Community treatment orders in New Zealand

Patient attitudes towards compulsory community treatment orders and advance directives

Objectives: The Mental Health Act 2001 was implemented in Ireland in 2006, however, within this new legislation there is no provision for compulsory community treatment or advance directives, which are now established practice in other countries. We aimed to determine the proportion of patients who believe that compulsory treatment may be justified, the preference for where the treatment should be delivered and factors which may influence this preference. We also sought to determine the proportion of people who would be interested in the option of having an advance directive in their future care plan.

Methods: Patients who had been admitted involuntarily in a 183 bedded psychiatric hospital in Dublin (St John of God Hospital) over a 15 month period were interviewed one year following discharge. A structured interview was used and included the Birchwood Insight Scale and Drug Attitude Inventory (DAI).

Results: Sixty-seven patients were interviewed, which resulted in a follow-up rate of 68%. A total of 56% of participants believe that there are situations in which involuntary treatment with medication may be justified. Of the participants 59% think that the person should be admitted to hospital if they are going to be administered medication without consent. A total of 41 % of participants stated they would have preferred to have been treated at home rather than hospital and this was associated with having a diagnosis of an affective disorder or it being their first involuntary admission. Of the participants 84% expressed interest in having the option of an advance directive in their treatment care plan.

Conclusions: With the increasing community based provision of mental health services in Ireland a debate on compulsory community treatment orders and advance directives needs to take place amongst all stakeholders.

Liberty or dignity: community treatment orders and rights

The use of community treatment orders (CTOs) remains controversial despite their widespread use in a number of different countries. The focus of a CTO should be on individuals with severe and enduring mental disorders, typically requiring adherence with recommended outpatient treatment in the community and requiring that they allow access to members of the clinical team for the purpose of assessment. There is no current provision for CTOs under Irish mental health legislation, although patients who are involuntarily detained under the MHA 2001 (Ireland) can be granted approved leave from hospital. This provision allows for the patient to be managed in the community setting, though, while technically on leave, they remain as inpatients detained under the MHA 2001 (Ireland). This article describes the use of CTOs and considerations relating to their implementation. There is discussion of the ethical grounds and evidence base for their use. Ethical considerations such as balancing autonomy against health needs and the utilisation of capacity principles need to be weighed by clinicians considering the use of CTOs. Though qualitative research provides some support for the use of CTOs, there remains a clear lack of robust evidence based findings to support their use in terms of hospitalisation rates, duration of illness remission and improved social functioning.