Psychiatric patients at greatest risk and in greatest need. Impact of the Supervision Register Policy

Assessing violence risk in general adult psychiatry

Aims and Method

We aimed to establish current practice in the risk assessment of harm to others within general adult psychiatry and review risk assessment documentation in use. Consultants working across 66 randomly selected trusts across England were surveyed. A qualitative analysis of risk assessment documentation was carried out.

Results

Data were obtained from 45 trusts (68%). Consultants reported that 30 (67%) of the trusts had standardised forms for risk assessment. Forty-one forms were subjected to content analysis. Wide variation was found in the methods used to identify risk factors and in approaches to quantifying risk.

Clinical Implications

Current risk assessment practice is highly variable, indicating a lack of consensus about suitable methods.

Care programme approach: relapsing or recovering?

The care programme approach (CPA) has become an accepted part of clinical practice, despite the continuing lack of strong direct evidence of its value. Guidance from the Department of Health has refined the original requirements, which were to ensure health and social care assessment, discharge from hospital to appropriate accommodation with necessary support, appointment of a mental health professional to draw up a care plan, and coordination of its implementation with necessary follow-up. The CPA now specifies that care plans include provision, as necessary, for risk assessment and management, employment, leisure, accommodation and plans to meet carers' needs. Levels of care have been simplified to ‘standard’ and ‘enhanced’. In future it will need to incorporate issues arising from the development of specialist teams as part of the National Health Service Plan, concern about the physical healthcare of those subject to it and the continuing development of psychosocial interventions.

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

Background

Coercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.

Design

The programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.

Participants

Participants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.

Outcomes

The OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.

Results

Community treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.

Conclusions

Community Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.

Trial registration

Current Controlled Trials ISRCTN73110773.

Funding

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

Who decides what evidence is? Developing a multiple perspectives paradigm in mental health

OBJECTIVE

To compare different perspectives on evidence in relation to mental health care.

METHOD

The method and materials constitute a selective literature review comparing key elements of evidence-based medicine and evidence-based policy with perspectives on evidence from users, carers and professionals. The aim was to develop an argument concerning these comparisons.

RESULTS

What constitutes evidence from the perspectives of different stakeholders is a field of contestation.

CONCLUSION

It is timely for a multiple perspective paradigm on evidence in science to be developed and this paper initiates this process in relation to mental health care.