Community treatment orders: Are they useful?

Compulsory treatment at home: an interview study exploring the experiences of an early group of patients, relatives and mental-health workers

BACKGROUND

When introduced in 2020, the Netherlands' Compulsory Mental Healthcare Act included provisions for compulsory community treatment (CCT) and compulsory treatment in patients' homes (CTH). Although CCT has been incorporated into mental health care in many countries, its effectiveness is debated. We know of no other countries in which CTH has been adopted. The aim of this study is to evaluate how an early group of participants experienced CTH. They were drawn from three stakeholder groups: patients, relatives and mental-health workers.

METHODS

In total, 17 open interviews were conducted with six patients, five relatives and six mental-health workers. All had experience with CTH. Thematic analysis was used to analyze the interviews.

RESULTS

Five themes were identified: 1). Reasons for applying for a court order with options for CTH. The reasons included preventing harm, avoiding hospitalization, and providing a safety net. 2.) Participants' experiences with CTH in practice. The four most noteworthy experiences were related to the process of applying for a court order; compulsory home visits and the compulsory use of medication; the involvement of relatives during treatment; and the influence of CTH on the relationship between patients and relatives.  3.) The advantages and disadvantages of CTH. The most important advantages were avoiding hospitalization; improving medication adherence; facilitating easy access to care; early signaling of deterioration; early intervention; and regained autonomy. The most important disadvantages were restricted autonomy; fewer options for monitoring compared to hospitalization; and problems regarding control of patient behavior. 4.) Participants' preferences. All preferred CTH to hospitalization. 5.) Participants' suggestions for improving CTH. These included the need not only to provide patients with better information, but also to improve the involvement of relatives during treatment.

CONCLUSION

The interviewees found that CTH might help to avoid hospitalization by providing stakeholders with more options for arranging effective care at home. Although this suggests that initial experiences of CTH under the new Dutch mental health law were positive, it is still uncertain whether CTH as currently implemented really differs from CCT.

Community treatment orders: A qualitative study of stakeholder perspectives

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry

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.

Compulsory treatment order and rehospitalisation: A New Zealand study

OBJECTIVE

The effectiveness of compulsory treatment orders (CTO) in psychiatric practice is an area in need of evidence. There are no recent New Zealand publications on outcomes for patients under CTOs. This study examined the association between CTOs and subsequent rehospitalisation for patients with schizophrenia or related disorders.

METHOD

Two year outcome data for 326 consecutive patients discharged in 2013 and 2014 was obtained from the Programme for the Integration of Mental Health Data database. Regression analyses were performed with rehospitalisation as the main outcome.

RESULTS

For the 54% of patients discharged under CTOs, rehospitalisation was 2-4 times more likely for the CTO group than for voluntary patients. Patients under CTOs also spent longer in hospital post index admission (IA). However, patients placed under CTOs during IA stayed longer than those under CTOs prior to IA. Ethnicity did not contribute significantly to any of the findings.

CONCLUSION

This study did not show that patients under CTOs were associated with subsequent reduced resource use. The subgroup analysis suggested that studies with a longer follow-up period may provide better insight into the utility of CTOs.

The therapeutic relationship in the context of involuntary treatment orders: The perspective of nurses and patients

WHAT IS KNOWN ON THE SUBJECT?: Involuntary treatment orders are increasingly being used around the world to allow the treatment of individuals living with a mental illness deemed incapable of giving consent and who are actively refusing treatment. The use of involuntary treatment orders can impact the nurse-patient therapeutic relationship, which is essential to offer quality care and promote recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses and patients do not agree on the possibility to develop a therapeutic relationship, with nurses believing they can build a bond with the patients despite the challenges imposed by the involuntary treatment order, and patients rejecting this possibility. Nurses caring for patients on involuntary treatment orders feel obligated to apply the conditions of this measure, even if it damages the relationship with their patients. This difficult aspect of their work leads them to question their role in relation to the management of involuntary treatment orders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware of the reasons why patients on involuntary treatment orders do not believe in the possibility of building a therapeutic relationship. Nurses need to reflect on and express their concerns about the damaging effects that managing involuntary treatment orders conditions can have on the nurse-patient therapeutic relationship. ABSTRACT: Introduction Involuntary treatment orders (ITO) can impact the nurse-patient therapeutic relationship (TR) negatively. Despite the increasing use of ITOs around the world, few studies have explored their influence on the TR from the perspectives of nurses and patients. Aim To describe the TR in the context of ITOs as reported by nurses and individuals living with a mental illness. Method Secondary data analysis of qualitative interviews with nurses (n = 9) and patients (n = 6) was performed using content analysis. Results Participants described the TR as fundamentally embedded in a power imbalance amplified by the ITO, which was discussed through the conflicting roles of nurses, the legal constraints imposed on patients and nurses, the complex relation between the ITO and the TR, and the influence of mental healthcare settings' context. Discussion Nurses and patients' views were opposed, questioning the authenticity of the relationship. Implications for Practice Nurses should be aware of the patients' lack of faith in the TR to ensure that they are sensitive to patients' behaviours that may falsely suggest that a relationship is established. Further studies should explore ways to alleviate the burden of the management of ITOs on nurses and allow for a trusting relationship to be build.

Gilles Deleuze's societies of control: Implications for mental health nursing and coercive community care

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.

Risk versus recovery: Care planning with individuals on community treatment orders

Community treatment orders (CTOs) require individuals with a mental illness to accept treatment from mental health services. CTO legislation in South Australia states that treatment and care should be recovery-focused, although justification for use is predominantly risk-based, and care often coercive. Although CTOs are contested, individuals, families, and clinicians frequently engage in care planning within this context. This paper examines how the concepts of risk and risk management impact care planning from the perspectives of individuals on CTOs, their families, and clinicians. Ethnographic methods of observation and interview provided a detailed account of the perspectives of each group over an 18-month period from two community mental health teams in South Australia. Findings show that care planning occurred within a culture of practice dominated by risk. Risk, however, was understood differently by each participant group, with the dominant narrative informed by biogenetic understandings of mental illness. This dominance impacted on the positioning of participant groups in care planning, focus of care contacts, and care options available. To improve care experiences and outcomes for individuals on CTOs, narrow conceptualizations of risk and recovery need to broaden to include an understanding of personal and social adversities individuals face. A broader understanding should reposition participants in the care planning context and rebalance care discussions, from a focus on clinical recovery to recovering citizenship.

Use of community treatment orders and their outcomes: an observational study

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.

Nurses' perspectives on human rights when coercion is used in psychiatry: a systematic review protocol of qualitative evidence

BACKGROUND

The World Health Organization describes the perpetuation of human rights violations against people with mental health problems as a global emergency. Despite this observation, recent studies suggest that coercive measures, such as seclusion, restraints, involuntary hospitalization, or involuntary treatment, are steadily or increasingly being used without proof of their effectiveness. In nursing, several literature reviews have focused on understanding nurses' perspectives on the use of seclusion and restraints. Although many studies describe the ethical dilemmas faced by nurses in this context, to this date, their perspectives on patient's rights when a broad variety of coercive measures are used are not well understood. The aim of this review is to produce a qualitative synthesis of how human rights are actually integrated into psychiatric and mental health nursing practice in the context of coercive work.

METHODS

Noblit and Hare's meta-ethnographic approach will be used to conduct this systematic review. The search will be conducted in CINAHL, Medline, PsycINFO, ERIC, and Scopus databases, using the PICo model (Population, phenomenon of Interest, Context) and a combination of keywords and descriptors. It will be complemented by a manual search of non-indexed articles, gray literature, and other applicable data sources, such as human rights related documents. Qualitative and mixed-method study designs will be included in this review. Empirical and peer-reviewed articles published between 2008 and 2019 will be selected. Articles will be evaluated independently by two reviewers to determine their inclusion against eligibility criteria. The quality of the selected papers will then be independently evaluated by two reviewers, using the Joanna Briggs Institute's Checklist for Qualitative Research. Data extraction and content analysis will focus on first- and second-order constructs, that is, the extraction of research participants' narratives and their interpretation.

DISCUSSION

This review will provide a synthesis of how psychiatric and mental health nurses integrate human rights principles into their practice, as well as it will identify research gaps in this area. The results of this review will then provide qualitative evidence to better understand how nurses can contribute to the recognition, protection, and advocate for human rights in a psychiatric context.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019116862.

Community treatment orders: international perspective

The use of community treatment orders (CTOs) is available in more than 70 jurisdictions around the world. Although CTOs are used extensively, their effectiveness remains doubtful. We comment on the existing evidence and focus on components that influence the outcomes of CTOs internationally. It is essential to identify factors that affect the delivery of CTOs, and mixed methodologies may improve our understanding regarding their efficiency.

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

BACKGROUND

Compulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence.

METHODS

For this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232.

FINDINGS

Of 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53-1·08; I²=94·74), use of community services (0·83, 0·46-1·21; I²=87·26), and treatment adherence (2·12, 1·69-2·55; I²=0), and a medium effect on inpatient bed-days (0·66, 0·46-0·85; I²=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19-0·58; I²=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants.

INTERPRETATION

We found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality.

FUNDING

National Institute for Health Research.