Community Treatment Orders Research Articles

Responsibilities with conflicting priorities: a qualitative study of ACT providers\u2019 experiences with community treatment orders

BackgroundPatients 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.MethodsThe 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.ResultsThe 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.ConclusionsMany 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.

The utility of outpatient commitment: acute medical care access and protecting health.

This study considers whether, in an easy access single-payer health care system, patients placed on outpatient commitment-community treatment orders (CTOs) in Victoria Australia-are more likely to access acute medical care addressing physical illness than voluntary patients with and without severe mental illness. For years 2000 to 2010, the study compared acute medical care access of 27,585 severely mentally ill psychiatrically hospitalized patients (11,424 with and 16,161 without CTO exposure) and 12,229 never psychiatrically hospitalized outpatients (individuals with less morbidity risk as they were not considered to have severe mental illness). Logistic regression was used to determine the influence of the CTO on the likelihood of receiving a diagnosis of physical illness requiring acute care. Validating their shared and elevated morbidity risk, 53% of each hospitalized cohort accessed acute care compared to 32% of outpatients during the decade. While not under mental health system supervision, however, the likelihood that a CTO patient would receive a physical illness diagnosis was 31% lower than for non-CTO patients, and no different from lower morbidity-risk outpatients without severe mental illness. While, under mental health system supervision, the likelihood that CTO patients would receive a physical illness diagnosis was 40% greater than non-CTO patients and 5.02 times more likely than outpatients were. Each CTO episode was associated with a 4.6% increase in the likelihood of a member of the CTO group receiving a diagnosis. Mental health system involvement and CTO supervision appeared to facilitate access to physical health care in acute care settings for patients with severe mental illness, a group that has, in the past, been subject to excess morbidity and mortality.

Coercion in Outpatients under Community Treatment Orders: A Matched Comparison Study.

Since the deinstitutionalization of psychiatric services around the world, the scope of outpatient psychiatric care has also increased to better support treatment access and adherence. For those with serious mental illness who may lack insight into their own illness, available interventions include coercive community practices such as mandated community treatment orders (CTOs). This paper examines the perceptions of coercion among service users treated with a CTO. We used a cross-sectional comparative design where service users treated under a CTO were matched to a comparison group of voluntary psychiatric outpatients. Both groups were receiving intensive community mental health services (n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at evaluating their perceptions of coercion and other aspects of the psychiatric treatment. The level of coercion reported by service users treated under a CTO was significantly higher than that in the comparison group. However, in adjusted analyses, service users' perception of coercion, irrespective of their CTO status, was directly correlated with their previous experience with probation and inversely correlated with the sense of procedural justice in their treatment. Evaluation of psychiatric service users' experiences of coercion should consider their past and current involvement with other types of coercive measures, particularly history of probation. Clinicians may be able to minimize these experiences of coercion by incorporating procedural justice principles into their practice.

Exploring experiences with compulsory psychiatric community treatment: A qualitative multi-perspective pilot study in an urban Canadian context

As medical, ethical and clinical effectiveness debates about the use of compulsory psychiatric treatment continues, it is important to further explore the actual experiences and perspectives of all relevant stakeholders in community treatment orders (CTOs). This qualitative pilot study engaged a total of twenty-seven clients, their family members, and care providers in Toronto, Canada. Semi-structured, one-on-one interviews were conducted between February and July 2013 and analyzed using thematic analysis. Top key themes from all the participants identified include, among others: 1) clients' experiences of coercion while treated under CTO, but a preference for CTOs compared to involuntary hospitalization, nevertheless; 2) limited real opportunities for collaboration in treatment decisions expressed by clients and family members; 3) acceptance of the potential for clinical recovery on CTOs while debating the role of CTO in a broader recovery journey by all stakeholders; 4) general preservation of therapeutic relationships between clients and care providers, while acknowledging the tension of taking on an “enforcer” role by providers; and 5) existence of different avenues for asserting agency by clients. The findings of this research illuminate the nuanced, complex, and adaptive perspectives held by different stakeholders, point to the importance of preserving and enhancing procedural justice in their use, and alert the field to incorporate recovery-based approaches in this controversial practice that is a widely and commonly used clinical tool across many jurisdictions.

Community treatment orders increase community care and delay readmission while in force: Results from a large population-based study.

There is debate about the effectiveness of community treatment orders in the management of people with a severe mental illness. While some case-control studies suggest community treatment orders reduce hospital readmissions, three randomised controlled trials find no effects. These randomised controlled trials measure outcomes over a longer period than the community treatment order duration and assess the combined effectiveness of community treatment orders both during and after the intervention. This study examines the effectiveness of community treatment orders in a large population-based sample, restricting observation to the period under a community treatment order. All persons ( n = 5548) receiving a community treatment order in New South Wales, Australia, over the period 2004-2009 were identified. Controls were matched using a propensity score based on demographic, clinical and prior care variables. A baseline period equal to each case's duration of treatment was constructed. Treatment effects were compared using zero-inflated negative binomial regression, adjusting for demographics, clinical characteristics and pre-community treatment order care. Compared to matched controls, people on community treatment orders were less likely to be readmitted (odds ratio = 0.90, 95% confidence interval = [0.84, 0.97]) and had a significantly longer time to their first readmission (incidence rate ratio = 1.47, 95% confidence interval = [1.36, 1.58]), fewer hospital admissions (incidence rate ratio = 0.90, 95% confidence interval = [0.84, 0.96]) and more days of community care (incidence rate ratio = 1.55, 95% confidence interval = [1.51, 1.59]). Increased community care and delayed first admission were found for all durations of community treatment order care. Reduced odds of readmission were limited to people with 6 months or less of community treatment order care, and reduced number of admissions and days in hospital to people with prolonged (>24 months) community treatment order care. In this large population-based study, community treatment orders increase community care and delay rehospitalisation while they are in operation. Some negative findings in this field may reflect the use of observation periods longer than the period of active intervention.

Community treatment orders: towards a new research agenda.

The aim of this study was to report on a half-day multi-stakeholder symposium on community treatment orders (CTOs) hosted by the Melbourne Social Equity Institute (MSEI), which identified research gaps and opportunities, and produced an agreed agenda for future CTO research. The MSEI convened a symposium for 22 experts in CTO research to discuss research priorities in this field in Australasia. An independent moderator elicited views and recommendations and produced a report detailing possible research projects. Research on CTOs is contentious and there is a need to gather and examine information regarding both their use and utility. Due to the complexities involved, it was agreed that research should be undertaken in partnership with persons with had lived experience of mental health problems, clinicians, policymakers and other interdisciplinary stakeholders. Five key areas for future investigation were identified. The issues and recommendations arising from the symposium should shape the scope, nature and conduct of future research directions in the field.

Community treatment orders: an analysis of the first five years of use in England.

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. 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. 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.

“This is not a Life Anyone would want”—A Qualitative Study of Norwegian ACT Service users' Experience with Mental Health Treatment

ABSTRACTWe discuss Norwegian service users' experiences with community mental health treatment in general, and the interprofessional Assertive Community Treatment (ACT) model in particular. To gain the right to treatment, service users have to accept certain limitations, such as medication and community treatment orders (CTOs). Seventy participants responded to five open-ended questions. In addition, eight of them participated in either focus group or interviews.A collaborative approach, using Stepwise-Deductive Induction (SDI) method was used to analyze the participants' experiences. The results showed that the treatment contributes to an experience of autonomy but also one of restriction. It provides service users with enhanced normalcy, but simultaneously a feeling of deviance. There needs to be an ongoing reflection and discussion about those paradoxes in treatment, and service users have to be involved.

'On Desolation Row': The Blurring of the Borders Between Civil and Criminal Mental Disability Law, and What It Means For All of Us

One of the great tensions of mental disability law is the unresolved, trompe d’oeil question of whether it is a subset of the civil law, of the criminal law, or something entirely different. The resolution of this question is not an exercise in formalism or pigeonholing, but is critical to an understanding of the future direction of mental disability law, the deeper meaning of US Supreme Court cases and important state legislative initiatives, and the whole array of hidden issues and agendas that lurk under the surface of mental disability law-decision making. As mental disability law has matured, a dual system appeared to have fallen into place: in civil cases, a patient was generally entitled to a relatively broad panoply of procedural and substantive due process rights in involuntary civil commitment and institutional rights decision making; on the other hand, the Supreme Court has made it explicit that defendants convicted of crimes would have fewer substantive treatment rights, specifying that at least in the area of the right to refuse treatment, “penological interests” would “trump” fundamental civil libertarian interests, and that insanity acquittees could have fewer substantive and procedural due process rights at retention and review hearings than would civil patients. Yet, subsequent important developments cast new light on this separation and call into question the future of a two-tiered mental disability law system: • the proliferation of so-called assisted outpatient treatment (AOT) statutes, of which New York’s Kendra’s Law is the most well-known example; • the expansion of sexually violent predator acts (SVPA), of which New Jersey’s Megan’s Law is often seen as the exemplar but which have been subject to Supreme Court scrutiny in cases from other jurisdictions such as Kansas v. Hendricks, Seling v. Young, Crane v. Kansas, and United States v. Comstock, • the policy implications of a system that provides no meaningful continuity of care, resulting in large numbers of persons continually “shuttling” between jails (or prisons) and mental hospitals, • and the sanctioning of the imprisonment of insanity acquittees in prison facilities. These overlaps blur the borderline between civil and criminal mental disability law in very troubling and problematic ways, and threaten to make this area of the law even more pretextual than it currently is. Laws such as these enforce social control in punitive ways under the guise of the beneficence of civil commitment. Although the universes of individuals subject to statutes such as Kendra’s Law or Megan’s Law, those who are shuttled from jail to hospitals to the street for minor crimes, or those who have been found not guilty by reason of insanity appear quite different – in the first instance, persons not subject to the inpatient involuntary civil commitment power but who may be in danger of deterioration in the absence of forced treatment; in the second, persons who have been charged and/or convicted of violent sexual offenses who are targeted as potentially recidivistic pedophiles; in the third, persons charged with crimes that basically involve “nuisance activities,” and, in the fourth, individuals who have been found not responsible for the antecedent criminal action – there are important, and troubling, points in common in the structures of these kinds of laws. Moreover, they all demonstrate comfort with a system in which many functions of civil and criminal mental disability law merge. Remarkably, until now, virtually no attention has been paid to this phenomenon. In this paper, we will first trace the development of the two-tiered mental disability law system (with a special focus on the right to refuse treatment). We will then review developments in AOT law (focusing on Kendra’s Law), SVPA law, continuity of care issues, and the imprisonment of insanity acquittees, and the blurring effects of each area and implications for the rest of mental disability law. We will next discuss those “blur” areas that may serve to, optimally, limit pretextuality (the creation and expansion of mental health courts, and the application of the Americans with Disabilities Act to cases arising out of the criminal justice system). We will then look at these issues from the perspectives of therapeutic jurisprudence, and then conclude with some modest recommendations.

Are Randomized Control Trials the Best Method to Assess the Effectiveness of Community Treatment Orders?

Many jurisdictions have enacted community treatment order (CTO) legislation that requires a person, who suffers from a severe mental disorder, to follow a treatment plan when living in the community. CTOs have been a source of debate because of controversies on whether evidence of effectiveness should only be considered from randomized controlled trials (RCTs). RCTs are considered the "gold standard" method to evaluate effectiveness of simple therapeutic interventions such as medication, but they are problematic for evaluation of complex interventions because valid attribution of causation in complex interventions is not guaranteed with RCTs. CTOs are complex interventions that require the interaction of many individuals and organizations to achieve their effects and effectiveness research must measure these complexities of delivery and outcomes. This paper examines conceptual, methodological and analytical challenges of CTO research within the context of RCTs and other research designs. It also discusses the current state of knowledge on effectiveness of CTOs. Finally, we suggest a way forward by presenting alternative causal inference approaches and potential models for evaluation complex interventions, such as CTOs. We propose that these approaches should be used alongside other research designs in a nuanced approach that may involve using findings from initial studies to refine the intervention and/or its implementation.

Cultural and linguistic diversity increases the likelihood of compulsory community treatment

BackgroundPeople from culturally and linguistically diverse (CALD) backgrounds are over-represented in compulsory admissions to hospital but little is known about whether this also applies to community treatment orders (CTOs). AimsWe investigated any differences between Australian- and foreign-born patients in the likelihood of CTO placement using state-wide databases from Western Australia. MethodsCases and controls from administrative health data were matched on age, sex, diagnosis and time of hospital discharge (the index date). Logistic regression was then used to identify potential predictors of a CTO. We also assessed if any differences in CTO placement between Australian- and foreign-born patients had effects on bed-days or community contacts in the subsequent year. ResultsWe identified 2958 CTO cases and controls from November 1997 to December 2008 (total n=5916). Of these, 74% had schizophrenia or other non-affective psychoses. Patients who were born in New Zealand, the United Kingdom or Ireland had very similar rates of CTO placement compared to those who were Australian-born. By contrast, there was a gradient of increasing risk of CTO placement for people born in Continental Europe (ORadj=1.36; 95% CI=1.07–1.71, p=0.01) and then the Rest of the World (ORadj=1.61; 95% CI=1.31–1.97, p<0.001). However, there was no evidence of additional benefit in terms of health service use in the following year. ConclusionsIn common with other coercive treatments, people from culturally and linguistically diverse (CALD) backgrounds are more likely to be placed on CTOs. Further research is needed to establish if this is for similar reasons.

Letters

Letters

Psychometric validation of a multi-dimensional capability instrument for outcome measurement in mental health research (OxCAP-MH)

BackgroundPatient reported outcome measures (PROMs) are widely used in mental healthcare research for quality of life assessment but most fail to capture the breadth of health and non-health domains that can be impacted. We report the psychometric validation of a novel, multi-dimensional instrument based on Amartya Sen’s capability approach intended for use as an outcome measure in mental health research.MethodsThe Oxford Capabilities Questionnaire for Mental Health (OxCAP-MH) is a 16-item self-complete capability measure that covers multiple domains of functioning and welfare. Data for validation of the instrument were collected through a national randomised controlled trial of community treatment orders for patients with psychosis. Complete OxCAP-MH data were available for 172 participants. Internal consistency was established with Cronbach’s alpha; an interclass correlation coefficient was used to assess test-retest reliability in a sub-sample (N = 50) tested one week apart. Construct validity was established by comparing OxCAP-MH total scores with established instruments of illness severity and functioning: EuroQol (EQ-5D), Brief Psychiatric Rating Scale (BPRS), Global Assessment of Functioning (GAF) and Objective Social Outcomes Index (SIX). Sensitivity was established by calculating standard error of measurement using distributional methods.ResultsThe OxCAP-MH showed good internal consistency (Cronbach’s alpha 0.79) and test-retest reliability (ICC = 0.86). Convergent validity was evidenced by strong correlations with the EQ-5D (VAS 0.52, p < .001) (Utility 0.45, p < .001), and divergent validity through more modest associations with the BPRS (−0.41, p < .001), GAF (0.24, p < .001) and SIX (0.12, p = ns). A change of 9.2 points on a 0–100 scale was found to be meaningful on statistical grounds.ConclusionsThe OxCAP-MH has demonstrable reliability and construct validity and represents a promising multi-dimensional alternative to existing patient-reported outcome measures for quality of life used in mental health research.

Assessment of outpatient commitment in randomised trials

The randomised controlled trial (RCT) is the gold standard of research and the clearest way to establish causal certainty. This design, however, was misapplied in three RCTs of involuntary outpatient civil commitment (also known as community treatment orders). 1 Swartz M Swanson JD Wagner HR Burns BJ Hiday VA Borum R Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry. 1999; 156: 1968-1975 PubMed Google Scholar , 2 Burns T Rugkåsa J Molodynski A et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet. 2013; 381: 1627-1633 Summary Full Text Full Text PDF PubMed Scopus (255) Google Scholar , 3 Steadman HJ Gounis K Dennis D et al. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Serv. 2001; 52: 330-336 Crossref PubMed Scopus (280) Google Scholar In contrast with the positive outcomes regarding outpatient commitment in epidemiological studies, 4 Segal SP Hayes SL Rimes L The utility of outpatient commitment: I. A need for treatment and a least restrictive alternative to psychiatric hospitalization. Psychiatric Serv. 2017; (published online Aug 1.)DOI:10.1176/appi.ps.201600161 Crossref Scopus (19) Google Scholar , 5 Link BG Epperson MW Perron BE Castille DM Yang LH Arrest outcomes associated with outpatient commitment in New York state. Psychiatric Serv. 2011; 62: 504-508 Crossref PubMed Scopus (39) Google Scholar a subsequent Cochrane review of these RCTs, 6 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.) Crossref PubMed Scopus (66) Google Scholar suggested that outpatient commitment “was no more likely to result in better service use, social functioning, mental state or quality of life compared with standard ‘voluntary’ care”. This conclusion is potentially harmful for patients in need of oversight to protect their health and safety, and that of others. The conclusion is also unjustified because the outpatient commitment RCTs have major design, measurement, implementation, and analytical flaws. Randomised controlled trials and outpatient commitmentSteven Segal's criticism1 of each of the published randomised controlled trials (RCTs)2–4 on outpatient commitment and the subsequent Cochrane systematic review5 are not new. We believe the criticisms reflect a limited understanding of: the clinical practice of outpatient commitment, the conduct of clinical effectiveness RCTs, and the stringent requirements for the inclusion of studies in Cochrane reviews. Psychiatry owes it to patients, their families, and the profession, to take uncomfortable research findings seriously and either conduct even better trials or change clinical practice. Full-Text PDF Randomised controlled trials and outpatient commitmentSteven Segal's critique1 of randomised control trials (RCTs) of outpatient commitment makes several incorrect assertions about these studies. For example, the North Carolina study did not completely exclude violent patients as Segal claims. Rather, patients with a documented history of serious violence were enrolled in a separate, non-randomised arm of the study. Participants were assigned to outpatient commitment at discharge but were followed up in the community with the same protocol as the one used for the other study participants, whether or not they remained under court-ordered treatment (many did not). Full-Text PDF

Community treatment orders should be introduced in the Republic of Ireland

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Carer involvement in compulsory out-patient psychiatric care in England

BackgroundThere is an expectation in current heath care policy that family carers are involved in service delivery. This is also the case with compulsory outpatient mental health care, Community Treatment Orders (CTOs) that were introduced in England in 2008. No study has systematically investigated family involvement through the CTO process.MethodWe conducted qualitative interviews with 24 family carers to ascertain their views and experiences of involvement in CTOs. The transcripts were subjected to thematic analysis that incorporated both deductive and inductive elements.ResultsWe found significant variation in both the type and extent of family carer involvement throughout the CTO process (initiation, recall to hospital, renewal, tribunal hearings, discharge). Some were satisfied with their level of involvement while others felt (at least partly) excluded or that they wanted to be more involved. Some wanted less involvement than what they had. From the interviews we identified key factors shaping carers' involvement. These included: perceptions of patient preference; concern over the relationship to the patient; carers’ knowledge of the CTO and of the potential for carer involvement; access to and relationships with health professionals; issues of patient confidentiality; opportunities for private discussions, and; health professionals limiting involvement. These factors show that health professionals have many opportunities to facilitate, or hinder, carer involvement. The various roles attributed to carers, such ‘proxy’ for patient decision, ‘gatekeeper’ to services, ‘mother’ or ‘expert carer’, however, conflict with one another and make the overall role unclear.ConclusionsThere is a need for clarification of the expectations of carers in individual care situations, for carers to be equipped with the information they need to in order to be involved, and for services to find flexible and innovative ways of ensuring continuous, open communication. The introduction of CTOs in England has not been successful in its ambition for carer involvement.

Review of Mental Health Act must address excessive detention rates

British Journal of Healthcare ManagementVol. 23, No. 11 CommentReview of Mental Health Act must address excessive detention ratesAlistair QuaileAlistair QuaileSearch for more papers by this authorAlistair QuailePublished Online:15 Nov 2017https://doi.org/10.12968/bjhc.2017.23.11.513AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferences BBC News. Ministers lose Mental Health vote. [Online]. 2007. [Cited on 25 Oct 2017]. Available from: http://news.bbc.co.uk/1/hi/uk_politics/6374547.stm Google Scholar Department of Health. Thousands of new roles to be created in mental health workforce plan. London: The Stationery Office; 2017 Aug 30 [cited 2017 Oct 18]. Available from https://publichealthmatters.blog.gov.uk/2017/08/30/moving-forward-with-the-prevention-of-mental-health-problems/ Google Scholar Health Education England. Stepping forward to 2020/21: The mental health workforce plan for England. Leeds: Health Education England; 2017 [cited 2017 Oct 18]. Available from https://www.hee.nhs.uk/sites/default/files/documents/CCS0717505185-1_FYFV%20Mental%20health%20workforce%20plan%20for%20England_v5%283%29.pdf Google Scholar Independent Police Complaints Commission. Mental health and police custody [Internet]. Sale: IPCC; 2017 [cited 2017 Oct 19]. Available from https://www.ipcc.gov.uk/page/mental-health-police-custody Google Scholar May T. Theresa May's Conservative conference speech, full text [Internet]. London: The Spectator; 2017 Oct 4 [cited 2017 Oct 18]. Available from https://blogs.spectator.co.uk/2017/10/theresa-mays-conservative-conference-speech-full-text/ Google Scholar Mental Health Taskforce. The Five Year Forward View for Mental Health. Leeds: NHS England; 2016. Google Scholar NHS Digital. Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment. Uses of the Mental Health Act: Annual Statistics, 2015/16. London: Health and Social Care Information Centre; 2016. Google Scholar Royal College of Nursing. RCN responds to Mental Health Workforce Plan. London: RCN; 2017 [cited 2017 Oct 18]. Available from https://tinyurl.com/yavm3ulq Google Scholar Wessely S. The Prime Minister Has Asked Me To Lead A Review Of The Mental Health Inequality In Britain - Here's Why. London: The Huffington Post; 2017 Oct 6 [cited 2017 Oct 19]. Available from http://www.huffingtonpost.co.uk/professor-sir-simon-wessely/mental-health-act_b_18192476.html Google Scholar FiguresReferencesRelatedDetails 2 November 2017Volume 23Issue 11ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 15 November 2017 Published in print 2 November 2017 Information© MA Healthcare LimitedPDF download

Community treatment orders and social outcomes for patients with psychosis: a 48-month follow-up study.

Community treatment orders (CTOs) are widely used internationally despite a lack of evidence supporting their effectiveness. Most effectiveness studies are relatively short (12-months or less) and focus on clinical symptoms and service data, while a little attention is given to patients' social outcomes and broader welfare. We tested the association between the duration of CTO intervention and patients' long-term social outcomes. A sub-sample (n=114) of community-based patients from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48 months after randomisation. Multivariate regression models were used to examine the association between the duration of the CTO intervention and social outcomes as measured by the social network schedule, Objective Social Outcomes Index, Euro-Qol EQ-5D-3L (EQ-5D), and Oxford Capabilities Questionnaire for Mental Health. No significant association was found between the duration of CTO intervention and social network size (IRR=0.996, p=.63), objective social outcomes (B=-0.003, p=.77), health-related quality of life (B=0.001, p=.77), and capabilities (B=0.046, p=.41). There were no between-group differences in social outcomes when outcomes were stratified by original arm of randomisation. Patients had a mean of 10.2 (SD=5.9) contacts in their social networks, 42% of whom were relatives. CTO duration was not associated with improvements in patients' social outcomes even over the long term. This study adds to growing concerns about CTO effectiveness and the justification for their continued use.

Misrepresenting community treatment orders.

To explore a contradiction between evidence suggesting community treatment order (CTO) ineffectiveness and clinical experience. The literature pertaining to CTOs actually provides an evidence base for both positions. The headline that three randomised controlled trials and subsequent meta-analyses fail to demonstrate significant differences between groups reflects selection bias. A case may still be made for CTOs.

The Utility of Outpatient Commitment: I. A Need for Treatment and a Least Restrictive Alternative to Psychiatric Hospitalization.

This study examined whether psychiatric patients assigned to community treatment orders (CTOs), outpatient commitment in Victoria, Australia, have a greater need for treatment to protect their health and safety than patients not assigned to CTOs. It also considered whether such treatment is provided in a least restrictive manner-that is, in a way that contributes to reduced use of psychiatric hospitalization. The sample included 11,424 patients first placed on a CTO between 2000 and 2010, and 16,161 patients not placed on a CTO. Need for treatment was independently assessed with the Health of the Nation Outcome Scales (HoNOS) at hospital admission and at discharge. Ordinary least-squares and Poisson regressions were used to assess savings in hospital days attributable to CTO placement. HoNOS ratings indicated that at admission and discharge, the CTO cohort's need for treatment exceeded that of the non-CTO cohort, particularly in areas indicating potential dangerous behavior. When analyses adjusted for the propensity to be selected into the CTO cohort and other factors, the mean duration of an inpatient episode was 4.6 days shorter for the CTO cohort than for the non-CTO cohort, and a reduction of 10.4 days per inpatient episode was attributable to each CTO placement. CTO placement may have helped patients with a greater need for treatment to experience shorter hospital stays. Whether the CTO directly enabled the fulfillment of unsought but required treatment needs that protected patient health and safety is a question that needs to be addressed in future research.