Supervised discharge orders in England

Consultant psychiatrists' experiences of using supervised discharge Results of a national survey

Aims and Method

Supervised discharge orders (SDOs) enable a degree of compulsion to be exerted over patients in the community. We aimed to establish the level of, and reasons for, their use and consultants' perceptions of their effectiveness. All mental health provider NHS trusts in England were surveyed, and a random sample cohort of cases was identified. Community responsible medical officers (CRMOs) were surveyed using a semi-structured questionnaire.

Results

We identified 596 cases subject to SDOs in 170 mental health provider trusts (100%) in England, involving 18% of consultant psychiatrists. Responses were obtained from the CRMOs of 185 patients (84%) from a sample of 221 cases. The SDO was described as helpful or very helpful in 77% of cases in which it had been in place for over 2 months. In 58% of cases the SDO was intended to improve medication compliance, and in 46% of these cases it was perceived to be effective in doing so.

Clinical Implications

SDOs are not widely used in England. However, for those patients who are made subject to supervised discharge, the order appears to be effective and may improve medication compliance, despite the absence of the legal power to enforce treatment.

Is compulsory community treatment ever justified?

On the evening of 23 February 2000 at the Maudsley Hospital in London the motion ‘This house believes that compulsory community treatment is not justified’ was debated in front of an audience of mental health professionals, carers, service users and other members of the general public. Peter Campbell, a mental health system survivor, and Dr Frank Holloway, consultant psychiatrist at the South London and Maudsley Trust, supported the motion. Cliff Prior, Chief Executive of the National Schizophrenia Fellowship (NSF), and Professor Tom Burns, professor of community psychiatry at St George's Hospital Medical School, opposed it.

Compulsory treatment in the community: current legal powers

Reform of mental health legislation has been under consideration for several years in England and Wales (Department of Health, 2000a), where the Mental Health Act 1983 is in force, and in Scotland (Millan Committee Secretariat, 2001), which is governed by the Mental Health (Scotland) Act 1984. The Mental Health (Northern Ireland) Order 1986 is also under review, although the findings have yet to be published.

Dilemmas for clinicians in use of Community Treatment Orders

Clinicians who treat patients using Community Treatment Orders (CTOs) face many potential dilemmas in their relations with involuntary outpatients and the exercise of their powers. We compare the dilemmas identified in the literature with those reported by responsible clinicians in New Zealand (NZ). These clinicians experienced a number of well-known dilemmas, such as determining the right moment for a person's discharge from a CTO, but they seemed less troubled by some other difficulties than might be expected, usually because they considered involuntary outpatient treatment the best option for the patient or the best way to manage the risks involved. Further dilemmas were identified by the NZ clinicians that have not been widely discussed, concerning the proper scope of clinical authority over patients under CTOs and the decision to revoke involuntary outpatient status. In conclusion, some suggestions are made as to how clinicians might best manage the dilemmas involved.

Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: clinical outcomes

OBJECTIVE

This study examined the effectiveness of community treatment orders (CTOs) used in the treatment of patients with schizophrenia. The hypotheses were that CTOs enhance outcome for patients whose mental health would otherwise be compromised by poor adherence with treatment and that CTOs would enable this when either oral or depot antipsychotic medication was prescribed.

METHOD

This was a naturalistic study using a retrospective mirror-image design. The sample consisted of patients with schizophrenia (n = 94) who were treated on a CTO between November 1996 and October 1999. Two subgroups were defined: patients treated with oral antipsychotic medication (n = 31), and patients treated with depot medication (n = 63). Data were gathered via file review using a questionnaire.

RESULTS

For the whole sample and both subgroups the findings included significant increased number of service contacts, decreased number of admissions and decreased length of inpatient stay. For the total sample numbers of crisis team referrals and other episodes of relapse were significantly decreased. For the subgroup on depot medication there was a non-significant trend towards fewer crisis team referrals and a significant decrease in other episodes of relapse. There were no significant differences for the oral subgroup in crisis team referrals or other episodes of relapse.

CONCLUSIONS

This study provides further evidence that CTOs may be effective in improving the outcome for selected persons with schizophrenia and some evidence that they may enhance the outcome for selected patients with schizophrenia on oral antipsychotic medication.

A 'bittersweet pill to swallow': learning from mental health service users' responses to compulsory community care in England

Two forms of compulsory mental healthcare and supervision in the community are provided within the Mental Health Act 1983: Supervised Discharge Orders (SDOs) and guardianship. At a time when the Government are proposing to extend powers of supervision over people with severe mental illness in the community, it is appropriate that service users' experiences of existing legislation are examined and reported. Despite a range of literature that presents mental health service users' views and experiences, it remains unclear how service users respond to compulsory community mental healthcare in England. The present paper presents the findings of a qualitative investigation into service users' perceptions and experiences of living with SDOs. In the interviews, service users communicated their understanding of why mental health professionals placed them on the order and how their lives have been affected. Individual service users are capable of seemingly contradictory responses, simultaneously accepting and resisting the orders. This paper presents a typology of the range of responses. These responses are fatalism and resignation, dependency, ownership, bargaining, cooperation, resistance, and rejection. The study provides a model with which we can begin to understand how service users respond to compulsory community care where their options are legally constrained.

Early outcomes of supervised discharge

We have previously described the generally positive initial experiences of Supervised Discharge (SD) in a large Mental Health Trust serving a mixed inner city, suburban and rural population. This paper seeks to extend our earlier findings by reporting a longitudinal cohort study examining hospitalization before and after SD for the original sample. The main outcome measures were: renewal of SD; time spent out of hospital; survival to readmission or the end of the study period (1 April 1999). Of the 22 patients commenced on SD orders between April 1996 and October 1997, by 1 April 1999: 12 patients were still subject to supervised discharge; 15 had not been readmitted to hospital; survival out of hospital was longer--717 days, compared with 607 days in the same period before SD (p = 0.037); survival to readmission was also longer than before SD (p = 0.023). Contrary to early professional expectations patients subject to SD seem to survive for longer periods in the community. Although not always effective, its wider use should at least be considered as part of the care package for detained patients with a history of non-compliance with care packages leading to relapse and readmission.

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

BACKGROUND

Mental health provider trusts in England were required in 1994 to establish local Supervision Registers of patients at risk.

AIMS

To identify the factors associated with registration, and obtain clinicians' views on its effectiveness.

METHOD

At a random sample of 14 trusts data were collected from case notes, key workers and responsible medical officers.

RESULTS

A sample of 133 registered patients were more disabled and had more extensive histories of violence and self-harm than 126 comparison patients on the upper tier of the Care Programme Approach (CPA). Those registered were a heterogeneous group. For some there was little evidence of risk. In most cases clinicians did not believe registration had improved care.

CONCLUSIONS

The Supervision Register policy has not resulted in the identification of a well-defined group. Its effectiveness is limited by the lack of operationalized measures of risk.