Compulsory Outpatient Treatment Research Articles

Clinical impacts of compulsory outpatient treatment in patients with psychiatric disorders: an observational study

BACKGROUND: Compulsory treatment is frequently applied in psychiatry practice, but it is still a controversial issue. This study aimed to investigate the effectiveness of compulsory outpatient treatment decisions in patients with psychiatric disorders.METHODS: A total of 141 patients who had compulsory outpatient treatment decisions were enrolled. To evaluate the clinical effectiveness of the compulsory outpatient treatment decisions, the number of admissions to the psychiatric emergency service, the number of hospitalization, and the total length of hospital stay of the patients 12 months before and after the compulsory treatment decision were compared.RESULTS: The patients with schizophrenia, bipolar disorder, and schizoaffective disorder showed a significant reduction in the number of emergency service admission 12 months after the compulsory outpatient treatment decision. However, the reduction in the number of hospitalization and total hospital stays was only significant in patients with schizophrenia and bipolar disorder. The duration of the compulsory outpatient treatment decision and frequency of compulsory outpatient follow-up visits did not have any effect on the emergency service admissions and hospitalization profiles.CONCLUSIONS: Compulsory outpatient treatment could be effective to reduce hospital readmissions particularly in patients with schizophrenia and bipolar disorder whose continuous treatment is important to prevent relapses.

Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry

BackgroundCompulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT.Main bodyThe current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002–2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT.ConclusionRoss Upshur’s principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.

P.0528 Long-acting antipsychotic injectables in patients under compulsory outpatient treatment: the right to choose

P.0528 Long-acting antipsychotic injectables in patients under compulsory outpatient treatment: the right to choose

L’article 122-1 et après ? Devenir des patients reconnus irresponsables sur le plan pénal, entre 2015 et 2019, dans l’Ouest de la France

ObjectivesArticle 122-1 of the French Penal Code regulates the status of non-criminally responsible (NCR) subjects due to an abolition of their judgment. Although little epidemiological data are available regarding the application of article 122-1, the French judicial literature reports a 0.2 to 0.5% rate of non-conviction due to psychiatric reasons. More recent studies report a higher rate, around 5%. The goal of our study was to determine the future of subjects considered to be NCR due to the abolition of their judgment, following article 122-1 §1 of the French Penal Code and to highlight a link between their pathology, their offenses and their management. Materials and methodsThis is a retrospective chart review, that included all the forensic assessments that took place between 2015 and 2019, of an expert psychiatrist, practicing at the Rennes Court of Appeal, and that resulted in a judgment of non-criminal responsibility. Information was retrieved from the Regional Health Agencies of the western region of France about the evolution of these subjects since their examination by the expert. Medico-psycho-criminological data was gathered, including the psychiatric profile, the committed offenses and the expert's conclusions regarding criminal accountability or non-criminal responsibility as well as the need for referral to the medical care or judicial system. Results58 of the 103 initially identified charts were retained. Our sample consisted mainly of single men with no children, lacking professional qualifications but mostly employed. A majority of them had a positive psychiatric history, a history of substance use but no criminal history or childhood trauma. The ages ranged from 17 to 82 years, the mean age being 41 years (SD=16 years). When the psychiatric expertise identified an abolition of judgment and non-criminally responsibility, 51.46% (95% CI: [41.40-61.43]) of the subjects were referred to in-patient psychiatric treatment. In 2020, 19,42% of subjects were hospitalized in a psychiatric unit, 18,45% were on compulsory outpatient treatment and 17,48% were no longer on compulsory treatment. Psychotic disorders were identified in 75,73% of the sample. For the same offense, this psychotic sub-population was more often hospitalized than the non-psychotic sub-population. Additionally, psychotic subjects were more often hospitalized in the event of a crime (injury to persons or sexual crimes) than of misdemeanor (31,83%). ConclusionsWhile we expected an overwhelming majority of hospital management following the recognition of the non-criminal responsibility, our study does not highlight a predominant outcome. Nonetheless, our initial hypothesis was confirmed by the trends we were able to identify: subjects considered to be non-criminally responsible tend to stay hospitalized, especially when they are psychotic and have committed a crime.

The modern problems of organization of mental stationary substitution out-patient service in Moscow

The article considers problematic issues in hospital-replacing out-patient mental care management on the basis of the Psychiatric Hospital № 13 in 2015-2017. The analysis covered structure of mental patients, their age and social status. Also, patients under active dispensary monitoring and compulsory continuous out-patient treatment were analyzed. The new management component - «the out-patient psychiatric module» - is proposed to be introduced into the structure of mental dispensary.

Psychiatrists' opinion about involuntary outpatient reatment.

ABSTRACTIntroductionInvoluntary outpatient treatment (IOT) is a kind of compulsory outpatient treatment, whose aim is to improve the adherence to the treatment in people with severe mental illness and with no awareness of disease. In these cases, therapeutic abandonment involves a high risk of relapse, with appearance of disruptive and/or self-aggressive or hetero-aggressive behavior, repeated hospitalizations and frequent emergencies. The application of IOT is not an issue without contention. Therefore, the need of legislative regulation in Spain has been a controversial subject for several years, and there are both advocates and opponents.Objective The objective of this study is to bring together the opinion of clinical psychiatrists and resident doctors in psychiatry on the involuntary outpatient treatment and its legislative regulation.Material and method This study is descriptive in nature. The study population consists of 42 clinical professionals in mental health (32 psychiatrists and 10 resident doctors in psychiatry). At the beginning of this study (March 2018), some of these professionals were working in the Psychiatry Department’s facilities of the University Hospital Complex of Huelva. A personal survey in paper form consisting of ten questions about IOT was carried out to each member of this study.Results85.7% of clinicians know the current initiative that tries to carry out the legislative regulation of IOT, and 92.8% of them agree to such regulation. In this sense, 83.3% of them are against the fact that more coercive measures for the psychiatric patients such as the involuntary commitment or the civil incapacitation are regulated and IOT is not. On the one hand, 78.6% of the professionals in mental health believe that IOT is beneficial for the patients. Moreover, 95.2% of them think that is beneficial for their relatives, too. On the other hand, 78.6% of clinicians do not consider that the application of IOT to mentallyill patients is stigmatizing.ConclusionThe vast majority of clinicians think that the legislative regulation of involuntary outpatient treatment is necessary in Spain, and they think this treatment is beneficial not only for the patient but also for their family.

PROCEEDINGS ON THE APPLICATION OF COMPULSORY MEDICAL MEASURES TO THE INSANE

In this article, the authors examined the issue of the application of compulsory medical measures to the insane. The use of compulsory medical measures in relation to the insane is a complex procedural act, since this section of the criminal procedure code considers the rights and legitimate interests of the insane person. In this article, the authors, having investigated the world and native opinions concerning this problem, try to give their own opinion on this problem. Also, the authors investigated and disclosed the features of the application of compulsory medical measures to the insane. The decision of the court on forced outpatient monitoring and psychiatric treatment is not only announced to the person, but also the court decision must be sent to the justice authorities, as well as to psycho-neurological clinics. The convicted is examined by a doctor at intervals determined by the psychiatrist. The person performs the diagnostic and therapeutic measures suggested by the psychiatrist. If the punishment is not related to imprisonment, social assistance will be provided to the person in the process of comprehensive medical and social rehabilitation. In the case of an increased risk of mental disorders of a person, the court may forcibly conduct compulsory outpatient treatment in a psychiatric clinic (usually, on the recommendation of the Commission, in a general hospital). The purpose of this article is, based on the theoretical and practical knowledge already accumulated in this field, as well as the norms of the current Code of Criminal Procedure, to investigate the problem, and on its basis to work out proposals for improving the criminal procedure legislation and law enforcement practice. The relevance of the research topic is due to the fact that, in the science of the criminal process the main thing is to ensure the right to defense of the suspect, the accused and the defendant, as well as to ensure the efficiency and economy of the criminal process. Based on the study, the authors attempted to analyze the application of coercive measures of a medical nature to the insane in native and international practices. Key words: compulsory medical measures, accused, guilt, criminal process, insane.

Les programmes de soins ambulatoires contraints dans le cadre de la loi de 2011, modifiée. Point de vue de la direction

A Compulsory Outpatient Treatment (COT) can be organized by the consulting psychiatrist, at the end of the period of 72hours of observation and care, if the patient requires no longer constant but regular monitoring. It may include exclusive ambulatory care, or short sequences of hospitalization if needed. This modality raises several questions concerning the psychiatrist, the Director of the facility, and the legal status of the patient in COT. The use of force is excluded if the patient does not comply with his compulsory treatment. At the same time, the COT is not subject to systematic control of the judge. The issues are both practical and legal, especially if the doctor decides that the patient needs urgently the return in inpatient facility for medical reasons. The quality of the information issued to the patient is fundamental, in this area where the Director's decision is bound by the decision of the psychiatrist, putting them both in an area of legal uncertainty.

Tratamento em regime compulsivo ambulatório: estudo de follow-up após um ano em Portugal

Enquadramento: Não existem evidências suficientes relativamente ao impacto do tratamento em regime compulsivo ambulatório (TCA). Objetivos: Avaliámos o impacto do TCA ao longo de um ano em sintomas, funcionamento pessoal e social, insight e cognição. Métodos: Análise naturalística, longitudinal, no início e no follow-up após um ano, de 15 pacientes seguidos numa consulta especializada de TCA. Os pacientes foram submetidos a avaliação estandardizada com o Positive and Negative Syndrome Scale (PANSS) (Escala Positiva e Negativa do Síndroma), Personal and Social Performance Scale (PSP) (Escala de Desempenho Pessoal e Social), Berrios-Markova Scale to Assess Unawareness in Mental Disorder (SUMD) (Escala de Avaliação da Falta de Consciência no Distúrbio Mental), Trails A e B, Digit Span, e o Controlled Oral Word Association Test (COWA) (Teste de Associação Verbal Controlada). Resultados: No follow-up houve melhorias significativas no funcionamento pessoal e social (PSP inicial total: média=46,9; follow-up: média=59,3), e nomeadamente nas atividades socialmente úteis incluindo trabalho e estudos (p=0,012) e relações pessoais e sociais (p=0,033). Três pacientes (20%) pontuaram =>69 no PSP, um bom nível de funcionamento. Porém, não verificámos melhorias significativas nos sintomas (PANSS=56,8), insight subjetivo ou objetivo (Berrios-Markova=10,0 e SUMD=11,0), ou desempenho cognitivo. Conclusões: No follow-up após um ano, os pacientes em TCA revelaram melhorias significativas no funcionamento pessoal e social, especificamente nas atividades socialmente úteis incluindo trabalho e estudos e nas relações pessoais e sociais, mas não registaram melhorias nos sintomas, insight e funcionamento cognitivo.

Is the Evidence Strong Enough to Warrant Long-Term Antipsychotic Use in Compulsory Outpatient Treatment?

Debate surrounding assisted outpatient treatment has mostly focused on issues of due process, cost-effectiveness, and efficacy as measured by readmission and incarceration rates. Less attention has been paid to whether long-term use of antipsychotic treatment is supported by sufficient evidence to warrant its compulsory use in assisted outpatient treatment programs. The authors examine the rationale and evidence for long-term use of antipsychotics, noting the pervasive belief within the psychiatric community that psychotic illness, especially schizophrenia, requires lifelong medication. They argue that although antipsychotics are clearly indicated for patients in the acute phase of psychotic illness, the evidence for long-term use is less convincing and may not justify compulsory long-term use.

Compulsory admission and involuntary treatment in Portugal.

This paper details the grounds for compulsory treatment, compulsory admissions in an emergency department and compulsory out-patient treatment in Portugal. Portuguese mental health legislation has improved significantly over recent years, with enhanced safeguards, rapid and rigorous review and clear criteria for compulsory treatment, although much remains to be done, especially in relation to the 'move into the community'.

Legislation for compulsory outpatient psychiatric treatment--contra

Immer wieder wird in Fachkreisen die Möglichkeit der ambulanten Zwangsbehandlung diskutiert. Im Jahr 2003 wurde in Deutschland erwogen, diese im Betreuungsrecht gesetzlich zu legitimieren. Es entstand aber eine politische Mehrheit, die dazu führte, dass ein gefährdeter Patient weiterhin nur stationär und bei fehlender Einwilligungsfähigkeit gegen seinen Willen behandelt werden darf. Trotzdem lebt der diesbezügliche Diskurs immer wieder auf.

Tratamiento ambulatorio involuntario en psiquiatría: una revisión desde la bioética

Freedom is a fundamental right of individuals and also is the freedom to decide on the type of treatment we choose for one disease. This freed is enshrined in various laws through the principle of informed consent. But in the field of psychiatry we can find patients who have decreased temporarily or permanently their capacity to decide about their treatment. Many of these people could be finally admitted to hospital involuntarily. Many countries have legislation that allows compulsory outpatient treatment in cases that defines the law and safeguarding the rights of patients. In Spain the legal situation of involuntary outpatient treatment is unresolved. This article will examine the current legal situation in Spain, the different types of compulsory outpatient treatment, the arguments for and against them and will defend the need to regulate this kind of treatment.

Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial

Compulsory supervision outside hospital has been developed internationally for the treatment of mentally ill people following widespread deinstitutionalisation but its efficacy has not yet been proven. Community treatment orders (CTOs) for psychiatric patients became available in England and Wales in 2008. We tested whether CTOs reduce admissions compared with use of Section 17 leave when patients in both groups receive equivalent levels of clinical contact but different lengths of compulsory supervision. OCTET is a non-blinded, parallel-arm randomised controlled trial. We postulated that patients with a diagnosis of psychosis discharged from hospital on CTOs would have a lower rate of readmission over 12 months than those discharged on the pre-existing Section 17 leave of absence. Eligible patients were those involuntarily admitted to hospital with a diagnosis of psychosis, aged 18-65 years, who were deemed suitable for supervised outpatient care by their clinicians. Consenting patients were randomly assigned (1:1 ratio) to be discharged from hospital either on CTO or Section 17 leave. Randomisation used random permuted blocks with lengths of two, four, and six, and stratified for sex, schizophrenic diagnosis, and duration of illness. Research assistants, treating clinicians, and patients were aware of assignment to randomisation group. The primary outcome measure was whether or not the patient was admitted to hospital during the 12-month follow-up period, analysed with a log-binomial regression model adjusted for stratification factors. We did all analyses by intention to treat. This trial is registered, number ISRCTN73110773. Of 442 patients assessed, 336 patients were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients). One patient withdrew directly after randomisation and two were ineligible, giving a total sample of 333 patients (166 in the CTO group and 167 in the Section 17 group). At 12 months, despite the fact that the length of initial compulsory outpatient treatment differed significantly between the two groups (median 183 days CTO group vs 8 days Section 17 group, p<0·001) the number of patients readmitted did not differ between groups (59 [36%] of 166 patients in the CTO group vs 60 [36%] of 167 patients in the Section 17 group; adjusted relative risk 1·0 [95% CI 0·75-1·33]). In well coordinated mental health services the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty. National Institute of Health Research.

Where is the path to recovery when psychiatric hospitalization becomes too difficult?

Where is the path to recovery when psychiatric hospitalization becomes too difficult?

LAWFULNESS OF A RANDOMISED TRIAL OF THE NEW COMMUNITY TREATMENT ORDER REGIME FOR ENGLAND AND WALES

This article debates and defends the lawfulness of a randomised controlled trial of compulsory outpatient treatment under the mental health legislation for England and Wales. The trial is designed to compare the outcomes for patients of their treatment under the new Community Treatment Order (CTO) regime with their treatment under the older leave scheme - the two main forms of compulsory care in the community now authorised by the revised Mental Health Act 1983. The methods for the trial involve the random allocation of some patients between the two schemes, when they are considered by their Responsible Clinicians to be eligible for some form of compulsory outpatient care. The main question we consider is the lawfulness of that aspect of the methods. Can a carefully selected group of patients be allocated at random between the two regimes to permit an evaluation to proceed? Or would that involve some departure from the decision-making criteria specified by law? We argue that a group of patients can be identified who meet - simultaneously - the tests for treatment under both the CTO and the leave schemes. Those patients could then be allocated lawfully to treatment under either scheme. This opens the door, we argue, to their random allocation between the two schemes for the purposes of the research. In reaching this conclusion, we explain the methods and aims of the trial and closely compare the respective features of the leave and CTO regimes.

Insight and use of community treatment orders

Background: Judgments about insight and compulsory treatment are routine, though contentious, aspects of psychiatric practice. But how should judgments about patients' insight inform involuntary treatment decisions?Aims: To explore the role played by judgments about patients' insight in reasoning concerning the use of community treatment orders (CTOs) in New Zealand.Method: Interviews were conducted with 42 patients treated on CTOs, their clinicians, and carers, concerning reasons for involuntary outpatient care. Their comments concerning patients' insight were analysed to investigate how they used the concept in reasoning about involuntary care.Results: Lack of insight was viewed as an important indicator for compulsory outpatient treatment, due to the perceived link with treatment compliance. There was also a common perception that outpatients could progressively gain insight during sustained treatment on a CTO. Obtaining good insight was not necessarily viewed as an indicator for discharge from a CTO, however, if the patient posed continuing risks of harm, or had a rapid or severe relapse profile.Conclusion: The patient's potential for treatment compliance appeared to be the primary focus of involuntary treatment decisions. Improved insight acted as one important indicator that such compliance would occur.

Compulsory psychiatric treatment of inmates in prisons in Russia

According to article 99 of the Criminal Code of the Russian Federation those persons who are imprisoned for different crimes but at the same time suffer from psychiatric disorders may receive compulsory treatment by the decision of the court. It is necessary to emphasize that these psychiatric disorders are not serious and that is why they do not exclude responsibility for the crimes committed. Thus, alongside with the punishment these inmates are appointed to receive compulsory outpatient treatment and supervision. There are 3 stages of this kind of treatment. At the first stage, which is called adaptation and the duration of which is usually one month, the doctors use correctional methods aimed at adaptation, reduce symptomatology of psychogenic disorders, and treat somatic pathology. Within the second stage complex treatment is used (psychotherapy, psychopharmacology, so called social measures of treatment aimed at improvement of adaptation skills in the social environment of the prison). The duration of this stage is determined by the effectiveness of the abovementioned methods of correction and also depends upon the duration of the terms appointed by the court. In case when steady improvement of the mental state is achieved the third stage mostly aims at the social adjustment of the persons who are ready to start their life in the society. Within this stage methods of psychotherapy, and psychological influences combined with social learning are used.

Ambulante Zwangsbehandlung in der Psychiatrie im europäisch-israelischen Vergleich: Aspekte der rechtlichen Diskussion

Recent German legal initiatives for ordering compulsory outpatient treatment in mental health care are discussed and contrasted with regulations from other European countries and Israel. The legal basis for such coercive measures is comparatively assessed by use of these documents. European countries seem somewhat hesitant to incorporate compulsory outpatient treatment into their civil legislation frameworks. Legal initiatives on this issue in Germany were rejected both on the level of the Federal civil law, and on the State-level of public administrative law. From the legal point of view reasons against compulsory outpatient treatment in mental health care are embedded in the constitutional law and in international human rights.

Regional psychiatric boards in Israel: Expectations and realities

As laid down by Israeli legislation, the Regional Psychiatric Board constitutes one of the chief instruments in the monitoring of compulsory hospitalization, of compulsory outpatient treatment and of the quality of all inpatient care of the mentally ill. This article presents the findings of a study into the working of these boards. Taking a sample of every second application ( N = 168) over a 6-month period to one of Israel's six existing Regional Psychiatric Boards, an examination was made of the decisions issued by the board and of other aspects of its functioning. Explanations for the findings of this analysis are suggested, and generalizing from these findings, recommendations are offered for the improvement of the future functioning of all six Boards.