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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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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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Kisely S, Moss K, Boyd M, Siskind D. Efficacy of compulsory community treatment and use in minority ethnic populations: A statewide cohort study. Aust N Z J Psychiatry 2020; 54:76-88. [PMID: 31558041 DOI: 10.1177/0004867419877690] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is conflicting and equivocal evidence for the efficacy of compulsory community treatment within Australia and overseas, but no study from Queensland. In addition, although people from Indigenous or culturally and linguistically diverse backgrounds are over-represented in compulsory admissions to hospital, little is known about whether this also applies to compulsory community treatment. AIMS We initially investigated whether people from Indigenous or culturally and linguistically diverse backgrounds in terms of country of birth, or preferred language, were more likely to be on compulsory community treatment using statewide databases from Queensland. We then assessed the impact of compulsory community treatment on health service use over the following 12 months. Compulsory community treatment included both community treatment orders and forensic orders. METHODS Cases and controls from administrative health data were matched on age, sex, diagnosis and time of hospital discharge (the index date). Multivariate analyses were used to examine potential predictors of compulsory community treatment, as well as impact on bed-days, time to readmission or contacts with public mental health services in the subsequent year. RESULTS We identified 7432 cases and controls from January 2013 to February 2017 (total n = 14,864). Compulsory community treatment was more likely in Indigenous Queenslanders (adjusted odds ratio = 1.45; 95% confidence interval = [1.28, 1.65]) subjects coming from a culturally and linguistically diverse background (adjusted odds ratio = 1.54; 95% confidence interval = [1.37, 1.72]), or those who had a preferred language other than English (adjusted odds ratio = 1.66; 95% confidence interval = [1.30, 2.11]). While community contacts were significantly greater in patients on compulsory community treatment, there was no difference in bed-days while time to readmission was shorter. Restricting the analyses to just community treatment orders did not alter these results. CONCLUSION In common with other coercive treatments, Indigenous Australians and people from culturally and linguistically diverse backgrounds are more likely to be placed on compulsory community treatment. The evidence for effectiveness remains inconclusive.
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Affiliation(s)
- Steve Kisely
- School of Medicine, The University of Queensland and Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,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
| | - Katherine Moss
- School of Medicine, The University of Queensland and Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,Metro South Health Service, Woolloongabba, QLD, Australia
| | - Melinda Boyd
- School of Medicine, The University of Queensland and Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,Metro South Health Service, Woolloongabba, QLD, Australia
| | - Dan Siskind
- 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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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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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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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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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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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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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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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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Trevithick L, Carlile J, Nodiyal S, Keown P. Community treatment orders: an analysis of the first five years of use in England. Br J Psychiatry 2018; 212:175-179. [PMID: 29439748 DOI: 10.1192/bjp.2017.51] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Community treatment orders (CTOs) were introduced in England in 2008. Aims To measure the rate of CTO use in England during the first 5 years following introduction. METHOD The number of involuntary detentions and CTOs in National Health Service (NHS) hospital trusts was collected between 2009 and 2014. Rates of CTO use and the ratio of CTOs to detentions on admission were calculated, and how these varied between trusts. RESULTS The number of new CTOs each year ranged between 3834 and 4647. The number subject to a CTO per 100 000 population increased from 6.4 in 2009/10 to 10.0 in 2013/14. There was variation between NHS trusts in the use of CTOs when compared with the number of involuntary detentions CONCLUSIONS: The number of patients on CTOs increased year on year. Those on forensic sections were more likely to be discharged on a CTO than those on civil sections. There was considerable variation in the pattern of use between hospitals. Declaration of interest None.
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Affiliation(s)
- Liam Trevithick
- Tees Esk and Wear Valleys National Health Service (NHS) Foundation Trust,Darlington
| | - Jane Carlile
- Northumberland Tyne and Wear NHS Foundation Trust,Newcastle
| | - Sunil Nodiyal
- Northumberland Tyne and Wear NHS Foundation Trust and Institute of Neuroscience, Newcastle University,Newcastle,UK
| | - Patrick Keown
- Northumberland Tyne and Wear NHS Foundation Trust and Institute of Neuroscience, Newcastle University,Newcastle,UK
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Kisely SR, Campbell LA, O'Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2017; 3:CD004408. [PMID: 28303578 PMCID: PMC6464695 DOI: 10.1002/14651858.cd004408.pub5] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND It is controversial whether compulsory community treatment (CCT) for people with severe mental illness (SMI) reduces health service use, or improves clinical outcome and social functioning. OBJECTIVES To examine the effectiveness of compulsory community treatment (CCT) for people with severe mental illness (SMI). SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (2003, 2008, 2012, 8 November 2013, 3 June 2016). We obtained all references of identified studies and contacted authors where necessary. SELECTION CRITERIA All relevant randomised controlled clinical trials (RCTs) of CCT compared with standard care for people with SMI (mainly schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features). Standard care could be voluntary treatment in the community or another pre-existing form of CCT such as supervised discharge. DATA COLLECTION AND ANALYSIS Authors independently selected studies, assessed their quality and extracted data. We used Cochrane's tool for assessing risk of bias. For binary outcomes, we calculated a fixed-effect risk ratio (RR), its 95% confidence interval (95% CI) and, where possible, the number needed to treat for an additional beneficial outcome (NNTB). For continuous outcomes, we calculated a fixed-effect mean difference (MD) and its 95% CI. We used the GRADE approach to create 'Summary of findings' tables for key outcomes and assessed the risk of bias of these findings. MAIN RESULTS The review included three studies (n = 749). Two were based in the USA and one in England. The English study had the least bias, meeting three out of the seven criteria of Cochrane's tool for assessing risk of bias. The two other studies met only one criterion, the majority being rated unclear.Two trials from the USA (n = 416) compared court-ordered 'outpatient commitment' (OPC) with entirely voluntary community treatment. There were no significant differences between OPC and voluntary treatment by 11 to 12 months in any of the main health service or participant level outcome indices: service use - readmission to hospital (2 RCTs, n= 416, RR 0.98, 95% CI 0.79 to 1.21, low-quality evidence); service use - compliance with medication (2 RCTs, n = 416, RR 0.99, 95% CI 0.83 to 1.19, low-quality evidence); social functioning - arrested at least once (2 RCTs, n = 416, RR 0.97, 95% CI 0.62 to 1.52, low-quality evidence); social functioning - homelessness (2 RCTs, n = 416, RR 0.67, 95% CI 0.39 to 1.15, low-quality evidence); or satisfaction with care - perceived coercion (2 RCTs, n = 416, RR 1.36, 95% CI 0.97 to 1.89, low-quality evidence). However, one trial found the risk of victimisation decreased with OPC (1 RCT, n = 264, RR 0.50, 95% CI 0.31 to 0.80, low-quality evidence).The other RCT compared community treatment orders (CTOs) with less intensive and briefer supervised discharge (Section 17) in England. The study found no difference between the two groups for either the main health service outcomes including readmission to hospital by 12 months (1 RCT, n = 333, RR 0.99, 95% CI 0.74 to 1.32, moderate-quality evidence), or any of the participant level outcomes. The lack of any difference between the two groups persisted at 36 months' follow-up.Combining the results of all three trials did not alter these results. For instance, participants on any form of CCT were no less likely to be readmitted than participants in the control groups whether on entirely voluntary treatment or subject to intermittent supervised discharge (3 RCTs, n = 749, RR for readmission to hospital by 12 months 0.98, 95% CI 0.82 to 1.16 moderate-quality evidence). In terms of NNTB, it would take 142 orders to prevent one readmission. There was no clear difference between groups for perceived coercion by 12 months (3 RCTs, n = 645, RR 1.30, 95% CI 0.98 to 1.71, moderate-quality evidence).There were no data for adverse effects. AUTHORS' CONCLUSIONS These review data show CCT results in no clear difference in service use, social functioning or quality of life compared with voluntary care or brief supervised discharge. People receiving CCT were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non-effective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and low- to moderate-quality evidence. In addition, clinical trials may not fully reflect the potential benefits of this complex intervention.
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Affiliation(s)
- Steve R Kisely
- The University of QueenslandSchool of MedicinePrincess Alexandra HospitalIpswich RoadWoolloongabbaQueenslandAustraliaQLD 4102
| | - Leslie A Campbell
- Dalhousie UniversityDepartment of Community Health and EpidemiologyRoom 415, 5790 University AvenueHalifaxNSCanadaB3K 1V7
| | - Richard O'Reilly
- Western UniversityMental Health Building, Parkwood InstituteLondon, OntarioCanadaN6C 0A7
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Dawson S, Lawn S, Simpson A, Muir-Cochrane E. Care planning for consumers on community treatment orders: an integrative literature review. BMC Psychiatry 2016; 16:394. [PMID: 27832769 PMCID: PMC5105250 DOI: 10.1186/s12888-016-1107-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders' perspectives and experiences of care planning for consumers' on CTOs. METHODS An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management. RESULTS Forty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions. CONCLUSIONS Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the 'control and care' dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.
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Affiliation(s)
- Suzanne Dawson
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia.
| | - Sharon Lawn
- School of Medicine, Flinders University, Adelaide, Australia
| | - Alan Simpson
- School of Health Sciences, Nursing, City University London, London, UK
| | - Eimear Muir-Cochrane
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia
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Recall of patients on community treatment orders over three years in the OCTET CTO cohort. BMC Psychiatry 2016; 16:392. [PMID: 27829396 PMCID: PMC5103421 DOI: 10.1186/s12888-016-1102-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Randomised studies consistently show that Community Treatment Orders (CTOs) do not have the intended effect of preventing relapse and readmissions of patients with severe and enduring mental illness. Critics suggest this in part can be explained by RCTs studying newly introduced CTO regimes and that patients therefore were not brought back to hospital for short-term observations ('recall') as frequently as intended. Our purpose was (i) to test the hypothesis that CTO practice as regards recall of patients to hospital in England and Wales was as rigorous under the OCTET trial period as in current routine use and (ii) to investigate the reasons for and outcomes of recalls and whether this changed over time. METHOD Thirty six-month observational prospective study of 198 patients in the OCTET Follow-up Study. RESULTS Forty percent of patients were recalled, 19 % more than once. This is in line with current national use. Deterioration in clinical condition was the most common reason for recalls (49 %), and 68 % of recalls resulted in revocation of the order (i.e., retention in hospital under compulsion). This pattern remained stable over time. CONCLUSION The use of recall cannot explain why RCTs have not confirmed any benefits from CTOs, and their continued use should be reconsidered. TRIAL REGISTRATION The OCTET Trial was retrospectively registered on 12 November 2009 ( ISRCTN73110773 ).
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