to be placed on CTOs. Further research is needed to establish if this is for similar reasons.
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Affiliation(s)
- Steve Kisely
- The University of Queensland School of Medicine, QLD, Australia; Metro South Health Service, Woolloongabba, QLD, Australia; Griffith Institute of Health, Griffith University, QLD, Australia; Dalhousie University, Department of Psychiatry, Halifax, Nova Scotia, Canada; Dalhousie University, Department of Community Health and Epidemiology, Halifax, Nova Scotia, Canada.
| | - Jianguo Xiao
- Health Department of Western Australia, Perth, Australia
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Brophy L, Edan V, Gooding P, McSherry B, Burkett T, Carey S, Carroll A, Callaghan S, Finch A, Hansford M, Hanson S, Kisely S, Lawn S, Light E, Maher S, Patel G, Ryan CJ, Saltmarsh K, Stratford A, Tellez JJ, Toko M, Weller P. Community treatment orders: towards a new research agenda. Australas Psychiatry 2018; 26:299-302. [PMID: 29463100 DOI: 10.1177/1039856218758543] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to report on a half-day multi-stakeholder symposium on community treatment orders (CTOs) hosted by the Melbourne Social Equity Institute (MSEI), which identified research gaps and opportunities, and produced an agreed agenda for future CTO research. METHODS The MSEI convened a symposium for 22 experts in CTO research to discuss research priorities in this field in Australasia. An independent moderator elicited views and recommendations and produced a report detailing possible research projects. RESULTS Research on CTOs is contentious and there is a need to gather and examine information regarding both their use and utility. Due to the complexities involved, it was agreed that research should be undertaken in partnership with persons with had lived experience of mental health problems, clinicians, policymakers and other interdisciplinary stakeholders. Five key areas for future investigation were identified. CONCLUSIONS The issues and recommendations arising from the symposium should shape the scope, nature and conduct of future research directions in the field.
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Affiliation(s)
- Lisa Brophy
- Associate Professor, Melbourne School of Population and Global Health, Centre for Mental Health, University of Melbourne, Melbourne, VIC, and; Principal Research Fellow, Research, Development and Advocacy, Mind Australia, Heidelberg, VIC, Australia
| | - Vrinda Edan
- Consumer Academic, Monash University, Southern Synergy, Dandenong Hospital, Dandenong, VIC, Australia
| | - Piers Gooding
- Postdoctoral Research Fellow, Melbourne Law School, Melbourne Social Equity Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Bernadette McSherry
- Foundation Director, Melbourne Social Equity Institute, University of Melbourne, Melbourne, VIC, and; Adjunct Professor of Law, Melbourne Law School and Adjunct Professor of Law, Faculty of Law, Monash University, Clayton, VIC, Australia
| | - Tatum Burkett
- Former Research Assistant, Melbourne Social Equity Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Sue Carey
- Psychiatrist, Mental Health Tribunal, Melbourne, VIC, Australia
| | - Andrew Carroll
- Associate Professor (Adjunct), Centre for Forensic Behavioural Science, CFBS, Swinburne University, Hawthorn, VIC, Australia
| | - Sascha Callaghan
- Lecturer, Sydney Law School, University of Sydney, Sydney, NSW, Australia
| | - Anne Finch
- Engagement Officer, Tandem, Melbourne, VIC, Australia
| | - Margaret Hansford
- Founder, Partnership Solutions, Melbourne, Melbourne, VIC, Australia
| | - Sarah Hanson
- Executive Officer, Mental Health Commission of New South Wales, Sydney, NSW, Australia
| | - Steven Kisely
- Professor of Psychiatry, Faculty of Medicine, Princess Alexandra Hospital Southside Clinical Unit, University of Queensland, St Lucia, QLD, Australia
| | - Sharon Lawn
- Professor, Department of Psychiatry, Faculty of Medicine Nursing and Health Sciences, Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, SA, Australia
| | - Edwina Light
- Postdoctoral Research Fellow, Sydney Health Ethics, University of Sydney, Sydney, NSW, Australia
| | - Sean Maher
- Legal Research Officer, Royal Australian and New Zealand College of Psychiatrists, Melbourne, VIC, Australia
| | - Gunvant Patel
- Consultant Psychiatrist, Forensicare, Melbourne, VIC, Australia
| | - Christopher James Ryan
- Clinical Associate Professor, Department of Psychiatry, Sydney Medical School and Sydney Health Ethics, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - Keir Saltmarsh
- Senior Education and Engagement Officer, Mental Health Complaints Commissioner, Melbourne, VIC, Australia
| | - Anthony Stratford
- Senior Advisor Lived Experience, Mind Australia, Heidelberg, VIC, Australia
| | - Juan Jose Tellez
- Research Assistant, Graduate School of Education, Melbourne Social Equity Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Maggie Toko
- Chief Executive Officer, Victorian Mental Awareness Council, Brunswick, VIC, Australia
| | - Penelope Weller
- Associate Professor, Graduate School of Business and Law, RMIT University, Melbourne, VIC, Australia
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Lofthus AM, Weimand BM, Ruud T, Rose D, Heiervang KS. "This is not a Life Anyone would want"-A Qualitative Study of Norwegian ACT Service users' Experience with Mental Health Treatment. Issues Ment Health Nurs 2018; 39:519-526. [PMID: 29370562 DOI: 10.1080/01612840.2017.1413459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We discuss Norwegian service users' experiences with community mental health treatment in general, and the interprofessional Assertive Community Treatment (ACT) model in particular. To gain the right to treatment, service users have to accept certain limitations, such as medication and community treatment orders (CTOs). Seventy participants responded to five open-ended questions. In addition, eight of them participated in either focus group or interviews. A collaborative approach, using Stepwise-Deductive Induction (SDI) method was used to analyze the participants' experiences. The results showed that the treatment contributes to an experience of autonomy but also one of restriction. It provides service users with enhanced normalcy, but simultaneously a feeling of deviance. There needs to be an ongoing reflection and discussion about those paradoxes in treatment, and service users have to be involved.
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Affiliation(s)
- Ann-Mari Lofthus
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway.,b National Centre for knowledge through experience in mental health , Skien , Norway.,c University of Oslo, Institute of Clinical Medicine , Oslo , Norway
| | - Bente M Weimand
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway
| | - Torleif Ruud
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway.,c University of Oslo, Institute of Clinical Medicine , Oslo , Norway
| | - Diana Rose
- d King's College London, Institute of Psychiatry, Psychology & Neuroscience , London , United Kingdom of Great Britain and Northern Ireland
| | - Kristin S Heiervang
- a Akershus Universitetssykehus HF , Department of Research and Development, Division of Mental Health Services , Lorenskog , Norway
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Oueslati B, Fekih-Romdhane F, Mrabet A, Ridha R. Correlates of offense recidivism in patients with schizophrenia. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 58:178-183. [PMID: 29853009 DOI: 10.1016/j.ijlp.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/04/2018] [Accepted: 05/04/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Schizophrenia increases the risk of offending. Recidivism rates are significant. Literature doesn't provide recidivism risk factors specific to patients with schizophrenia independently of the offenses' types. OBJECTIVE Identifying recidivism risk factors in schizophrenia patients independently of the offenses' types. METHODS We conducted a case-control study. All included patients were admitted, at least once, to the forensic psychiatry unit in Razi Hospital between January 1st, 1985 and December 31st, 2014 after a decision of irresponsibility by reason of insanity. All those who reoffended during this period were considered as cases. Univariate and multivariate analyses were performed to identify recidivism risk factors. RESULTS We included 25 cases and 38 controls. Eight recidivism risk factors were identified. Living in poor urban neighborhoods (P = 0.023; OR = 4.86), having been unemployed (P = 0.042; OR = 2.18) and not having lived with the family (P = 0.039; OR = 1.36) after discharge were considered as risk factors. The same applied to alcohol (P = 0.026; OR = 4.89) and cannabis use disorders (P = 0.018; OR = 6.01). A hospitalization shorter than 6 months multiplied the risk by 1.79 (P = 0.046). A combination of conventional antipsychotics (P = 0.023; OR = 4.81) and a poor adherence to treatment (P = 0.001; OR = 10.42) were considered as recidivism risk factors too. CONCLUSIONS All eight recidivism risk factors are dynamic. This makes recidivism prevention conceivable. Measures involving the patient, the health care system, patients' families, society and the government should be undertaken.
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Affiliation(s)
| | | | - Ali Mrabet
- Preventive Medicine Department, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia
| | - Rym Ridha
- Forensic Psychiatry Department, Razi Hospital, Tunisia
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Stuen HK, Landheim A, Rugkåsa J, Wynn R. Responsibilities with conflicting priorities: a qualitative study of ACT providers' experiences with community treatment orders. BMC Health Serv Res 2018; 18:290. [PMID: 29669558 PMCID: PMC5907185 DOI: 10.1186/s12913-018-3097-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 04/05/2018] [Indexed: 11/21/2022] Open
Abstract
Background Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting. Methods The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data. Results The main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs. Conclusions Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport. Electronic supplementary material The online version of this article (10.1186/s12913-018-3097-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hanne Kilen Stuen
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Anne Landheim
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway.,Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University College of Southeast Norway, Porsgrunn, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway. .,Divison of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway.
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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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O'Reilly R, Vingilis E. Are Randomized Control Trials the Best Method to Assess the Effectiveness of Community Treatment Orders? ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2017; 45:565-574. [PMID: 29285729 DOI: 10.1007/s10488-017-0845-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Many jurisdictions have enacted community treatment order (CTO) legislation that requires a person, who suffers from a severe mental disorder, to follow a treatment plan when living in the community. CTOs have been a source of debate because of controversies on whether evidence of effectiveness should only be considered from randomized controlled trials (RCTs). RCTs are considered the "gold standard" method to evaluate effectiveness of simple therapeutic interventions such as medication, but they are problematic for evaluation of complex interventions because valid attribution of causation in complex interventions is not guaranteed with RCTs. CTOs are complex interventions that require the interaction of many individuals and organizations to achieve their effects and effectiveness research must measure these complexities of delivery and outcomes. This paper examines conceptual, methodological and analytical challenges of CTO research within the context of RCTs and other research designs. It also discusses the current state of knowledge on effectiveness of CTOs. Finally, we suggest a way forward by presenting alternative causal inference approaches and potential models for evaluation complex interventions, such as CTOs. We propose that these approaches should be used alongside other research designs in a nuanced approach that may involve using findings from initial studies to refine the intervention and/or its implementation.
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Affiliation(s)
- Richard O'Reilly
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada. .,St. Joseph's Health Care London, Stn B, P.O. Box 5777, London, ON, N6A 4V2, Canada.
| | - Evelyn Vingilis
- Departments of Family Medicine and Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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