Community Treatment Orders Research Articles

The efficacy of involuntary outpatient commitment in preventing offense recidivism in patients with schizophrenia

The efficacy of involuntary outpatient commitment in preventing offense recidivism in patients with schizophrenia

The social utility of community treatment orders: Applying Girard's mimetic theory to community-based mandated mental health care.

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.

The lived experience of community treatment orders (CTOs) from three perspectives: A constant comparative analysis of the results of three systematic reviews of published qualitative research

The lived experience of community treatment orders (CTOs) from three perspectives: A constant comparative analysis of the results of three systematic reviews of published qualitative research

The need for independent advocacy for people subject to mental health community treatment orders

Independent mental health advocacy (IMHA) has been proposed as a way of maintaining peoples' rights in involuntary settings, but little is known about the challenges and opportunities associated with the provision of independent mental health advocacy to those on compulsory treatment orders in the community. In Victoria, Australia, an IMHA service is available to people who are at risk of or subject to compulsory treatment, including those who are subject to Community Treatment Orders. The IMHA service is based on the independent advocacy model developed in the United Kingdom. This paper details the benefits and challenges of providing independent non-legal advocacy to those in the community, drawing on a 15-month independent co-produced evaluation of the IMHA service. With limited publicly available sector level data, the evaluation employed qualitative approaches. Issues raised include the need to better target limited resources in the most effective way and the problem of ensuring timely and adequate access. While advocacy was well received by consumers, tensions specific to the community setting were influenced by the attitudes of clinicians to need, risk and recovery as opposed to a coherent understanding of consumer preference and choice.

Community Treatment Orders and Supported Decision-Making.

This paper presents findings from an interdisciplinary project undertaken in Victoria, Australia, investigating the barriers and facilitators to supported decision-making (SDM) for people living with diagnoses including schizophrenia, psychosis, bipolar disorder, and severe depression; family members supporting them; and mental health practitioners, including psychiatrists. We considered how SDM can be used to align Australian laws and practice with international human rights obligations. The project examined the experiences, views, and preferences of consumers of mental health services, including people with experiences of being on Community Treatment Orders (CTOs), in relation to enabling SDM in mental health service delivery. It also examined the perspectives of informal family members or carers and mental health practitioners. Victoria currently has high rates of use of CTOs, and the emphasis on SDM in the Mental Health Act, 2014, is proposed as one method for reducing coercion within the mental health system and working towards more recovery-oriented practice. Our findings cautiously suggest that SDM may contribute to reducing the use of CTOs, encouraging less use of coercive practices, and improving the experience of people who are subject to these orders, through greater respect for their views and preferences. Nonetheless, the participants in our study expressed an often ambivalent stance towards CTOs. In particular, the emphasis on medication as the primary treatment option and the limited communication about distressing side effects, alongside lack of choice of medication, was a primary source of concern. Fears, particularly among staff, about the risk of harm to self and others, and stigma attached to complex mental health conditions experienced by consumers and their families, represent important overarching concerns in the implementation of CTOs. Supporting the decision-making of people on CTOs, respecting their views and preferences about treatment, and moving towards reducing the use of CTOs require system-wide transformation and a significant shift in values and practice across mental health service delivery.

The impact of substance use on treatment as a compulsory patient.

This paper considers the impact of having a diagnosis of substance use disorder on the utilisation of compulsory orders under the Victorian Mental Health Act (2014). We analysed the subsequent treatment episodes over 2 years of people who had been on a community treatment order for at least 3 months and determined the odds of a further treatment order if there was a diagnosis of substance use at or about the time the index community treatment order ended. An additional diagnosis of a substance use disorder was coded in 47.7% and was associated with significantly increased odds of a subsequent treatment order in the following 2 years for those with a main diagnosis of schizophrenia (AOR = 3.03, p<0.001) and 'other' disorders (AOR = 11.60, p=0.002). Those with a main diagnosis of mood disorder had a significant increase in odds for an inpatient treatment order if there was an additional substance use disorder diagnosis (AOR = 3.81, p=0.006). Having an additional diagnosis of substance use disorder was associated with increased likelihood of being placed on an order. This study supports greater emphasis being given to treatment of substance use concurrently with that of mental illness.

Final orders at the last chance saloon?

In 2017, the prime minister announced the first independent review of the Mental Health Act 1983 since its reform in 2007. Last December, shrouded by Brexit, the report was published—Modernising...

Advocacy Coalition Framework and Policy Changes in a Third‐World Country

This work concerns health sector reform in Nigeria between 2003 and 2014. Using qualitative content analysis, I investigate the factors that led to the reform, the reform process, and its outcome. The objective is to assess the conformity of the policy reform to Sabatier and Weible's Advocacy Coalition Framework (ACF) in order to ascertain the applicability, or otherwise, of the ACF in policy analysis in stable democratic African states. In the article, external shock, policy subsystem, stable parameter, technical experts, advocacy coalitions, the “devil shift,” and policy core beliefs—which are basic components of ACF—were all identified in the policy reform process. I conclude that the ACF can be applied in policy reform in democratic African states, so long as there is the rule of law, a separation of powers, freedom of speech and association, a fairly stable political environment, and the presence of policy participants with expert knowledge of the policy issues.Related ArticlesMorris, Mary Hallock. 2007. “The Political Strategies of Winning and Losing Coalitions: Agricultural and Environmental Groups in the Debate over Hypoxia.” Politics &amp; Policy 35 (4): 836‐871. https://doi.org/10.1111/j.1747-1346.2007.00086.xSwigger, Alexandra, and Bruce Timothy Heinmiller. 2014. “Advocacy Coalitions and Mental Health Policy: The Adoption of Community Treatment Orders in Ontario.” Politics &amp; Policy 42 (2): 246‐270. https://doi.org/10.1111/polp.12066Udjo, Eric O., and Barney Erasmus. 2014. “Impact of Retirement Age Policy on the Workforce of a Higher Education Institution in South Africa.” Politics &amp; Policy 42 (5): 744‐768. https://doi.org/10.1111/polp.12092 Related Media CNBC Africa. 2017. “How Can Nigeria Improve Its Healthcare System?” https://www.cnbcafrica.com/videos/2017/09/14/how-can-nigeria-improve-its-healthcare-system/Opeyemi, Agbaje. 2012. “Health Sector Reforms in Nigeria 1.” https://www.youtube.com/watch?v=0YvV_xj0meU

Trust and Community Treatment Orders.

There are conflicting views about the benefits of community treatment orders (CTOs) for people with mental illness. While there is a significant literature on the coercive nature of CTOs, there is less on the impact that CTOs have upon trust. A recovery-oriented approach requires a trusting therapeutic relationship and the coercion inherent in the CTO process may make it difficult for trust to be built, nurtured, and sustained between workers and patients. Our aim was therefore to examine the role of trust within the CTO experience for mental health workers and patients on CTOs. Methods: We conducted a thematic discourse analysis of 8 in-depth interviews with people who were currently on a CTO and 10 interviews with multi-disciplinary mental health workers in Adelaide, Australia (total N = 18 interviews). The interviews were coded and analyzed with the assistance of a patient representative. The findings reveal the challenges and opportunities for trust within the coercive relationship of a CTO. Findings: We found that patients have diverse experiences of CTOs and that trust or mistrust played an import role in whether or not they found the CTO beneficial.

Applying the triple bottom line of sustainability to healthcare research-a feasibility study.

The triple bottom line (TBL) of sustainability is an important emerging conceptual framework which considers the combined economic, environmental and social impacts of an activity. Despite its clear relevance to the healthcare context, it has not yet been applied to the evaluation of a healthcare intervention. The aim of this study was to demonstrate whether doing so is feasible and useful. Secondary data analysis of a 12-month randomized controlled trial. Community based mental health care. Patients with chronic psychotic illnesses (n = 333). Community treatment orders. Financial and environmental (CO2 equivalent) costs of care, obtained from healthcare service use data, were calculated using publicly available standard costs; social sustainability was assessed using standardized social outcome measures included in the trial data. Standardized costing and CO2e emissions figures were successfully obtained from publicly available data, and social outcomes were available directly from the trial data. This study demonstrates that TBL assessment can be retrospectively calculated for a healthcare intervention to provide a more complete assessment of the true costs of an intervention. A basic methodology was advanced to demonstrate the feasibility of the approach, although considerable further conceptual and methodological work is needed to develop a generalizable methodology that enables prospective inclusion of a TBL assessment in healthcare evaluations. If achieved, this would represent a significant milestone in the development of more sustainable healthcare services. If increasing the sustainability of healthcare is a priority, then the TBL approach may be a promising way forward.

Community Treatment Orders and Other Forms of Mandatory Outpatient Treatment.

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.

The experience of the use of Community Treatment Orders following recovery-oriented practice training

States across Australia are changing and adapting policy and laws to deliver mental health services using principles of personal recovery. Yet, the use of Community Treatment Orders (CTOs) remains high in apparent contradiction with this change. As part of the PULSAR trial investigating the outcomes of recovery oriented practice (ROP) training in primary and secondary care services within Metropolitan Melbourne, Victoria, a qualitative study was undertaken to explore the intersection between implementing ROP and working with consumers on CTOs. In-depth interviews were undertaken with consumers with experience being on CTOs and staff of secondary care services, and inductively analysed to identify themes. For consumers, being on a CTO meant lacking choice and control, an emphasis on medication, fear of the threat of hospitalisation, an absence of recovery oriented practice, and staying supported. For staff, recovery oriented practice in the presence of CTOs is challenging, with CTOs being seen to be a primary way to manage risk. Staff supported recovery as a practice, but identified a lack of organisational ‘buy in’ by services. The findings of this small scale study, embedded in a much larger study about ROP, support other literature that identifies implementing ROP in services that use CTOs as potentially problematic; and that ROP can enhance both consumers and staff experiences of services but, without systemic change, there may not be a significant shift in the use of CTOs, while CTOs also inhibit uptake of ROP.

Factors influencing use of community treatment orders and quality of care that people receive: results of a national survey in England and Wales.

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.

Community treatment orders: international perspective.

The use of community treatment orders (CTOs) is available in more than 70 jurisdictions around the world. Although CTOs are used extensively, their effectiveness remains doubtful. We comment on the existing evidence and focus on components that influence the outcomes of CTOs internationally. It is essential to identify factors that affect the delivery of CTOs, and mixed methodologies may improve our understanding regarding their efficiency.

LIMITATIONS OF AN OUTPATIENT COMMITMENT IN A GERIATRIC PATIENT WITH LATE-LIFE MANIA

Introduction The prevalence of mania among >65-year-olds ranges from 0.1% to 0.4% and its treatment poses several challenges for clinicians. Aside from the challenges posed when selecting a medication, there is also the challenge of patients lacking insight into their illness. This can be a specific challenge for geriatric patients who have not had previous psychiatric diagnoses and struggle with adjusting with a diagnosis of bipolar disorder which is associated quite often with shame and denial. This can often lead to involuntary inpatient commitment and court ordered medications but also an outpatient commitment process. In this case, we discuss the limitations of enforcing the outpatient commitment process with a patient who presented with late life mania. Methods This case report focuses on a geriatric patient with corticosteroid-induced mania who was first seen and treated in the inpatient psychiatric hospital and then was followed in an outpatient resident geriatric clinic. Patient's clinical documents were reviewed both in the inpatient setting and outpatient setting. A literature survey was performed on the topics of corticosteroid-induced mania, involuntary commitment process, and outpatient commitment process as well as ethical considerations involved regarding involuntary commitment and court- ordered medications. Results A previously healthy, 75 year old Caucasian male was acutely hospitalized in an inpatient psychiatric hospital after presenting with manic symptoms with psychosis after taking prednisone prescribed for his rheumatoid arthritis. The patient displayed poor insight into his symptoms and refused medications. Involuntary hospitalization was pursued as well as court- ordered medications. The patient agreed to take his medications but continued to demonstrate poor insight into his illness. Based on concerns from his providers as well as his family, the patient was placed on an outpatient commitment to help with treatment adherence, and he was seen in geriatric psychiatry resident clinic. He would present for appointments but was self-titrating doses of medications and had discontinued his antipsychotic medication. Through this case, more knowledge was gained about the limitations of the outpatient commitment process and how its effectiveness is not as robust as an inpatient commitment. This patient eventually discontinued all treatment and terminated care with the clinic. Conclusions The involuntary outpatient commitment process was put in place to allow patients who lacked insight into their mental illness to access psychiatric care. There has been much discussion about the ethical principles of beneficence and autonomy that are pitted against each other when discussing the outpatient commitment process, but the hope is that this process helps providers to care for patients especially geriatric patients who are diagnosed with late-life bipolar disorder and may lack the insight with being diagnosed with a psychiatric illness. However, from treating this patient, we have come across challenges that exist with implementing and enforcing the outpatient commitment process. This warrants a discussion on the limitations it poses and what are the other strategies that we can implement to continue treating this population.

Rates of use of community treatment orders in Australia

ObjectivesThe variable and changing rates of use of involuntary community treatment orders (CTOs) in the treatment of people living with mental illness are not well-documented or well understood. This new study sought to determine contemporary rates of use in Australia, where local jurisdictions were previously shown to have varied and shifting rates of use that were high by world standards. MethodsAustralian state and territory mental health review tribunals, health departments, and/or offices of the chief psychiatrist were surveyed for the most recent published annual data on the total number of individual people placed on a CTO and/or the total number of CTOs made. FindingsContemporary rates of CTO use in Australia range from 40.0 per 100,000 population (in Western Australia) to 112.5 per 100,000 (in South Australia). Since the last national survey, the rates of people subject to CTOs fell into in two jurisdictions (Victoria and Western Australia). However, rates of CTOs made were higher than previous figures in all jurisdictions reporting data. Use of CTOs in Australia varies considerably within and between jurisdictions. ConclusionsAustralian jurisdictions continue to use CTOs at high and varying rates, despite unresolved questions about their role and impact. Transparency and accountability around their use would be improved by regular and nationally uniform public reporting of CTO data. Further research into how and why CTOs are used may also provide opportunities to respond to factors driving their use and thereby reduce the use of coercion in mental health care.

Orange, Yolo counties find positive outcomes with Laura's Law

An MHW interview with two California county executives revealed that funding and concerns about forced treatment occurred before the implementation of Laura's Law, the state's assisted outpatient treatment (AOT) program in both counties.

Citing success, TAC report urging all California counties to adopt AOT law

Observing that California's assisted outpatient treatment (AOT) law has substantially improved conditions for highly vulnerable individuals in the program for counties that implemented the program, there remains untapped potential within counties surveyed, according to a report released Feb. 5 by the Treatment Advocacy Center (TAC).

Using community treatment orders: key provisions.

Richard Griffith, Senior Lecturer in Health Law at Swansea University, continues his series on community mental health law with a review of community treatment orders under the Mental Health Act 1983.

Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities.

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.