Abstract
BackgroundCommunity treatment orders (CTOs) were legally implemented in psychiatry in Sweden in 2008, both in general psychiatry and in forensic psychiatric care. A main aim with the reform was to replace long leaves from compulsory psychiatric inpatient care with CTOs. The aims of the present study were to examine the use of compulsory psychiatric care before and after the reform and if this intention of the law reform was fulfilled.MethodsThe study was based on register data from the computerized patient administrative system of Örebro County Council. Two periods of time, two years before (I) and two years after (II) the legal change, were compared. The Swedish civic registration number was used to connect unique individuals to continuous treatment episodes comprising different forms of legal status and to identify individuals treated during both time periods.ResultsThe number of involuntarily admitted patients was 524 in period I and 514 in period II. CTOs were in period II used on relatively more patients in forensic psychiatric care than in general psychiatry. In all, there was a 9% decrease from period I to period II in hospital days of compulsory psychiatric care, while days on leave decreased with 60%. The number of days on leave plus days under CTOs was 26% higher in period II than the number of days on leave in period I. Among patients treated in both periods, this increase was 43%. The total number of days under any form of compulsory care (in hospital, on leave, and under CTOs) increased with five percent. Patients with the longest leaves before the reform had more days on CTOs after the reform than other patients.ConclusionsThe results indicate that the main intention of the legislator with introducing CTOs was fulfilled in the first two years after the reform in the studied county. At the same time the use of coercive psychiatric care outside hospital, and to some extent the total use of coercive in- and outpatient psychiatric care, increased. Adding an additional legal coercive instrument in psychiatry may increase the total use of coercion.
Highlights
Community treatment orders (CTOs) were legally implemented in psychiatry in Sweden in 2008, both in general psychiatry and in forensic psychiatric care
When the patient is assessed to be in need for further compulsory care, but not to be in need for inpatient care, the chief psychiatrist may apply to an administrative court for the patient to be transferred to CTO
In our study based on data from one Swedish county, the main findings were that the total number of days of psychiatric in-patient care spent in hospital was reduced with nine percent after the implementation of CTOs, and that the recurrent patients had 20% less days in hospital in the two-year period after the reform than before
Summary
Community treatment orders (CTOs) were legally implemented in psychiatry in Sweden in 2008, both in general psychiatry and in forensic psychiatric care. During the last 20 – 25 years many countries and states have implemented legal regulations of coercive psychiatric care in the community [1], often labelled ‘Community Treatment Orders’ (CTOs). This form of treatment, in the literature named for example compulsory community (mental health) treatment or care, (involuntary) outpatient commitment/treatment, supervised community treatment, or involuntary community treatment, implies that the patient is allowed to live in the community but is. Research so far gives no clear picture of whether the total use of coercion in psychiatry will increase or decrease by implementing CTOs as a legal opportunity, but an increase over time in the use of CTOs has been reported from different countries [12,13]
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