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Outcomes for a Hypothetical Person With Schizophrenia That Were Rated in a Study of Preferences Concerning Involuntary Outpatient Commitment
Source publication
Study findings indicating that involuntary outpatient commitment can improve treatment outcomes among persons with severe mental illness remain controversial. Opponents of outpatient commitment argue that its coerciveness is unacceptable even given its arguable benefits. However, it is unclear to what extent the public debate surrounding outpatient...
Context in source publication
Context 1
... assess the preferences of participants, we described a hypo- thetical person with schizophrenia, Mr. Smith, and provided a brief description of outpatient commitment. Mr. Smith was intro- duced as having had problems with drug and alcohol abuse and as being released from the hospital after an involuntary admis- sion for threatening strangers on the street. This description of Mr. Smith, i.e., as an individual with schizophrenia, substance use problems, and a history of threatening behavior, was intended to reflect the population in which outpatient commitment is most frequently applied. This introduction was followed by eight vignettes, each of which described a different set of outcomes that Mr. Smith could experi- ence after leaving the hospital at the end of an involuntary psychi- atric hospitalization. The eight vignettes were constructed by us- ing four possible outcome domains presented in the following order: involuntary outpatient commitment, interpersonal rela- tionships, interpersonal violence, and involuntary rehospitaliza- tion. Within each domain, two levels of outcome-a "good" and a "bad" outcome-were possible. Placing outpatient commitment first was necessary for the temporal and causal ordering assumed in the vignettes, but this placement also served to ensure that out- patient commitment was less likely to be overlooked by the partic- ipant. The vignettes were presented in random order. See Figure 1 for the description of Mr. Smith and a summary of the ...
Citations
... However, the staff's attitudes to coercion and how the law is interpreted may also vary within and between national institutions, and between different groups of staff (Diseth et al., 2011;Husum et al., 2011;Lepping et al., 2004;Luchins et al., 2004;Morandi et al., 2021;Swartz et al., 2003;Wynn, 2003;Wynn et al., 2006Wynn et al., , 2007Wynn et al., , 2011. ...
Objective
There is debate regarding the use of coercion in the psychiatric services and how to minimize its use. We examine changes in the use of coercion in one Norwegian psychiatric service area during a nine‐year period.
Methods
All patients receiving psychiatric services during the periods 2003–2006 and 2008–2012 in the study area were identified, subsequently also only those who had been involuntarily admitted or subjected to involuntary outpatient treatment. Yearwise rates of patients admitted to coercion and coercive treatment‐episodes throughout the study period were calculated.
Results
The overall number and the rate of coerced patients decreased to the total patient population. Most of the reduction were initially of the observational period. However, the number of coercive episodes per coerced patient increased. The pattern of outpatient versus inpatient modes of coercion both reflected this main trend.
Conclusion
The use of coercion seem to be reduced overall, although the increase in treatment‐episodes per patient may indicate a complex pattern in use and registration of coercion. The results may be related to legislative changes, restructuring of psychiatric services, or/and modified attitudes of health‐personnel to coercion following a range of efforts to reduce it.
... Swartz et al. 19,20 studied opinions about IOT amongst patients, family members, clinicians and the general public, in which results showed that the four groups approved the use of IOT for patients with schizophrenia. ...
... As regards the opinion of mental health professionals about the application of involuntary outpatient treatment, there is little information in the existing bibliography, although there are outstanding foreign studies by Swartz et al. 19 , and others carried out in Spain by Hernández-Viadel et al. 22 , in which the opinions of family members and physicians are collected alongside those of the patients. In both cases, the vast majority of family members and medical doctors feel that the application of IOT benefits a patient with severe mental illness. ...
... As is the case in the studies by Swartz et al. 19 and Hernández-Viadel et al. 22 , most of the mental health professionals (78.6%) think that IOT is of benefit for the patient, while an even larger percentage (95,2%) thinks that it is also good for the patient's family. It is worth noting that no interviewee thought that the application of IOT would be harmful for the patient's family. ...
Introduction
Involuntary 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.
Results
85.7% 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.
Conclusion
The 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.
... There are some studies internationally on what professionals think of CCT, they find generally positive attitudes towards CCT [9][10][11][12][13]. We could not find any studies that identify mental health care workers' opinions on CTH. ...
... The disadvantages of CCT identified by health professionals in these studies, such as use of compulsion, seemed to be considered to be outweighed by the advantages, such as facilitation of contact, medication compliance and early identification of relapse [4,[11][12][13]. It should be borne in mind that the circumstances of all these studies were different from those that will apply under the new Dutch legislation. ...
Background:
Compulsory treatment in patients' homes (CTH) will be introduced in the new Dutch mental health legislation. The aim of this study is to identify the opinions of mental health workers in the Netherlands on compulsory community treatment (CCT), and particularly on compulsory treatment in the patients' home.
Methods:
This is a mixed methods study, comprising a semi-structured interview and a survey. Forty mental health workers took part in the semi-structured interview about CCT and 20 of them, working in outpatient services, also completed a questionnaire about CTH. Descriptive analyses were performed of indicated (dis) advantages and problems of CCT and of mean scores on the CTH questionnaire.
Results:
Overall, the mental health workers seemed to have positive opinions on CCT. With respect to CTH, all mean scores were in the middle of the range, possibly indicating that clinicians were uncertain regarding safety issues and potential practical problems accompanying the use of CTH.
Conclusions:
The majority of the participating mental health workers in this study had a positive attitude towards CCT, but they seemed relative uncertain about potential possibilities and problems of working with CTH.
... It is not surprising that the rates varied much within Norway, as former studies have suggested that rates of different types of coercion vary within countries and even between comparable hospitals [108]. Such intra-country variation in rates can be explained by differences in study methods, study populations and hospitals/wards and local attitudes to coercion [5,60,72,76,108,[111][112][113][114][115][116]. ...
Background
It is an important objective of the psychiatric services to keep the use of involuntary procedures to a minimum, as the use of coercion involves clinical, ethical, and legal issues. It has been claimed that Norway has a relatively high rate of involuntary admissions. We reviewed the peer-reviewed literature on the use of involuntary admission in Norway, with the purpose of identifying the current state of knowledge and areas in need of further research.
Methods
A systematic review following the PRISMA statement was conducted. We searched the electronic databases PsycInfo, PubMed, Web of Science, CINAHL, and Embase for studies relating to involuntary admission to Norwegian adult psychiatric hospitals published in the period 1 January 2001 to 8 August 2016. The database searches were supplemented with manual searches of relevant journals, reference lists, and websites.
Results
Seventy-four articles were included and grouped into six categories based on their main topics: Patients’ experiences, satisfaction and perceived coercion (21 articles), the Referral and admission process (11 articles), Rates of admission (8 articles), Characteristics of the patients (17 articles), Staff attitudes (9 articles), and Outcomes (8 articles). Four of the included articles described intervention studies. Fifty-seven of the articles had a quantitative design, 16 had a qualitative design, and one a mixed-method design. There was a broad range of topics that were studied and considerable variation in study designs. The findings were largely in line with the international literature, but the particularities of Norwegian legislation and the Norwegian health services were reflected in the literature. The four intervention studies explored interventions for reducing rates of involuntary admission, such as modifying referring routines, improving patient information procedures, and increasing patients’ say in the admission process, and represent an important avenue for future research on involuntary admission in Norway.
Conclusions
The review suggests that Norway has a relatively high rate of involuntary admissions. The identified studies represent a broad mix of topics and designs. Four intervention studies were identified. More studies with strong designs are needed to bring research on involuntary admission in Norway to a next level.
Electronic supplementary material
The online version of this article (10.1186/s13033-018-0189-z) contains supplementary material, which is available to authorized users.
... Personal experiences of CTOs have been explored in a handful of jurisdictions, including the UK (Ridley 2010;Canvin 2014;Stroud 2015), all with similar findings. Patients, clinicians and family members agree that CTOs are preferable to treatment in hospital (Swartz 2003). Clinicians generally prefer working in a system with CTOs (although there are exceptions) and find them helpful. ...
In the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.
Learning Objectives
• Gain an overview of the development and use of CTOs in the UK and internationally
• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence
• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future
... In many of the studies we reviewed subjects reported that "being on a CTO is better than being in hospital." This is in keeping with the findings of a quantitative study by Swartz, Swanson, et al. (2003), who reported that persons with schizophrenia, who are potential subjects of CTO, rated the coerciveness of outpatient commitment as less problematic than other possible outcomes such as inpatient admission. ...
Objective:
CTOS have been the subject of many qualitative and quantitative research studies. Both research approaches add value to our understanding of CTOs. Qualitative studies provide an understanding of CTOs and the experience of being on a CTO that quantitative studies cannot provide. Many qualitative studies that have examined the views of subjects of CTOs have been published. However, authors of these studies continue to note that views and experiences of the subjects of these orders are not well known. This paper provides the results of a systematic review of qualitative studies focused on understanding the experiences of individuals who have been the subjects of CTOs.
Method:
Relevant databases and grey literature were searched. To be included, a study had to have used a qualitative methodology for data collection and analysis, and focus on examining stakeholder perspectives on the lived experience of CTOs.
Results:
After a rigorous review of the abstracts, we identified 22 papers that met the criteria. These papers were analysed in detail in order to examine the existence of common themes. The 22 papers represented the views of 581 participants from 7 countries around the world. Ten themes were found to be common among the research findings of the 22 papers. Three themes in particular were highlighted: feelings of coercion and control, medication seen as the main reason for a CTO and that the perception of CTOs as a safety net. Findings also highlight the ambivalence that subjects of CTOs experience, the importance of the therapeutic relationship for successful engagement of the subject of the CTO and the complex role of coercion.
Recommendations:
We have made a number of recommendations about how clinicians might use the views of the subjects of CTOs achieve a more positive experience of a CTO.
... All groups gave the highest preference to avoiding involuntary hospitalization, followed by avoiding interpersonal violence. It was concluded that stakeholders were willing to accept the coerciveness of outpatient commitment [51]. ...
Introduction: Involuntary admissions to acute psychiatric units are one of the most ethically challenging practices in Psychiatry. However, published literature falls back in examining this area that touches patient's rights and freedom.
... Many find some aspects of the order helpful, while other aspects restrict their lives in ways that can be highly problematic. [13][14][15][16][17][18] The highest priority for all 3 groups is usually to avoid hospital admission. 16 It is worth noting that the experienced advantages of CTO often are expressed by way of comparison with detention in hospital, not with receiving comprehensive community services voluntarily. ...
... [13][14][15][16][17][18] The highest priority for all 3 groups is usually to avoid hospital admission. 16 It is worth noting that the experienced advantages of CTO often are expressed by way of comparison with detention in hospital, not with receiving comprehensive community services voluntarily. ...
Objective: Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness.
Method: The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies.
Results: The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion.
Conclusion: There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs.
... It yielded 439 unique articles, of which 31 appeared to meet selection criteria. Eight articles were excluded because they reported on prospective atti- tudes about hypothetical compulsory community treatment, rather than firsthand experience (29)(30)(31)(32)(33), or discussed the use of leverage in mental health care but did not focus on CTOs (34)(35)(36). If a study of multiple forms of leverage pre- sented CTO experiences separately, it was included and the CTO data were extracted (37). ...
Objective:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
... 11 There are different types of Advance Statements, some of which may not involve clinicians (an aspect which may facilitate the free expression of service users' views 2 ); however, clinicians often express concern that service users will make decisions that are at odds with their well-being. 2,[12][13][14][15] Involving clinicians in the generation of Advance Statements may therefore help allay such concerns and improve the likelihood of implementation of the statement's content. Yet, ensuring the recognition of alternative actions, including service users feeling enabled to question or reject clinicians' recommendations, remains problematic. ...
Despite increasing calls for shared decision making (SDM), the precise mechanisms for its attainment are unclear. Sharing decisions in mental health care may be especially complex. Fluctuations in service user capacity and significant power differences are particular barriers.
We trialled a form of facilitated SDM that aimed to generate patients' treatment preferences in advance of a possible relapse. The 'Joint Crisis Plan' (JCP) intervention was trialled in four mental health trusts in England between 2008 and 2011. This qualitative study used grounded theory methods to analyse focus group and interview data to understand how stakeholders perceived the intervention and the barriers to SDM in the form of a JCP.
Fifty service users with psychotic disorders and 45 clinicians participated in focus groups or interviews between February 2010 and November 2011. Results suggested four barriers to clinician engagement in the JCP: (i) ambivalence about care planning; (ii) perceptions that they were 'already doing SDM'; (iii) concerns regarding the clinical 'appropriateness of service users' choices'; and (iv) limited 'availability of service users' choices'. Service users reported barriers to SDM in routine practice, most of which were addressed by the JCP process. Barriers identified by clinicians led to their lack of constructive engagement in the process, undermining the service users' experience.
Future work requires interventions targeted at the engagement of clinicians addressing their concerns about SDM. Particular strategies include organizational investment in implementation of service users' choices and directly training clinicians in SDM communication processes.
© 2015 John Wiley & Sons Ltd.
