A systematic review and meta-analysis of predictors and outcomes of community treatment orders in Australia and New Zealand

2020 ◽  
pp. 000486742095428
Author(s):  
Steve Kisely ◽  
Dong Yu ◽  
Saki Maehashi ◽  
Dan Siskind
Keyword(s):  
New Zealand ◽  
Meta Analysis ◽  
Linguistically Diverse ◽  
Community Treatment ◽  
Culturally And Linguistically Diverse ◽  
Community Treatment Orders ◽  
Indigenous Status ◽  
Compulsory Community Treatment ◽  
Treatment Order ◽  
Community Treatment Order

Objectives: Australia and New Zealand have some of the highest rates of compulsory community treatment order use worldwide. There are also concerns that people from culturally and linguistically diverse backgrounds may have higher rates of community treatment orders. We therefore assessed the health service, clinical and psychosocial outcomes of compulsory community treatment and explored if culturally and linguistically diverse, indigenous status or other factors predicted community treatment orders. Methods: We searched the following databases from inception to January 2020: PubMed/Medline, Embase, CINAHL and PsycINFO. We included any study conducted in Australia or New Zealand that compared people on community treatment orders for severe mental illness with controls receiving voluntary psychiatric treatment. Two reviewers independently extracted data, assessing study quality using Joanna Briggs Institute scales. Results: A total of 31 publications from 12 studies met inclusion criteria, of which 24 publications could be included in a meta-analysis. Only one was from New Zealand. People who were male, single and not engaged in work, study or home duties were significantly more likely to be subject to a community treatment order. In addition, those from a culturally and linguistically diverse or migrant background were nearly 40% more likely to be on an order. Indigenous status was not associated with community treatment order use in Australia and there were no New Zealand data. Community treatment orders did not reduce readmission rates or bed-days at 12-month follow-up. There was evidence of increased benefit in the longer-term but only after a minimum of 2 years of use. Finally, people on community treatment orders had a lower mortality rate, possibly related to increased community contacts. Conclusion: People from culturally and linguistically diverse or migrant backgrounds are more likely to be placed on a community treatment order. However, the evidence for effectiveness remains inconclusive and limited to orders of at least 2 years’ duration. The restrictive nature of community treatment orders may not be outweighed by the inconclusive evidence for beneficial outcomes.

scholarly journals Community treatment orders in New Zealand

2009 ◽  
Vol 6 (3) ◽  
pp. 59-60 ◽  
Author(s):  
John Dawson
Keyword(s):  
New Zealand ◽  
Psychiatric Care ◽  
Mental Healthcare ◽  
Community Treatment ◽  
Community Treatment Orders ◽  
Community Based ◽  
Community Psychiatric ◽  
Conditional Discharge ◽  
Treatment Order ◽  
Community Treatment Order

Many legal mechanisms can be used to authorise compulsory community mental healthcare: leave or conditional discharge for compulsory in-patients; adult guardianship (or incapacity) legislation; treatment as a condition of a community-based criminal sentence, like probation, or of parole from imprisonment; or a full-fledged community treatment order (CTO) scheme. It is the specific mix of mechanisms employed in a particular jurisdiction that will characterise how that legal system manages the delivery of compulsory (or quasi-consensual) community psychiatric care.

scholarly journals Efficacy of compulsory community treatment and use in minority ethnic populations: A statewide cohort study

2019 ◽  
Vol 54 (1) ◽  
pp. 76-88 ◽  
Author(s):  
Steve Kisely ◽  
Katherine Moss ◽  
Melinda Boyd ◽  
Dan Siskind
Keyword(s):  
Confidence Interval ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Linguistically Diverse ◽  
Community Treatment ◽  
Culturally And Linguistically Diverse ◽  
Community Treatment Orders ◽  
Diverse Backgrounds ◽  
Compulsory Community Treatment ◽  
Bed Days

Background: There is conflicting and equivocal evidence for the efficacy of compulsory community treatment within Australia and overseas, but no study from Queensland. In addition, although people from Indigenous or culturally and linguistically diverse backgrounds are over-represented in compulsory admissions to hospital, little is known about whether this also applies to compulsory community treatment. Aims: We initially investigated whether people from Indigenous or culturally and linguistically diverse backgrounds in terms of country of birth, or preferred language, were more likely to be on compulsory community treatment using statewide databases from Queensland. We then assessed the impact of compulsory community treatment on health service use over the following 12 months. Compulsory community treatment included both community treatment orders and forensic orders. Methods: Cases and controls from administrative health data were matched on age, sex, diagnosis and time of hospital discharge (the index date). Multivariate analyses were used to examine potential predictors of compulsory community treatment, as well as impact on bed-days, time to readmission or contacts with public mental health services in the subsequent year. Results: We identified 7432 cases and controls from January 2013 to February 2017 (total n = 14,864). Compulsory community treatment was more likely in Indigenous Queenslanders (adjusted odds ratio = 1.45; 95% confidence interval = [1.28, 1.65]) subjects coming from a culturally and linguistically diverse background (adjusted odds ratio = 1.54; 95% confidence interval = [1.37, 1.72]), or those who had a preferred language other than English (adjusted odds ratio = 1.66; 95% confidence interval = [1.30, 2.11]). While community contacts were significantly greater in patients on compulsory community treatment, there was no difference in bed-days while time to readmission was shorter. Restricting the analyses to just community treatment orders did not alter these results. Conclusion: In common with other coercive treatments, Indigenous Australians and people from culturally and linguistically diverse backgrounds are more likely to be placed on compulsory community treatment. The evidence for effectiveness remains inconclusive.

scholarly journals Community treatment orders – principles and attitudes

2013 ◽  
Vol 37 (2) ◽  
pp. 58-59 ◽  
Author(s):  
Vimal Kumar Sharma
Keyword(s):  
Community Treatment ◽  
Successful Implementation ◽  
Care Providers ◽  
Community Treatment Orders ◽  
Expected Number ◽  
The Past ◽  
Number Of Patients ◽  
Patient Groups ◽  
Treatment Order ◽  
Community Treatment Order

SummaryThe community treatment order (CTO) was implemented in 2008 as part of the 2007 amendments to the Mental Health Act 1983. Initially, health professionals and patient groups were sceptical about the successful implementation of CTOs. However, as more than the expected number of patients has been subjected to CTOs in the past 3 years in England and Wales, the professionals' views are shifting in favour of CTOs. More needs to be done to improve the approach and attitude of care providers so that CTOs are used in the most appropriate and effective way for the patients.

scholarly journals Community treatment orders: Current evidence and the implications

2013 ◽  
Vol 203 (6) ◽  
pp. 406-408 ◽  
Author(s):  
Jorun Rugkåsa ◽  
John Dawson
Keyword(s):  
Controlled Trial ◽  
Revolving Door ◽  
Community Treatment ◽  
Current Evidence ◽  
Case Control Studies ◽  
Community Treatment Orders ◽  
Evaluation Trial ◽  
Randomised Controlled ◽  
Treatment Order ◽  
Community Treatment Order

SummaryCommunity treatment orders (CTOs) have been widely introduced to address the problems faced by ‘revolving door’ patients. A number of case–control studies have been conducted but show conflicting results concerning the effectiveness of CTOs. The Oxford Community Treatment Order Evaluation Trial (OCTET) is the third randomised controlled trial (RCT) to show that CTOs do not reduce rates of readmission over 12 months, despite restricting patients' autonomy. This evidence gives pause for thought about current CTO practice. Further high-quality RCTs may settle the contentious debate about effectiveness.

scholarly journals This strange republic of the good: Community treatment orders and their conditions

2014 ◽  
pp. 39 ◽  
Author(s):  
David Hewitt
Keyword(s):  
Mental Health ◽  
Health Professional ◽  
Mental Health Professional ◽  
Community Treatment ◽  
Community Treatment Orders ◽  
Mental Health Act ◽  
Treatment Order ◽  
Community Treatment Order

The Community Treatment Order (CTO) was introduced by the Mental Health Act  2007, and from the start, it was controversial. There is evidence that even the principle of community compulsion was opposed by a majority of psychiatrists, and it was said that many would resign rather than implement CTOs. Happily, that prediction has not been realised. In fact, it seems that many psychiatrists, and more than one Approved Mental Health Professional (AMHP), have seized upon CTOs with something approaching alacrity.

scholarly journals Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care

2016 ◽  
Vol 4 (21) ◽  
pp. 1-354 ◽  
Author(s):  
Tom Burns ◽  
Jorun Rugkåsa ◽  
Ksenija Yeeles ◽  
Jocelyn Catty
Keyword(s):  
Mental Health ◽  
Community Mental Health ◽  
Primary Outcome ◽  
Research Programme ◽  
Community Treatment ◽  
Community Treatment Orders ◽  
Informal Coercion ◽  
Treatment Order ◽  
Community Treatment Order

BackgroundCoercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.DesignThe programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.ParticipantsParticipants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.OutcomesThe OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.ResultsCommunity treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.ConclusionsCommunity Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.Trial registrationCurrent Controlled Trials ISRCTN73110773.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Community treatment order legislation in the Commonwealth

2016 ◽  
Author(s):  
John Dawson
Keyword(s):  
Outpatient Treatment ◽  
Community Care ◽  
Common Law ◽  
Community Treatment ◽  
Community Treatment Orders ◽  
Treatment Plans ◽  
The Uk ◽  
Treatment Order ◽  
Community Treatment Order

This chapter provides an overview of legislation governing the use of community treatment orders (CTOs)—that authorize compulsory outpatient treatment—in the UK, Canada, Australia, and New Zealand. It focuses particularly on the cluster of powers that CTOs confer on community mental health teams, permitting them to continue supervising a person’s outpatient care. It covers the criteria, procedures, and structure of authority for a CTO, the conditions such an order can impose on a person’s community care, the role of statutory treatment plans, and the powers available to enforce the outpatient treatment regime, especially the power of recall to hospital—analysing and comparing the subtly different regimes enacted in these Commonwealth nations that share a common law tradition.

scholarly journals Community treatment orders: background and implications of the OCTET trial

2014 ◽  
Vol 38 (1) ◽  
pp. 3-5 ◽  
Author(s):  
Tom Burns ◽  
Andrew Molodynski
Keyword(s):  
Controlled Trial ◽  
Community Treatment ◽  
Community Treatment Orders ◽  
International Evidence ◽  
Obvious Benefit ◽  
Evaluation Trial ◽  
Randomised Controlled ◽  
The Uk ◽  
Treatment Order ◽  
Community Treatment Order

SummaryCommunity treatment orders (CTOs) were introduced into the UK despite unconvincing international evidence for their effectiveness. The Oxford Community Treatment Order Evaluation Trial (OCTET) is a multisite randomised controlled trial of 333 patients with psychosis conducted in the UK. It confirms an absence of any obvious benefit in reducing relapse despite significant curtailment of liberty. Community mental health teams need to seriously consider whether they should continue using CTOs or shift their clinical focus to strengthening the working alliance.

Misrepresenting community treatment orders

2017 ◽  
Vol 26 (1) ◽  
pp. 38-40 ◽  
Author(s):  
John Little
Keyword(s):  
Selection Bias ◽  
Randomised Controlled Trials ◽  
Evidence Base ◽  
Community Treatment ◽  
Controlled Trials ◽  
Community Treatment Orders ◽  
Randomised Controlled ◽  
Meta Analyses ◽  
Treatment Order ◽  
Community Treatment Order

Objectives: To explore a contradiction between evidence suggesting community treatment order (CTO) ineffectiveness and clinical experience. Conclusions: 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.

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