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Nyttingnes O, Benth JŠ, Hofstad T, Rugkåsa J. The relationship between area levels of involuntary psychiatric care and patient outcomes: a longitudinal national register study from Norway. BMC Psychiatry 2023; 23:112. [PMID: 36803444 PMCID: PMC9942375 DOI: 10.1186/s12888-023-04584-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/02/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Mental health legislation permits involuntary care of patients with severe mental disorders who meet set legal criteria. The Norwegian Mental Health Act assumes this will improve health and reduce risk of deterioration and death. Professionals have warned against potentially adverse effects of recent initiatives to heighten involuntary care thresholds, but no studies have investigated whether high thresholds have adverse effects. AIM To test the hypothesis that areas with lower levels of involuntary care show higher levels of morbidity and mortality in their severe mental disorder populations over time compared to areas with higher levels. Data availability precluded analyses of the effect on health and safety of others. METHODS Using national data, we calculated standardized (by age, sex, and urbanicity) involuntary care ratios across Community Mental Health Center areas in Norway. For patients diagnosed with severe mental disorders (ICD10 F20-31), we tested whether lower area ratios in 2015 was associated with 1) case fatality over four years, 2) an increase in inpatient days, and 3) time to first episode of involuntary care over the following two years. We also assessed 4) whether area ratios in 2015 predicted an increase in the number of patients diagnosed with F20-31 in the subsequent two years and whether 5) standardized involuntary care area ratios in 2014-2017 predicted an increase in the standardized suicide ratios in 2014-2018. Analyses were prespecified (ClinicalTrials.gov NCT04655287). RESULTS We found no adverse effects on patients' health in areas with lower standardized involuntary care ratios. The standardization variables age, sex, and urbanicity explained 70.5% of the variance in raw rates of involuntary care. CONCLUSIONS Lower standardized involuntary care ratios are not associated with adverse effects for patients with severe mental disorders in Norway. This finding merits further research of the way involuntary care works.
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Affiliation(s)
- Olav Nyttingnes
- Health Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway. .,Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway.
| | - Jūratė Šaltytė Benth
- grid.411279.80000 0000 9637 455XHealth Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tore Hofstad
- grid.412008.f0000 0000 9753 1393Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway ,grid.5510.10000 0004 1936 8921Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Jorun Rugkåsa
- grid.411279.80000 0000 9637 455XHealth Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway ,grid.463530.70000 0004 7417 509XCentre for Care Research, University of South-Eastern Norway, Notodden, Norway
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Ogilvie JM, Kisely S. Examining the health and criminal justice characteristics for young people on compulsory community treatment orders: An Australian birth cohort and data linkage study. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2022; 83:101813. [PMID: 35759935 DOI: 10.1016/j.ijlp.2022.101813] [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: 01/13/2022] [Revised: 03/27/2022] [Accepted: 06/13/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Most studies on the predictors and effectiveness of community treatment orders (CTOs) are restricted to health-related variables and do not consider forensic contacts as established by criminal justice databases or predictors from birth. We used linked administrative health and criminal justice data for a birth cohort in Queensland, Australia to investigate the characteristics and outcomes of people placed on CTOs. METHODS CTOs were identified from administrative data for hospital admissions and community mental health service contacts for a population cohort of 45,141 individuals born in Queensland in 1990. These data were linked with administrative court records, with individuals followed up to age 23/24 years. Logistic regression analyses were used to examine characteristics associated with CTO placement and Tobit regression analyses to examine factors predicting health and criminal justice outcomes in the following year. RESULTS There were 211 CTO cases by age 23/24 years, for whom it was possible to identify 413 controls on voluntary treatment. Non-affective psychoses [F20-F29] were the strongest predictors of CTO placement (ORadj = 4.07, 2.77-5.99) followed by a court appearance (ORadj = 1.99, 1.28-3.09). CTOs were associated with greater, not lower, subsequent psychiatric hospital admissions, inpatient bed-days and community mental health service contacts, although on sensitivity analyses psychiatric hospital admissions were the same as voluntary controls. CTOs were not associated with more subsequent court appearances despite higher rates of offending before CTO placement. CONCLUSIONS Both clinical and forensic variables can determine CTO placement and, on adjustment for these covariates, CTOs were not associated with reductions in psychiatric hospital admission, time spent as an inpatient, or subsequent court appearances. The latter finding might mean that CTOs reduce the risk of offending to that of voluntary controls.
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Affiliation(s)
- James M Ogilvie
- Griffith Criminology Institute, Griffith University, Australia
| | - Steve Kisely
- Griffith Criminology Institute, Griffith University, Australia; School of Medicine, The University of Queensland and Princess Alexandra Hospital, Woolloongabba, QLD, Australia; Metro South Health Service, Woolloongabba, QLD, Australia.
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Flynn S, Ibrahim S, Kapur N, Appleby L, Shaw J. Mental disorder in people convicted of homicide: long-term national trends in rates and court outcome. Br J Psychiatry 2021; 218:210-216. [PMID: 32624025 DOI: 10.1192/bjp.2020.94] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Homicide rates have fallen markedly in the UK over the past decade. There has been little research on whether homicides by people with mental disorder have contributed to this downward trend. Furthermore, there is limited information on trends in court outcomes for people with mental disorder who commit homicide. AIMS To examine trends in general population homicide and homicide by people with mental disorder, and to explore court outcome. METHOD We conducted a national, consecutive case series of homicide in England and Wales (1997-2015). Data were received from the Home Office Statistics Unit of Home Office Science. Clinical information was obtained from psychiatric reports and mental health services. RESULTS There has been a fall in the homicide rate in England and Wales since 2008. Despite this, the relative contribution of mental disorder as a proportion of all homicide has increased. Our findings also showed the inappropriate management of people with serious mental illness convicted of homicide. Of those who committed homicide and were diagnosed with schizophrenia, a third were imprisoned, and there was a marked fall in hospital order referrals. We found this to be linked to substance misuse comorbidity. CONCLUSIONS The proportional increase in homicide by people with schizophrenia suggests more complex factors may be driving rates, such as substance misuse. Addressing substance misuse comorbidity and maintaining engagement with services may help prevent patient homicide. Despite their complex needs, people with serious mental illness continue to be imprisoned. Improvements in assessment and the timely transfer of prisoners to health services are required.
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Affiliation(s)
- Sandra Flynn
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
| | - Saied Ibrahim
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
| | - Nav Kapur
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
| | - Louis Appleby
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
| | - Jenny Shaw
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, UK
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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: 16] [Impact Index Per Article: 4.0] [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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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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Riley H, Sharashova E, Rugkåsa J, Nyttingnes O, Christensen TB, Austegard ATA, Løvsletten M, Lau B, Høyer G. Out-patient commitment order use in Norway: incidence and prevalence rates, duration and use of mental health services from the Norwegian Outpatient Commitment Study. BJPsych Open 2019; 5:e75. [PMID: 31474238 PMCID: PMC6737513 DOI: 10.1192/bjo.2019.60] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Norway authorised out-patient commitment in 1961, but there is a lack of representative and complete data on the use of out-patient commitment orders. AIMS To establish the incidence and prevalence rates on the use of out-patient commitment in Norway, and how these vary across service areas. Further, to study variations in out-patient commitment across service areas, and use of in-patient services before and after implementation of out-patient commitment orders. Finally, to identify determinants for the duration of out-patient commitment orders and time to readmission. METHOD Retrospective case register study based on medical files of all patients with an out-patient commitment order in 2008-2012 in six catchment areas in Norway, covering one-third of the Norwegian population aged 18 years or more. For a subsample of patients, we recorded use of in-patient care 3 years before and after their first-ever out-patient commitment. RESULTS Annual incidence varied between 20.7 and 28.4, and prevalence between 36.5 and 48.9, per 100 000 population aged 18 years or above. Rates differed significantly between catchment areas. Mean out-patient commitment duration was 727 days (s.d. = 889). Use of in-patient care decreased significantly in the 3 years after out-patient commitment compared with the 3 years before. Use of antipsychotic medication through the whole out-patient commitment period and fewer in-patient episodes in the 3 years before out-patient commitment predicted longer time to readmission. CONCLUSIONS Mechanisms behind the pronounced variations in use of out-patient commitment between sites call for further studies. Use of in-patient care was significantly reduced in the 3 years after a first-ever out-patient commitment order was made. DECLARATION OF INTEREST None.
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Affiliation(s)
- Henriette Riley
- Research Director, Division of Mental Health and Substance Abuse, University Hospital of North Norway, Norway
| | - Ekaterina Sharashova
- Postdoctoral Fellow, Department of Community Medicine, UiT The Arctic University of Norway, Norway
| | - Jorun Rugkåsa
- Professor, Health Services Research Unit, Akershus University Hospital; and Centre for Care Research, University of South-Eastern Norway, Norway
| | - Olav Nyttingnes
- Postdoctoral Fellow, Health Services Research Unit, Akershus University Hospital; and R&D Department, Division of Mental Health Services, Akershus University Hospital, Norway
| | | | | | - Maria Løvsletten
- Doctoral Research Fellow, Division of Mental Health Care, Innlandet Hospital Trust, Norway
| | - Bjørn Lau
- Professor, Lovisenberg Diaconal Hospital, Norway
| | - Georg Høyer
- Professor Emeritus, Division of Mental Health and Substance Abuse, University Hospital of North Norway; and Department of Community Medicine, UiT The Arctic University of Norway, Norway
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Lei H, Barnicot K, Maynard E, Etherington A, Zalewska K, Quirk A, Sanatinia R, Cooper SJ, Crawford MJ. Factors influencing use of community treatment orders and quality of care that people receive: results of a national survey in England and Wales. BJPsych Bull 2019; 43:227-235. [PMID: 30971324 DOI: 10.1192/bjb.2019.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Aims and methodWe conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive. RESULTS: Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive-behavioural therapy.Clinical implicationsCTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.Declaration of interestNone.
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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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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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