Compulsory Community Treatment Orders Research Articles

The perspectives of Māori on community treatment orders: A thematic analysis.

To understand the themes for Māori subjected to compulsory community treatment orders. The Mental Health (Compulsory Assessment and Treatment) Act 1992 has been utilised in Aotearoa New Zealand for more than three decades. Despite Māori having higher rates of being subject to community treatment orders, there is little research examining their perspectives of its benefits and harms. Thematic analysis of a purposive sample of Māori in Hawke's Bay, New Zealand. Five themes were developed. Māori described community treatment orders as restrictive and stigmatising. Some Māori described being poorly informed of the structures surrounding the use of community treatment orders and saw it as a mechanism to circumvent information-giving regarding treatment. Counterbalancing these, Māori described community treatment orders as mandating support and saw them as a mechanism to access care. Finally, some described their compulsory treatment status as unimportant and irrelevant. Thematic analysis identified five clear themes from interview participants. Conceptualisation of community treatment orders was largely negative, although Māori acknowledged that being subject to community treatment orders demanded more support from services. Themes of stigma and restriction are common in the literature, however, conception of the use of community treatment orders to bypass consent is novel. The literature describes community treatment orders as providing support, however, in this study, the interpretation suggests a need to lose personal autonomy to receive care, a potentially 'slippery slope' towards a two-tier type service. These findings remind services of the importance of attending to cultural elements of care, being clear around the process of consent. In terms of policy, weaving in cultural understanding appears to be important from an Indigenous perspective.

Compulsory Community Treatment Orders and health outcomes for Ma-ori in New Zealand.

We have previously analysed outcomes for all community treatment orders commenced during a 10-year period in New Zealand. Given Te Tiriti O Waitangi obligations to scrutinise health and consider equity for Māori, we completed this analysis to consider community treatment-order outcomes according to ethnicity. Ministry of Health databases provided demographic, service use and medication dispensing data for community treatment-order recipients between 2009 and 2018. As non-Māori on community treatment orders are older, less deprived and less likely to be diagnosed with a Psychotic Disorder, data were categorised according to age (<35/⩾35 years), level of deprivation (New Zealand Dep levels ⩽3, 4-6 and ⩾7) and diagnosis (Psychotic Disorder/non-Psychotic Disorder). The incidences of key outcome measures (admissions, community care, medication dispensing) were calculated for periods on/off community treatment orders for Māori and non-Māori to consider the differential impact of community treatment orders according to ethnicity. Māori have high rates of community treatment order utilisation and are younger, more likely to be diagnosed with a Psychotic Disorder and spend longer receiving compulsory treatment than non-Māori. Non-Māori are more likely to receive more additional depot antipsychotic medication on-community treatment orders compared with periods off-community treatment order than Māori but other clear patterns of response distinguishing between Māori and non-Māori were not present. The differences between Māori and non-Māori for community treatment-order utilisation suggest the presence of structural inequity in underlying mental illness distribution and treatment provision. Māori cultural expertise at all levels of healthcare including healthcare planning and delivery is required to make advances and reduce disparity.

Compulsory community treatment orders (CTOs): recent research and future directions

Compulsory community treatment orders (CTOs) are controversial because the right to refuse treatment is overridden, even when patients may not be acutely unwell. Scrutiny of outcomes associated with CTOs is therefore required. This editorial provides an overview of the evidence for CTOs. It also discusses recent papers reporting outcomes associated with CTOs and makes recommendations for researchers and clinicians to consider.

Variation in the use of compulsory community treatment orders between district health boards in New Zealand.

To report rates of Compulsory Community Treatment Order (CTO) use by District Health Boards (DHBs) in New Zealand and analyse whether socio-demographic factors explain any variability. The annualised rate of CTO use per 100,000 population was calculated for the years 2009-2018 using national databases. Rates were adjusted for age, gender, ethnicity, and deprivation and are reported according to DHBs to allow comparisons between regions. The annualised rate of CTO use for New Zealand was 95.5 per 100,000 population. CTO use varied between DHBs from 53 to 184 per 100,000 population. Standardising for demographic variables and deprivation made little difference to this variation. CTO use was higher in males and young adults. Rates for Māori were more than three times that of Caucasian people. CTO use increased as deprivation became more severe. CTO use increases with Maori ethnicity, young adulthood, and deprivation. Adjusting for socio-demographic factors does not explain the wide variation in CTO use between DHBs in New Zealand. Other regional factors appear to be the major driver of variation in CTO use.

Examining the health and criminal justice characteristics for young people on compulsory community treatment orders: An Australian birth cohort and data linkage study

BackgroundMost studies on the predictors and effectiveness of community treatment orders (CTOs) are restricted to health-related variables and do not consider forensic contacts as established by criminal justice databases or predictors from birth. We used linked administrative health and criminal justice data for a birth cohort in Queensland, Australia to investigate the characteristics and outcomes of people placed on CTOs. MethodsCTOs were identified from administrative data for hospital admissions and community mental health service contacts for a population cohort of 45,141 individuals born in Queensland in 1990. These data were linked with administrative court records, with individuals followed up to age 23/24 years. Logistic regression analyses were used to examine characteristics associated with CTO placement and Tobit regression analyses to examine factors predicting health and criminal justice outcomes in the following year. ResultsThere were 211 CTO cases by age 23/24 years, for whom it was possible to identify 413 controls on voluntary treatment. Non-affective psychoses [F20-F29] were the strongest predictors of CTO placement (ORadj = 4.07, 2.77–5.99) followed by a court appearance (ORadj = 1.99, 1.28–3.09). CTOs were associated with greater, not lower, subsequent psychiatric hospital admissions, inpatient bed-days and community mental health service contacts, although on sensitivity analyses psychiatric hospital admissions were the same as voluntary controls. CTOs were not associated with more subsequent court appearances despite higher rates of offending before CTO placement. ConclusionsBoth clinical and forensic variables can determine CTO placement and, on adjustment for these covariates, CTOs were not associated with reductions in psychiatric hospital admission, time spent as an inpatient, or subsequent court appearances. The latter finding might mean that CTOs reduce the risk of offending to that of voluntary controls.

Compulsory Community Treatment Orders in New Zealand and the provision of care: An examination of national databases and predictors of outcome.

BackgroundCompulsory Community Treatment Orders (CTOs) are contentious because they impose severe restrictions on individuals in community settings. The existing evidence for CTOs is constrained by ethical and methodological limitations and may not support usual clinical practise. This study examines the effectiveness of CTOs using routine data in the New Zealand context.MethodsMinistry of Health, New Zealand databases provided demographic, service use, and medication dispensing data for all individuals placed on a CTO between 2009 and 2018. We examined the effectiveness of CTOs through a comparison of psychiatric endpoints identified as useful in the literature according to CTO status. Further analyses examined the moderating influences of age, sex, ethnicity, and diagnosis on outcome.Findings14,726 patients were placed under a CTO over the 10 year period between 1 January 2009 and 31 December 2018. Patients on CTOs experienced a reduced frequency of admissions (rate ratio of 0∙94, 95% CI 0.93-0.95, p<0.01) reduced admission days (rate ratio 0∙97, 95% CI 0.97-0.98 p<0∙01), increased frequency of psychiatric community contacts (rate ratio 3∙03, 95% CI 3.02-3.03 p<0.01), and increased dispensing of psychiatric medication (rate ratio 2.27, 95% CI 2.27-2.28, p<0.01). When sub-group analyses were undertaken, the association between treatment under a CTO and reduced admission frequency was only present for those with Psychotic Disorders.InterpretationCTOs in New Zealand are associated with increased community care, and increased dispensing of psychiatric medication. Patients with Psychotic Disorders also experienced reduced frequency and length of admissions whilst under a CTO.FundingNo specific funding was received for this study.

Community Treatment Order Outcomes in Quebec: A Unique Jurisdiction.

We study compulsory community treatment orders (CTOs) for patients with severe and persistent mental illness (SPMI). Focusing on a unique jurisdiction in Canada that allows for long duration CTOs with strict enforcement procedures, our objectives are to determine whether extended duration CTOs are effective and to determine whether associated hospitalization costs are reduced. A mirror image, naturalistic design was employed using patients as their own controls to enhance external validity. No inclusive or exclusive criteria were employed for the 367 SPMI clinic patients who were studied over a 5-year period. Detailed documentation of the dates of all CTOs, long-acting antipsychotic injections (LAIs), emergency visits, hospitalizations, duration of hospitalizations, crimes and/or police involvement were collected. To study the relation between CTO and injection adherence, we use a mixed-effect linear regression model. To study the effect of injection adherence and hospitalization, we use survival analysis via Kaplan-Meier and Cox survival models. CTO and non-CTO patients did not differ with respect to demographics, but CTO patients were significantly more severely ill. Following a CTO, adherence to LAIs increased over time (P < 0.001). The average time the patients spent in the community, that is, outside the hospital, was significantly longer under a CTO, and the duration of hospitalizations was decreased. LAI adherence and outpatient office visits were enhanced by extended duration CTOs, as was time out of the hospital. The shorter duration of hospital stays implies cost savings. These must be weighed against their undesirable coercive nature.

Compulsory community treatment and ethnicity: Findings from a culturally and linguistically diverse area of Queensland

ObjectiveTo compare the use of community treatment orders (CTOs) and forensic orders (FOs) in a culturally and linguistically diverse (CALD) population to that in a non-CALD population. MethodsWe analysed the relationship between coming from a CALD background and the use of CTOs and FOs on discharge from hospital using merged data from the Metro South Addiction and Mental Health Service's Transitions of Care (ToC) and Consumer Integrated Mental Health Application (CIMHA) databases. ResultsNine hundred and seventy-six individual records were included in the data set, of whom eighty-six were from a CALD background (8.8%). Three hundred and eleven patients were on compulsory community treatment. Use of compulsory community treatment (CTOs and FOs) was similar for those born in Australasia, British Isles, North America and Europe but significantly higher for those born elsewhere even after adjusting for socio-demographic and clinical variables (Adj OR 2.19, 95% CI 1.36–3.52). The use of an interpreter significantly increased the likelihood of compulsory community treatment (Adj OR 2.76, 95% CI 1.20–6.35). Restricting the analyses to CTOs only did not alter these results. ConclusionsMetro South residents from a CALD background outside of Europe were over-represented on compulsory community treatment orders. This could reflect the difficulties in accessing voluntary services, communication barriers, stigma associated with mental illness, discrimination, or issues related to accurately diagnosing mental illness cross-culturally. Clinicians need to be aware of the complexity of working with people from diverse cultures and apply these orders judiciously.

Who’s Talking About Us Without Us? A Survivor Research Interjection into an Academic Psychiatry Debate on Compulsory Community Treatment Orders in Ireland

This paper presents a user/survivor researcher perspective to the debate among psychiatrists on the suggested introduction of Community Treatment Orders in Ireland. Critical questions are raised about evidence and the construction of psychiatric knowledge. Important questions include: How is this evidence created? What and whose knowledge have not been considered? Some critical issues around coercion, ‘insight’, and attributions of ‘lack of capacity’ are briefly considered. Further legal considerations are then introduced based on the United Nations Convention on the Rights of Persons with Disability. The paper concludes with a human rights-based appeal to reject the introduction of coercive community treatment in Ireland.

Towards Changing Compulsory Community Mental Health Treatment in New Zealand: Shining Light on How Community Treatment Orders Are Produced

In this paper, we use a constructed scenario to illustrate making a compulsory community treatment order in the New Zealand context. Drawing on publicly available documentation, we outline the existing mental health law framework that produces community treatment orders and emerging complex problems of their high, increasing and disproportionate use. We provide examples of human rights, indigenous and clinical effectiveness research that appear to be destabilising the existing mental health law framework. We argue assemblage theory (Deleuze &amp; Guattari) is a useful theoretical tool to unpack the making and continued use of compulsory community treatment orders in the context of complex destabilising and stabilising influences. This is followed by an outline of the concept of assemblage with reference to the constructed scenario, focusing on processes, practices, places, types of knowledge, roles, documents and how they connect to produce certain effects that both enable and constrain participants’ actions. In the New Zealand context, we examine the potential for assemblage theory to generate new ways of thinking about compulsory mental health treatment in community settings by challenging perceived limitations and revealing opportunities for participants to act otherwise. We conclude with a proposal for further research shaped by this theory that explores the making of actual community treatment orders to reveal where there is potential to change existing relations towards more positive effects for participants.

Perception of Coercion Among Patients With a Psychiatric Community Treatment Order: A Literature Review.

Various forms of compulsory psychiatric community treatment orders (CTOs) are commonly utilized internationally. CTOs remain contentious because of the ethical implications of coercing patients to receive treatment. Understanding patients' experience of CTOs can assist in the development of more patient-centered and recovery-focused community care. This review examined the relationship between CTOs and patients' perceptions of coercion in the literature. A search of key terms relating to CTOs and patients' perceptions of coercion was conducted of relevant databases from their inception to March 31, 2014. Publications were included if they were peer reviewed, reported on original research, surveyed or interviewed patients who were or had been subject to a CTO, and were written in English. Factors influencing patients' perceptions of coercion, including the regional context of the studies, were identified. Twenty-three primary research articles, reporting on 14 studies from seven countries, were included. Evidence indicated that CTOs may contribute to a patient's sense of coercion, with marked variations among studies in the levels of coercion. Contextual factors, including perceptions of alternatives to CTOs, the presence of additional forms of leverage in patients' lives, and the process of CTO initiation and enforcement, may mitigate or enhance perceptions of coercion. Coercive elements of CTOs may be reduced through increased patient access to information, better working relationships with service providers, and accessible, fair processes. The coercive aspects of CTOs should be seen as part of a broader understanding of the daily pressures and leverage applied in outpatient psychiatric treatment.

A Factor Analysis of Patients’ Views of Compulsory Community Treatment Orders: The Factors Associated with Detention

Quantitative analysis of patients’ views about compulsory community treatment has not been undertaken although qualitative analysis identifies some positive and negative themes. This research is designed to identify the factor structure of patients’ subjective experience of community detention in a quantitative fashion. The authors assessed 79 psychiatric patients either currently or previously detained under a compulsory community treatment order for in excess of 6 months. A structured questionnaire was used to assess patients’ views of community detention and exploratory factor analysis was performed. Principal component analysis with oblique rotation identified three factors associated with detention. Although overlapping, these factors represent interpersonal difficulties, intrapsychic threat and a safety factor associated with detention. The safety factor also loaded for unhappiness. These factors accounted for 60% of the variance in the data set. Recognizing these factors may improve the use of community treatment orders and make them more acceptable to patients.

Assessing the Outcome of Compulsory Treatment Orders on Management of Psychiatric Patients at 2 McGill University- Associated Hospitals

Some literature suggests that compulsory community treatment orders (CTOs) are effective in reducing hospitalizations in a subgroup of psychiatric patients with histories of repeated hospitalization, allowing them to be treated in the community under less restrictive measures. However, studies have yielded contradictory findings, in part because of methodological differences. Our study examines the effectiveness of CTOs in reducing hospitalizations and increasing community tenure of such patients. The sample included all psychiatric patients who had been given a CTO during a 9-year period at 2 of McGill University's hospitals. This is a naturalistic, observational, retrospective, before-and-after study where patients acted as their own control subjects. We examined variables, including the number, duration, and time to psychiatric admissions, comparing 4 time periods: early, pre-index, index (when the first CTO was in force), and post-index periods. The total study duration per subject encompasses the longest period of observation within existing studies in Canada. Psychiatric patients with histories of frequent readmissions demonstrated a significant reduction in their number of hospitalizations as well as an increase in the median time to re-hospitalization, during the period when they were treated under a CTO. This effect of CTO was sustained even after the CTO had expired. Our study suggests that CTOs are effective in assisting psychiatric patients with histories of repeated hospitalizations to live and be treated in the community, diminishing the occurrence of frequent hospitalization.

Do we need community treatment orders in Ireland?

Re-admissions to inpatient psychiatric care are now so frequent as to be designated the 'revolving door' phenomenon and constitute 72% of admissions to Irish inpatient psychiatric units and hospitals. It is commonly believed that treatment non-adherence with aftercare following inpatient discharge contributes to readmission. Attempts to improve adherence and reduce or shorten readmission through compulsory community treatment orders have been made in several countries including Scotland in 2005 and, from November 2008, England and Wales. Provision for conditional discharge in Ireland has already been furnished by the Criminal Law (Insanity) Act 2006 but has been compromised by the inability to impose enforcement of conditions. The paper aims to determine whether compulsory community treatment orders are effective in improving adherence and reducing re-admission and whether, in consequence, their introduction in Ireland should be considered. The legislative measures adopted to improve treatment adherence and thereby reduce re-admissions are presented. The evidence of their effectiveness is examined. Evaluation of the effectiveness of community treatment orders is limited and hindered by confounding factors. What evidence there is does not provide convincing evidence of their utility. It is concluded that there is insufficient evidence to advocate their early introduction in Ireland in civil mental health legislation. Instead a wait and see policy is suggested with critical assessment of the outcome of such developments in Scotland and England and Wales. In addition further research on the characteristics of revolving door patients in Ireland and the circumstances determining their readmission is advocated. There is an anomaly in the Criminal Law (Insanity) Act 2006 which allows of conditional discharge but does not provide for its enforcement.

Patient attitudes towards compulsory community treatment orders and advance directives.

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. 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). 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. 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.

Community treatment orders: how ethical without experimental evidence?

Compulsory community treatment orders are a feature of most advanced mental health systems without convincing experimental evidence of benefits. Is it ethical to continue without such evidence ? This paper argues that the responsibility for ensuring it is collected lies as much with Parliament as with researchers.

Family Perspective on Community Treatment Orders: A New Zealand Study

People with serious mental disorders typically live with family members. Despite increasing interest in compulsory community treatment for such patients, the experience and views of their family members have been little studied. Qualitative interviews with 27 family members, whose relatives have been subject to compulsory community treatment. Family members are generally in favour of the use of compulsory community treatment orders. They perceive a positive influence on their relative, on themselves, on family relationships, and on relations with the clinical team. Family members are aware of the ethical and other dilemmas that attend the use of compulsory community care.

26,000 people may be forced into treatment

Thousands of people with mental illness will be subject to compulsory community treatment orders if the draft Mental Health Bill becomes law, the King’s Fund health think tank warned this week.

Effects of Compulsory Treatment Orders on Time to Hospital Readmission

To evaluate the effect of compulsory community treatment orders on subsequent time out of the hospital, the authors studied the admission dates of psychotic patients who had repeated hospitalizations in Quebec, Canada, and divided each admission according to its time in relation to the index admission, during which the judicial order was obtained. The data were stratified by type of admission (early, preindex, index, or postindex), and the hypothesis tested was that the median time to readmission would be greatest for the index admission. The hypothesis was confirmed, supporting previous findings that judicial orders that mandate severely ill psychotic patients to undergo compulsory community treatment are associated with decreased time spent in the hospital and thus increased personal freedom.

Values in the definition of mental disorder

There has been rapidly increasing interest in the concept of mental disorder in the last few years. One of the main forces behind this has been the increasing importance and sophistication of diagnostic manuals such as DSM-IV and ICD-10, alongside continuing discontent about psychiatric diagnosis (e.g. Kutchins and Kirk, 1997). Critiques of the medical model have charged it with being a means by which individuals or groups are, among other things, disqualified, stigmatized and socially excluded, and these concerns continue to be pressed by patients and their advocates. We have seen concerns about community care, the beginnings of compulsory community treatment orders, uncertainty about response to dangerousness associated with ‘personality disorder’, as well as the growing influence of the service user movement. Further, advances in the sciences – biological, psychological and social – modify our concept of mind, its biological and social basis, and hence our ways of understanding mental disorder. The arguments and perspectives on mental disorder move in and around these themes: the medical model, social values and the sciences.