Decision-Making in Community Treatment Orders: A Comparison of Clinicians and Mental Health Review Board Members

Background Community treatment orders (CTOs) enable patients to be treated in the community rather than under detention in hospital. Population-based studies of suicide among patients subject to a CTO are scarce. Aims To compare suicide rates among patients subject to a CTO with all discharged psychiatric patients and those detained for treatment but not subject to a CTO at discharge (‘CTO-eligible’ patients). Method From a national case series of patients who died by suicide within 12 months of contact with mental health services in England during 2009–2018, we estimated average annual suicide rates for all discharged patients, those on a CTO at the time of suicide, those ever treated under a CTO and CTO-eligible patients. Results Suicide rates for patients on a CTO at the time of suicide (191.3 per 100 000 patients) were lower than all discharged patients (482.3 per 100 000 discharges). Suicide rates were similar in those ever treated under a CTO (350.1 per 100 000 CTOs issued) and in CTO-eligible patients (382.9 per 100 000 discharges). Suicide rates within 12 months of discharge were higher in persons ever under a CTO (205.1 per 100 000 CTOs issued) than CTO-eligible patients (161.5 per 100 000 discharges), but this difference was reversed for rates after 12 months of discharge (153.2 per 100 000 CTOs issued v. 223.4 per 100 000 discharges). Conclusions CTOs may be effective in reducing suicide risk. The relative benefits of CTOs and intensive aftercare may be time-dependent, with the benefit of a CTO being less before 12 months after discharge but greater thereafter. CTO utilisation requires a careful balancing of patient safety versus autonomy.

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The association between discontinuation of community treatment orders and outcomes in the 12-months following discharge from residential mental health rehabilitation

International Journal of Law and Psychiatry ◽

10.1016/j.ijlp.2020.101664 ◽

2021 ◽

Vol 74 ◽

pp. 101664

Author(s):

Stephen Parker ◽

Urska Arnautovska ◽

Gemma McKeon ◽

Steve Kisely

Keyword(s):

Mental Health ◽

Community Treatment ◽

Community Treatment Orders ◽

Health Rehabilitation ◽

Mental Health Rehabilitation

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Community treatment orders and mental health social work: Issues for policy and practice in the UK and Ireland

International Journal of Law and Psychiatry ◽

10.1016/j.ijlp.2019.04.003 ◽

2019 ◽

Vol 64 ◽

pp. 230-237 ◽

Cited By ~ 1

Author(s):

Jim Campbell ◽

Gavin Davidson ◽

Pearse McCusker ◽

Hannah Jobling ◽

Tom Slater

Keyword(s):

Mental Health ◽

Social Work ◽

Community Treatment ◽

Community Treatment Orders ◽

Policy And Practice ◽

The Uk

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The frequency of references to decision-making capacity in reports to the NSW Mental Health Review Tribunal did not change after legislative reforms that promoted them

Australasian Psychiatry ◽

10.1177/1039856220901475 ◽

2020 ◽

Vol 28 (2) ◽

pp. 171-174

Author(s):

Tim Foley ◽

Christopher J Ryan

Keyword(s):

Mental Health ◽

Decision Making ◽

Education Campaign ◽

Mental Health Act ◽

Decision Making Capacity ◽

Before And After ◽

Legislative Reforms ◽

The Impact ◽

Health Review

Objective: To assess the impact of a 2015 reform to the Mental Health Act 2007 (NSW) ( MHA) that was interpreted as requiring a reference to decision-making capacity (DMC) in reports to the NSW Mental Health Review Tribunal (MHRT). Method: A sample of reports to the MHRT were audited for references to the MHA’s treatment criteria and DMC in periods before and after the reforms, and the frequency of references between the two periods was compared. Results: The frequency of references to DMC did not change significantly after the reforms. (However, references to the ‘least restriction’ criterion increased markedly between the two periods). Conclusion: Despite legislative reforms and a supporting education campaign promoting the importance of consideration of DMC, references to DMC did not increase after the reforms.

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The ethics of coercion in community mental health care

10.1093/med/9780198788065.003.0014 ◽

2016 ◽

Author(s):

Tania Gergel ◽

George Szmukler

Keyword(s):

Mental Health ◽

Health Care ◽

Community Mental Health ◽

Mental Health Care ◽

Community Treatment ◽

Best Interests ◽

Community Mental Health Care ◽

Involuntary Treatment ◽

Community Treatment Orders ◽

Specific Context

The specific context of community mental health care affects the debate surrounding coercion in psychiatry, not by raising radically new questions but by highlighting the complexity of this debate and some of the associated ethical difficulties. This chapter begins by looking at the varying conventional justifications for involuntary treatment and then considers the different mechanisms through which such ‘coercion’ is enforced within the community—from formal compulsion via community treatment orders (CTOs) through to ‘softer’ pressures, such as ‘persuasion’ or ‘interpersonal leverage’. Some commonly accepted ideas surrounding interventions such as ‘incentives’ and ‘threats’ are challenged. The chapter concludes with some broad suggestions as to a how a reformulated ‘decision-making capability and best interests’ approach may be one way to increase the ethical viability of community coercion.

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Coercion in Community Mental Health Care

10.1093/med/9780198788065.001.0001 ◽

2016 ◽

Cited By ~ 5

Keyword(s):

Mental Health ◽

Health Care ◽

Mental Health Care ◽

Mentally Ill ◽

Community Care ◽

Current Knowledge ◽

Community Services ◽

Community Treatment ◽

Community Treatment Orders ◽

Improved Outcome

The use of coercion is one of the defining issues of mental health care and has been intensely controversial since the very earliest attempts to contain and treat the mentally ill. The balance between respecting autonomy and ensuring that those who most need treatment and support are provided with it has never been finer, with the ‘move into the community’ in many high-income countries over the last 50 years and the development of community services. The vast majority of patients worldwide now receive mental health care outside hospital, and this trend is increasing. New models of community care, such as assertive community treatment (ACT), have evolved as a result and there are widespread provisions for compulsory treatment in the community in the form of community treatment orders. These legal mechanisms now exist in over 75 jurisdictions worldwide. Many people using community services feel coerced, but at the same time intensive forms of treatment such as ACT, which arguably add pressure to patients to engage in treatment, have been associated with improved outcome. This volume draws together current knowledge about coercive practices worldwide, both those founded in law and those ‘informal’ processes whose coerciveness remains contested. It does so from a variety of perspectives, drawing on diverse disciplines such as history, law, sociology, anthropology, and medicine and for is explored

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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

The Journal of Law Medicine & Ethics ◽

10.1177/1073110519840492 ◽

2019 ◽

Vol 47 (1) ◽

pp. 126-133 ◽

Cited By ~ 1

Author(s):

Giles Newton-Howes

Keyword(s):

Decision Making ◽

Psychiatric Treatment ◽

Community Treatment ◽

Psychiatric Practice ◽

Individual Autonomy ◽

Ethical Considerations ◽

Community Treatment Orders ◽

Persons With Disabilities ◽

Medical Interventions ◽

Modern Context

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.

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