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Community Treatment Orders: the Australian experience
... CTOs have been a feature of psychiatric services in Australia since 1986 and more recently in New Zealand and parts of Canada (Power, 1999;Dawson et al., 2003). They also appear in various forms in different jurisdictions in the USA (Hiday, 2003). ...
... Literature on the subject reveals a number of contested positions about the efficacy and ethical justification for the use of CTOs (Dawson et al., 2003;Hiday, 2003). A number of studies have found that the use of CTOs has led to reduced hospitalization, shorter hospital stays, improved access to support and treatment services and familial relationships, and lessened the person's vulnerability (Power, 1999;Muirhead, 2000;Jaworoswski and Guneva, 2000;O'Reilly, 2001;Dawson et al., 2003;Hiday, 2003;). However, some authors have suggested that the use of CTOs may not in fact lead to better health outcomes (Calsyn et al., 2000) or that other methods, e.g. ...
... This reliance on 'depots' can be understood in the context of inadequate infrastructures of accommodation, social supports and intensive services which could assist in the supervision of treatment. Concerns about the efficacy and ethical standing of depot treatment creates problems for the social worker and may act as a barrier to engagement and the development of therapeutic alliances which, in turn, may prevent relapse (Power, 1999). ...
Substantial changes to mental health law and policy have occurred throughout the Western world during the last decade. The
drift towards control, particularly in the form of Community Treatment Orders (CTOs), has profound implications for the role
of mental health social workers, yet this issue is rarely discussed in academic literature. This paper seeks to redress this
gap in knowledge by examining aspects of law, policy and practice using three case studies: Victoria, Australia; Ontario,
Canada; and regions of the UK. The paper begins by critically reviewing selected literature on CTOs, revealing competing claims
about efficacy and their impact upon service users1 and practitioners. A discussion of policy and practice contexts in the three jurisdictions is then presented and supported
with a typology, to illustrate contrasts and comparisons. In their conclusions, the authors assert that mental health social
workers often have a crucial part to play in the implementation of CTOs but that this is not always acknowledged in law and
organizational policy. Social workers’ roles and responsibilities need to be more explicitly identified in mental health law.
At the same time, there should be a continuing debate about how such coercive powers fit with codes of ethics and practice
standards, at national and international levels.
... Further studies have been conducted in Canada (O'Reilly et al., 2000;O'Brien and Farrell, 2004); Australia (Power, 1999;Brophy and Ring, 2004;Kisely et al., 2004); New Zealand (Dawson et al., 2003;Romans et al., 2004) and the UK Atkinson et al., 2002aAtkinson et al., , 2002bPinfold et al., 2002). Studies have considered the impact of CTOs on service users, as well as the views of MHPs. ...
... In Western Australia, a survival analysis of a newly introduced CTO regime found that it did not reduce rates of readmission to hospital in the first year of its operation (Kisely et al., 2004). Power (1999), on the other hand, in a study of the regime in the Australian state of Victoria, recorded significant therapeutic benefits for patients. Other Australian studies have noted the complexities of consumer experiences with this form of care, including enhanced stigma (Brophy and McDermott, 2003;Brophy and Ring, 2004). ...
... MHPs generally favour the availability of CTOs because they assist with engagement, supervision and compliance, but they struggle with decisions about the optimal time for the order to end. Other studies have shown that consumers find it difficult to obtain discharge from a CTO (McDonnell and Bartholomew, 1997;Power, 1999). This research shows psychiatrists also struggle to determine what will count as success in this form of care (Dawson et al., 2003). ...
New Zealand legislation allows for the involuntary outpatient treatment of people with serious mental illness. This study
examines the views of service users, family members and mental health professionals (MHPs) about the impact of this regime.
Semi-structured interviews were completed with forty-two service users, twenty-seven family members and ninety MHPs, with
recent experience of the regime. Participants were asked to comment on the functions of community treatment (or non-resident)
orders, their benefits and restrictions, decisions about their termination and any impact on relationships. Most service users
believed the main purpose of the order was to ensure they took medication. They also believed the order provided better access
to other treatments, supported accommodation and care from MHPs. Families considered the orders provided relief for them and
a supportive structure for their relative’s care. MHPs found the orders useful for engaging service users in a continuing
therapeutic relationship, and for promoting treatment adherence. In each group, a majority of those interviewed viewed involuntary
community treatment in a generally positive light, while acknowledging the restrictions imposed on service users’ freedom.
... The negative views concerned loss of freedom, infrequent contact with health professionals and medication side-effects. Other Australian studies [12,13] report patients' views that CommTOs reduce their liberty, control their medication and last too long, with patients facing difficulties obtaining discharge. ...
... The experience of these patients was not substantially different from others interviewed in the larger study. Their views as a whole are consistent with patient perspectives previously reported in the literature, including perspectives on coercion [6][7][8][9][10][11][12][13][14]. The Maori patients felt CommTOs both helped them in their recovery and imposed significant constraints on their choices, particularly about medication, travel and residence. ...
... Australian studies [12,13] have reported patient views that it is very difficult to obtain discharge from a CommTO. Elsewhere we have talked of the 'dilemma of discharge' and the 'paradox of success' [3], to describe how hard it is to determine the right moment for discharge, when continuing use of the CommTO without the patient's relapse can be viewed both as a successful, and as an unnecessary, use of the order, depending on the criteria of success employed. ...
To consider the impact of community treatment orders (CommTOs) on Maori patients and their whanau (extended family) and the associated views of mental health professionals.
As a distinct aspect of a larger study of CommTOs, eight Maori patients under compulsory community care were interviewed and, where possible, members of their whanau. Associated interviews were held with their psychiatrists, key workers and other carers: 39 interviews in total.
Both benefits and drawbacks of CommTOs for Maori were identified by patients and whanau. CommTOs were considered helpful in increasing patient safety and whanau security and in promoting access to services. They were favoured over hospital care, forensic care and homelessness. The drawbacks included the sense of external control imposed on both Maori patients and staff, particularly concerning medication and restrictions on choices.
This was a small study of a limited number of Maori patients under CommTOs. Their views may not be fully representative. There was a general consensus among those interviewed that the timely use of CommTOs can enhance the mental wellbeing and social relationships of Maori patients. Continuing efforts are needed by health professionals to communicate effectively with whanau and to understand the conflicts experienced by Maori in reconciling their traditional beliefs with the medical model of mental illness.
... Victoria was the first Australian state to introduce CTO in 1986 (Power, 1999). This new form of compulsion has been implemented in the context of deinstitutionalised services and well-developed networks of community mental health teams (Churchill et al., 2007). ...
... However, while this attitude may have seemed intuitively sound at the time of the study, more recent data stemming from various randomized controlled trials show that CTOs have no significant impact regarding engagement in treatment when compared to voluntary ambulatory care (Burns et al., 2013b;Steadman et al., 2001;Swartz et al., 1999). Moreover, patients who experience the poorest outcome while on CTO are the younger patients who are in the early phase of their illness (Power, 1999). Considering our data stem from an observational study and not from a randomized controlled trial, it is impossible to know if this holds true in a FEP population. ...
Objectives:
Community Treatment Order (CTO) is a legal regime that obliges patients suffering mental disorder to adhere to treatment in the community and allows for a swift admission to hospital if necessary. Study aims were to: (i) determine CTO frequency in a large representative sample of first episode psychosis (FEP) patients; (ii) compare the characteristics of patients with or without CTO before entry, during treatment and at discharge from an early psychosis program.
Methods:
Information on 660 patients treated at the Early Psychosis Prevention and Intervention Centre (EPPIC) between 1998 and 2000 was collected from medical files.
Results:
19.2% of patients were under CTO at least once during treatment and they differed on most pre-treatment, baseline, treatment and service discharge variables. They were less educated, more likely to have a history of offending behavior, had lower pre-morbid functioning, longer duration of untreated psychosis, increased prevalence and more persistent substance use disorders, greater severity of symptoms, lower functioning, poorer insight at any time during treatment and were more likely to be admitted to hospital.
Conclusions:
CTO frequency was high, likely related to the representativeness of the cohort. Characteristics of patients on CTO are comparable to those with serious and persistent mental illness. Considering the absence of solid evidence regarding the effectiveness of this form of compulsion, it is crucial to study the use of CTO in FEP patients in order to explore its impact and identify patients for whom it may be beneficial.
... has occurred predominately in the US , Australia (27)(28)(29)(30), and New Zealand (31,32). The existing literature can be categorized under 2 headings: philosophical discussions (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)27,30,32,(33)(34)(35) and empirical studies (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)28,29,31). ...
... has occurred predominately in the US , Australia (27)(28)(29)(30), and New Zealand (31,32). The existing literature can be categorized under 2 headings: philosophical discussions (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)27,30,32,(33)(34)(35) and empirical studies (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)28,29,31). The philosophical discussions most often focus on the ethical implications of CTOs. ...
This study reports the first published Canadian profile of a sample of psychiatric patients from the Royal Ottawa Hospital in Ottawa, Ontario, who were issued community treatment orders (CTOs).
We undertook a population study of sociodemographic and health care use patterns from January 2001 to September 2003, using a standardized information collection tool.
The issuance of CTOs was associated with a statistically significant reduction in the number and length of hospital admissions and increased use of supportive community-based services and supportive housing.
CTOs are effective tools for allowing patients to live in the least restrictive setting possible while they receive diverse services. They also effectively reduce rates and lengths of readmission to hospital.
... Damage to the therapeutic relationship was challenged; a compulsory order would require a relationship with the service users, based at least in part on mutual respect and trust, in order to work. In countries that use CCT the number of individuals affected is small (see, for example, Torrey & Kaplan, 1995;Power, 1999), as are the numbers currently subject to supervised discharge (Section 25) and guardianship in this country. CCT would not be used to`sweep the streets' of people who are determinedly non-compliant. ...
On the evening of 23 February 2000 at the Maudsley Hospital in London the motion ‘This house believes that compulsory community treatment is not justified’ was debated in front of an audience of mental health professionals, carers, service users and other members of the general public. Peter Campbell, a mental health system survivor, and Dr Frank Holloway, consultant psychiatrist at the South London and Maudsley Trust, supported the motion. Cliff Prior, Chief Executive of the National Schizophrenia Fellowship (NSF), and Professor Tom Burns, professor of community psychiatry at St George's Hospital Medical School, opposed it.
... Community treatment orders (CTOs) exist in various forms in many different countries, although the use of CTOs remains a controversial area in the management of patients with severe mental illnesses (Moncrieff & Smyth, 1999;Crawford et al. 2000;Pinfold & Bindman, 2001;O'Reilly, 2004;Lawton-Smith et al. 2008). Australia and New Zealand have well-developed CTO regimes (Dawson, 1991;Power, 1999;Dawson & Romans, 2001;Brophy & Ring, 2004;Schwartz et al. 2010), whereas up to five European countries had provisions for compulsory outpatient treatment in place (Dressing & Salize, 2004) before the introduction of CTOs in Scotland in 2005. This was followed by their use in England and Wales in 2008, with their introduction in the 2007 amendment of the 1983 Mental Health Act (MHA, 1983). ...
The use of community treatment orders (CTOs) remains controversial despite their widespread use in a number of
different countries. The focus of a CTO should be on individuals with severe and enduring mental disorders, typically
requiring adherence with recommended outpatient treatment in the community and requiring that they allow access to
members of the clinical team for the purpose of assessment. There is no current provision for CTOs under Irish mental
health legislation, although patients who are involuntarily detained under the MHA 2001 (Ireland) can be granted
approved leave from hospital. This provision allows for the patient to be managed in the community setting, though,
while technically on leave, they remain as inpatients detained under the MHA 2001 (Ireland). This article describes the
use of CTOs and considerations relating to their implementation. There is discussion of the ethical grounds and evidence
base for their use. Ethical considerations such as balancing autonomy against health needs and the utilisation of capacity
principles need to be weighed by clinicians considering the use of CTOs. Though qualitative research provides some
support for the use of CTOs, there remains a clear lack of robust evidence based findings to support their use in terms of
hospitalisation rates, duration of illness remission and improved social functioning.
... Advantages include the accessibility of mental health professionals, ease of readmission to hospital when desired and the opportunity for discharge from hospital to community care. The disadvantages include reduced liberty, control over medication and restrictions on decision-making capacity (Carne, 1996;Gibbs et al., 2004;Power, 1999). ...
Background:
New Zealand operates a well-embedded community treatment order scheme for patients with serious mental disorders. A similar scheme may be enacted for England and Wales.
Aim:
To explore the views of patients with recent experience of community treatment orders.
Method:
All patients in one region under an order in the last 2 years, not readmitted to hospital for at least 6 months, were included, subject to their capacity and consent. Forty-two patients out of 84 potential participants were interviewed.
Results:
The majority of patients were generally supportive of the community treatment order, especially if the alternative was hospital. Many valued the access to services and sense of security obtained, and attributed improvements in their health to treatment under the order. They also experienced reduced choice about medication and restrictions on residence and travel. For a minority this meant they were strongly opposed to the order, but for most the restrictions did not unduly hinder them. The majority of patients viewed the order as a helpful step towards community stability.
Conclusions:
The usefulness of community treatment orders is accepted by most patients under them in NZ, as well as by most psychiatrists. Critical factors include the quality of therapeutic relationships and the structure provided for community mental health care.
... Their introduction is actively under consideration in England and Wales (Department of Health, 2000). They are used extensively in Australia and New Zealand (Dawson, 1991; Dawson & Romans, 2001; Power, 1999; Vaughan, McConaghy, Wolf, Myhr, & Black, 2000). It seems CommTOs are now politically acceptable in many places. ...
... But because of their expense and substitution for court and clinical decisions, only three random control trials (RCT) of OPC have been conducted. One in Victoria, Australia, found most patients on CTO's improved in multiple measures; but knowledge of this study's design, measurement, and analysis is limited as it was only briefly described in an editorial (Power, 1999). Another RCT in New York City 13 of a trial OPC law found no statistical difference in multiple outcomes between experimental and control groups of persons with severe mental illness . ...
The lively debate over mandated community treatment in general and outpatient commitment laws (OPC) in particular has raised many issues. At its core, the debate is over how and to what extent laws should be formulated to persuade, leverage or coerce (PLC) persons with severe mental illness living in the community to comply with medications that mental health professionals believe they need. The alternative to PLC is what we call TLC (tender loving care): a strategy of using benefits - improved patient-centered treatment, entitlements and service delivery, including assertive outreach - rather than penalties or conditions on access to services, to induce compliance. We examine three aspects of the debate: (1) the empirical case for the need for OPC court orders to maintain revolving-door severely mentally ill persons in the community; (2) the normative argument over whether such orders constitute coercion, and, if so, whether that coercion is justifiable; and (3) the incentives such orders create to leverage community providers to augment resources and tailor treatment and services to entice patients to become willing participants in the management of their disorders.
... I nvoluntary outpatient commitment provisions are explicitly written into mental health law in most Western nations (1)(2)(3)(4)(5)(6)(7)(8)(9)(10). They require that an individual with a mental disorder who refuses care and is believed to be potentially dangerous or in need of health and safety protection accept and comply with community treatment in lieu of involuntary psychiatric hospitalization (11). ...
This study examined a sample of patients in Victoria, Australia, to identify factors in selection for conditional release from an initial hospitalization that occurred within 30 days of entry into the mental health system.
Data were from the Victorian Psychiatric Case Register. All patients first hospitalized and conditionally released between 1990 and 2000 were identified (N=8,879), and three comparison groups were created. Two groups were hospitalized within 30 days of entering the system: those who were given conditional release and those who were not. A third group was conditionally released from a hospitalization that occurred after or extended beyond 30 days after system entry. Logistic regression identified characteristics that distinguished the first group. Ordinary least-squares regression was used to evaluate the contribution of conditional release early in treatment to reducing inpatient episodes, inpatient days, days per episode, and inpatient days per 30 days in the system.
Conditional release early in treatment was used for 11 percent of the sample, or more than a third of those who were eligible for this intervention. Factors significantly associated with selection for early conditional release were those related to a better prognosis (initial hospitalization at a later age and having greater than an 11th grade education), a lower likelihood of a diagnosis of dementia or schizophrenia, involuntary status at first inpatient admission, and greater community involvement (being employed and being married). When the analyses controlled for these factors, use of conditional release early in treatment was significantly associated with a reduction in use of subsequent inpatient care.
... In North America the 'risk-liberty' rationale of civil commitment extends to CTOs, often by insisting on satisfaction of the very same grounds which warrant involuntary inpatient care (Torrey and Kaplan, 1995). 14 Australasian models by contrast favour relatively easy access to orders laying down medication or other regimes to be complied with, and also empower enforced engagement, stopping just short of enforced medication in the community (Power, 1999;Preston, Kisely and Xiao, 2002;Dawson, 2005). Here community treatment is conceived more as a least restrictive option for the patient and the mental health system as a whole. ...
Major transformations in forms of governance of the liberal state have been wrought over the course of the last century, including the rise of neoliberalism and 'new public management.' Mental health too has witnessed change, with pharmacological treatment displacing residential care, a shift to community-based services, mainstreaming with general health care, and greater reliance on civil society institutions such as the family or markets. This article considers whether mental health law, and its court/tribunal 'gatekeepers' have kept pace with those changes. It argues that the focus of the liberal project needs to shift to measures which will better guarantee access to mental health services, and keep a more watchful eye on both 'hidden' coercion of people on community treatment orders, and passive neglect of human need.
This article reviews the effectiveness of community treatment orders (CTOs), a community-based treatment program initiated to improve compliance with treatment plans and address societal concerns regarding seriously mentally ill individuals. It assesses the impact of CTOs on individuals who have participated in this treatment and addresses the question of whether CTOs have the potential to resolve mental health problems in the community. This article examines the use of CTOs in a number of countries, and in particular, the outcomes of a CTO program in Toronto, Canada. Finally, it looks at advanced directives, intensive case management, and recovery-oriented service system reform as viable and empowering alternatives to CTOs.
How are different ‘forms’ of knowledge developed, transmitted and institutionalised in social work? Foucault’s concept of ‘power/knowledge’ famously enabled us to understand such developments via the evolving methodological approach he variously referred to as archaeology, genealogy and governmentality. In this paper, we will use this and other conceptual resources as the basis for advocating an adapted and flexible methodological framework which constitutes knowledge as local, situated and embedded, but also dynamic, interactive and ‘flowing’ between actors, institutions and jurisdictions at an international level. The model has the potential for integrating two distinct cross-disciplinary approaches to understanding the operation of power within society: first, ‘an analytics of government’, specified by Dean as particularly useful in addressing ‘how’ questions and second, the potentially complementary approach known as historical–political sociology which seeks to integrate explanatory and descriptive causal formulations. Together, these act as a basis for extending Foucault’s formulation of power/knowledge to accommodate the dynamic nature of trans-disciplinary, intercontinental knowledge flow. We will examine the potential relevance and utility of the model using the example of how one ‘form’ of knowledge, in this case, policy knowledge, has informed the development of a particular approach to social work practice—supervised community treatment in mental health—in various Western jurisdictions over the last few decades.
The patient's consent is a prerequisite for treatment. The physician fulfils an important role in determining whether the patient should be regarded as competent or incompetent, due to the legal consequences, competency being a legal concept. The matter is even more complicated in psychiatric practice. The present article addresses the medico-legal issues raised and discusses possible perspectives such as Advance Directives. The patient's psychological status and competency are currently determined with the help of various psychological tests. These are currently used in combination, because alone none provides a useful standard. If the patient is deemed incompetent, treatment of the psychological disorders can be administered without his consent. However, authors are not unanimous regarding the treatment of the possible somatic complications such as self-mutilations. Furthermore, ethical justifications of involuntary hospitalisation are discussed. Advance Directives are used in some countries, and might represent a useful aid in solving some difficult situations, provided that they are used in conjunction with a thorough clinical examination of the patient.
The use of involuntary outpatient treatment in people with a mental illness is increasing. We review the policy, ethical and practical implications of this trend, draw parallels with other areas of medical care, and briefly discuss alternative and possibly more effective strategies for increasing adherence with psychiatric care.
Objective:Involuntary treatment in the community has become an increasing and accepted part of the landscape of mental health service delivery. Community Treatment Orders (CTOs) or Outpatient Commitment (OPC) may be understood to be an inevitable consequence of the process of deinstitutionalisation and an acceptance that many clients are at constant risk in the community and may require long-term involuntary treatment. However, there are important social, economic and political imperatives influencing CTOs; this article explores these driving forces and identifies the concerns of the critics of involuntary treatment in the community. Methods:Using the concept of force field analysis, the driving and restraining forces surrounding the development and implementation of CTOs are identified. Results: All Australian states and territories now have provision for involuntary community treatment. However, despite an increasing reliance on, and to some extent, acceptance of, the validity of involuntary community treatment in mental health, these developments are not uncontested. Consumer groups, legal advocates and service providers have questioned the use of involuntary treatment in the community and identified various concerns, including the potential for human rights abuses, ethical dilemmas and doubts regarding effectiveness. Conclusions: The paper concludes by arguing for stronger evidence base to support the use of CTOs. In doing so it focuses on the social, policy, legal and ethical context within which CTOs are implemented.
Objective: The purpose of the study was to evaluate the use of supervision in the community under two provisions of the Mental Health Act 1983, England. Method: A cohort sample of 205 mentally ill patients subject to Supervised Discharge and 121 subject to Guardianship was identified in England. Data were collected at two time points. Outcomes examined were compliance with requirements, clinician ratings of effectiveness of interventions, clinical ratings, “risk events” and instances of hospitalization in the study period. Results: High levels of compliance with requirements were achieved, although compliance was sometimes only “reluctant” or “partial”. Interventions involving psychiatric treatment and risk management were most common, and also best maintained between time points. Broader health and social interventions were less common, and declined more in effectiveness between time points. Clinical ratings improved between time points. Conclusions: The measures appear to have been used principally to manage medication and risks, and a good level of compliance was achieved. Interventions to give psychiatric treatment and manage risk were associated with reduced hospitalization amongst Supervised Discharge cases whilst wider social and health interventions were associated with reduced hospitalization in Guardianship cases. Declaration of interest: None.
Though community treatment orders (CTOs) were first used in 1986 in Australia, debate about their clinical and ethical merits continues even today. For some, the benefits of reduced frequency and duration of involuntary hospitalizations are believed to adequately outweigh the harms of restricted liberties in community living. For others, however, such benefits are believed to be achievable by simply arranging integrated, devoted community resources sans any threat of forced re-hospitalization. In response to this enduring controversy, this article examines the ethical merits of community orders using a novel approach. "Novel" because the examination is based on research ethics and its foundational principles. When hospital and community clinicians, family members, consumer/survivors, and advocacy groups discussed the idea of amending Ontario's mental health legislation to permit CTOs in the late 1990s, evidence of their effects and efficacy was very limited. Moreover, an order was characterized much like standard pharmacological or medical therapies because the person or an appropriate substitute decision maker's consent was necessary to authorize the order or make it valid. These two factors prompted this retrospective analysis: if CTOs--as a public policy initiative--had been treated like most other promising therapies, would any different ethics-related concerns have been raised that, in turn, would have benefited the public debate and the legislature's decisions? In other words, if respected safeguards that apply to new drugs and medical devices had applied to CTOs, would anything have changed?
Following their introduction in the United States in the 1970s various forms of compulsory treatment in the community have been introduced internationally. Compulsory treatment in the community involves a statutory framework that mandates enforceable treatment in a community setting. Such frameworks can be categorized as preventative, least restrictive, or as having both preventative and least restrictive features. Research falls into two categories; descriptive, naturalistic studies and controlled and uncontrolled comparative studies. The research has produced equivocal results, and presents numerous methodological challenges. Where programmes have demonstrated improved outcomes debate continues as to whether these outcomes are associated with legal compulsion or enhanced service provision. Service user, family and clinician perspectives demonstrate a divergence of views within and across groups, with clinicians more strongly in support than service users. The issue of compulsory community treatment is an important one for nurses, who are often at the forefront of clinical service provision, in some cases in statutory roles. Critical reflection on the issue of compulsory community treatment requires understanding of the limitations of empirical investigations and of the various ethical and social policy issues involved. There is a need for further research into compulsory community treatment and possible alternatives.
To assess the uses of Community Treatment Orders (CommTOs) in New Zealand.
A retrospective study of patients' records held by the regional administrator of mental health legislation and a survey of psychiatrists attending a conference in Dunedin.
Males under Community Treatment Orders (CommTOs) outnumbered females 6:4; a high proportion were considered to have a major psychotic disorder; and one fifth remained under a CommTO for more than a year without inpatient care. Among the psychiatrists, there was a high level of agreement that, when used appropriately, the benefits of CommTOs outweigh their coercive impact on the patients; the most strongly supported indicator for use was the promotion of compliance with medication. The rate of use of CommTOs in Otago is remarkably similar to the rate in Victoria, Australia.
Records suggest that a significant proportion of patients under CommTOs are not soon readmitted; and many clinicians in New Zealand consider CommTOs to be a useful strategy for managing the community care of long-term patients with schizophrenia and major affective disorders.
Involuntary outpatient commitment (OPC), also referred to as community treatment orders or assisted outpatient treatment, is a legal intervention intended to improve treatment adherence among persons with serious mental illness. This paper reviews the empirical literature on the procedure's effectiveness.
We identified and reviewed all English-language studies of OPC and related procedures available in Medline and other bibliographic search services.
Existing naturalistic and quasi-experimental studies, taken as a whole, moderately support the view that the procedure is effective, although all do have methodological limitations. Two randomized controlled studies of OPC have conflicting findings and are reviewed in detail.
On balance, empirical studies support the view that OPC is effective under certain conditions, although some of the evidence has been contested and the policy remains controversial.
The use of community treatment orders and other forms of mandatory outpatient treatment has been controversial. The debate on the appropriateness of compulsory treatment in the community addresses a volatile mix of clinical, social policy, legal, and philosophical issues. This paper describes the major sources of contention, outlines the position of the protagonists, and where possible, attempts to answer some of the questions raised and identify common ground.
This paper explores the clinical, social and demographic characteristics of 164 people on Community Treatment Orders (CTOs) in one area mental health service in Victoria, Australia. The results of an exploratory cluster analysis are presented to address the question of whether people on Community Treatment Orders can be categorised into statistically reliable, qualitatively distinct groupings. The data are presented in the context of key stakeholder perspectives on the current use and purpose of CTOs. Three stable clusters emerged and each potentially reflects how social dimensions, as well as clinical issues, influence decision making regarding the implementation of CTOs. These findings are important in the context of policy and practice in Victoria, where the use of CTOs is common practice, and orders are generally made for a 12 month period. The potential for improved targeting of CTOs and more specific treatment planning is identified.
The human and legal rights under the Western Australian Mental Health Act (1996) of involuntary patients on community treatment orders (CTOs) include being provided with information by clinicians about the treatment expectations of the order, the procedure for review of status by the Mental Health Review Board, access to the Council of Official Visitors, and the opportunity for a second opinion about their psychiatric condition. To date, there has been no specific research in this area. This paper presents the findings of a study conducted in Western Australia where consumers on CTOs were asked to provide feedback as to whether they were informed of these legal rights. A questionnaire was distributed which asked eight questions related to being informed of these rights. The results indicated that from the consumer's perspective, the process of providing them with information about their rights was only partially met. Most consumers were informed about first appointments, their right to a review by the Mental Health Review Board, and provided with the appropriate legal form. However, in relation to what it means to be on a CTO, access to the Council of Official Visitors and the right to a second opinion, information was not being provided to the majority of consumers. The findings suggest that mental health clinicians need to make significant improvements in providing information to consumers. This level of consumer engagement could have beneficial results for the development of therapeutic relationships which in turn may lead to improved compliance with the CTO and better health outcomes for the consumer.
It is one of the failures of contemporary psychiatry that many patients who respond well to neuroleptic medication given to them when they are in-patients relapse after discharge due to not taking any further medication. Those working closely with the acute psychiatric patient in the community are often forced to stand by powerlessly as a patient deteriorates, causing damage to himself and his social milieu until such a point is reached when he is again ill enough to warrant compulsory admission and treatment. This process is, of course, devastating for a patient's family and also disheartening for professionals involved, and is perhaps partly responsible for the high turnover of staff involved in front line services. Even if assertive outreach methods are employed such as those involved in a number of comprehensive community-based programmes (Stein & Test, 1980; Borland et al , 1989) so that contact with the patient is not lost, it is not possible without the necessary legislation to enforce treatment in the community.
Because of the nature of some mental illness,care and compulsion in psychiatry are not always antithetical. However, it is no longer acceptable to link compulsory treatment almost exclusively to compulsory hospitalisation. Treatment should occur in the least restrictive environment possible. This paper looks at experience of extended leave of absence in Scotland, and in England and Wales before 1986, at the recent evidence for an increased risk of violence and homicide in schizophrenia and the danger of a backlash against community care if it is perceived as unsafe, and makes suggestions in relation to research and to provision for treatment in the community in the absence of consent.
Following in-patient psychiatric treatment under Section 3 of the Mental Health Act, some patients have in the past remained on Section after discharge, and subsequently the Section has been renewed while the patient remained 'on leave'. People treated thus with 'extended leave' probably resemble closely those who would be placed on a community treatment order if this were available. A group of these extended-leave patients was compared with a control group, matched for age, sex and diagnosis, selected by consultant psychiatrists as not requiring treatment using a community treatment order. The two groups showed very few differences, but the extended-leave patients more commonly had a history of recent dangerousness and non-compliance with psychiatric treatment. Use of extended leave improved treatment compliance, reduced time spent in hospital, and reduced levels of dangerousness.
Mental health laws regarding involuntary commitment are under pressure for reform in many states. One popular proposal is to use direct involuntary commitment to outpatient treatment without initial hospitalization or preventive detention. This article reviews the empirical evidence concerning this approach, and discusses administrative and policy implications for community mental health agencies that will bear the burden of such reform.
Doubts about the reality of mental illness and the benefits of psychiatric treatment helped foment a revolution in the law's attitude toward mental disorders over the last 25 years. Legal reformers pushed for laws to make it more difficult to hospitalize and treat people with mental illness, and easier to punish them when they committed criminal acts. Advocates of reform promised vast changes in how our society deals with the mentally ill; opponents warily predicted chaos and mass suffering. Now, with the tide of reform ebbing, Paul Appelbaum examines what these changes have wrought. The message emerging from his careful review is a surprising one: less has changed than almost anyone predicted. When the law gets in the way of commonsense beliefs about the need to treat serious mental illness, it is often put aside. Judges, lawyers, mental health professionals, family members, and the general public collaborate in fashioning an extra-legal process to accomplish what they think is fair for persons with mental illness. Appelbaum demonstrates this thesis in analyses of four of the most important reforms in mental health law over the past two decades: involuntary hospitalization, liability of professionals for violent acts committed by their patients, the right to refuse treatment, and the insanity defense. This timely and important work will inform and enlighten the debate about mental health law and its implications and consequences. The book will be essential for psychiatrists and other mental health professionals, lawyers, and all those concerned with our policies toward people with mental illness.
Outpatient commitment has recently developed as a legal device for maintaining noncompliant chronically mentally ill patients in the community and for preventing the revolvingdoor syndrome, but this new approach presents difficult problems in reconciling the liberty of patients with their treatment needs.
Successful involuntary psychiatric outpatient treatment requires identifying patients who are suited to such treatment and ensuring that the service system is able to deliver the treatment. Based on his clinical experience, the author has developed ten sequential guidelines that can help clinicians identify patients who are appropriate for involuntary outpatient treatment. The sequential order of the guidelines means that a patient must meet the criteria for each guideline before being evaluated on subsequent guidelines. The guidelines assume that the patient has a chronic mental illness and a history of dangerousness to self or other because of that illness. The author believes that achieving consensus about who should receive involuntary outpatient treatment is an important first step in permitting evaluation of the efficacy of the approach.
KIE
An issue of concern to Britain's mental health community is the problem of a discharged psychiatric patient who suffers a relapse and requires treatment, but who may not be ill enough to justify recommitment. Under the revised Mental Health Act 1983, psychiatrists have no power to treat patients without their consent outside the hospital. Both the Royal College of Psychiatrists and the Mental Health Act Commission have produced discussion documents outlining several legal approaches to the problem of outpatient treatment. Dyer summarizes the debate over these proposals that took place during a September 1987 conference cosponsored by the Commission and the National Association of Health Authorities. There is general agreement among mental health professionals that changes in the law are needed, with support divided between compulsory treatment in the community and an expanded form of guardianship authorizing guardian consent to treatment.
To determine the extent of use of outpatient commitment, a survey was undertaken of each state and the District of Columbia.
One of the authors, an attorney, reviewed pertinent state statutes, then conducted telephone interviews with individuals in each state who were knowledgeable about the use of outpatient commitment.
Thirty-five states and the District of Columbia have laws permitting outpatient commitment. Georgia, Hawaii, and North Carolina use different criteria for outpatient commitment than for inpatient commitment. In only 12 states and the District of Columbia was use of outpatient commitment rated as very common or common. Reasons for not using it include concerns about civil liberties, liability, and fiscal burden as well as lack of information and interest, the failure of some states to set enforceable consequences for noncompliance, and criteria that are too restrictive. Some states use alternative formal or informal mechanisms to encourage treatment compliance; conditional release is widely used in New Hampshire and conservatorship-guardianship in California. Within many states the availability of outpatient commitment varies considerably by locale.
To clarify the role of outpatient commitment in psychiatric services, more research is needed to identify optimal candidates for its use. Research is also needed on its overall effectiveness compared with conditional release and conservatorship-guardianship and on the consequences of not using such mechanisms to improve treatment compliance.
Involuntary outpatient commitment has been used as a method of improving tenure in community programs for individuals with severe and persistent mental illness. This paper reviews literature on research about involuntary outpatient commitment and suggests questions and methods for future research.
Literature describing research studies of involuntary outpatient commitment, located by searching MEDLINE and following up references cited in relevant articles, was reviewed with attention to patient characteristics and diagnostic, treatment, and outcomes measures.
Involuntary outpatient commitment appears to provide limited but improved outcomes in rates of rehospitalization and lengths of hospital stay. Variability in community treatment makes interpretation of other types of outcome difficult. Few studies specifically identify results among patients with severe and persistent mental illness.
No studies have examined the extent to which outpatient commitment affects compliance and treatment when essential community services such as case management are consistently and aggressively provided, nor have studies controlled for potentially confounding factors such as treatment and nontreatment effects, including informal coercion. A randomized trial of involuntary outpatient commitment should be useful in evaluating the effectiveness of this type of intervention.
The 1991 Israeli Mental Patients Law permits involuntary outpatient commitment (IOC) in an attempt to lessen the problem of recidivism of chronic patients who do not comply with medical treatment after discharge, relapse and are readmitted. The history of IOC in its different forms in several states in the United States is reviewed, with emphasis placed on indications and enforcement. Research assessment of the efficacy of IOC is discussed. The Israeli law is compared with the American law. Three case reports are presented.
Involuntary outpatient commitment (OPC) is a civil justice procedure intended to enhance compliance with community mental health treatment, to improve functioning, and to reduce recurrent dangerousness and hospital recidivism. The research literature on OPC indicates that it appears to improve outcomes in rates of rehospitalization and length of stay. However, all studies to date have serious methodological limitations because of selection bias; lack of specification of target populations; unclear operationalization of OPC; unmeasured variability in type, frequency, and intensity of treatment; as well as other confounding factors. To address limitations in these studies, the authors designed a randomized controlled trial (RCT) of OPC, combined with community-based case management, which is now under way in North Carolina. This article describes ethical dilemmas in designing and implementing an RCT of a legally coercive intervention in community-based settings. These ethical dilemmas challenge the experimental validity of an RCT but can be successfully addressed with careful planning and negotiation.
Issues affecting the research of outcomes of involuntary outpatient commitment (OC) of persons with serious mental illness are explored. These issues include the reliance on hospital recidivism as a primary measure of outcome, the role of family members and coercion in the process of outpatient commitment, and the conceptualization and design of studies. A conceptual framework that attempts to incorporate responses to these issues is proposed. Continued research on OC should build on conceptual models that include family role and burden, services delivered, an accounting for varied coercive mechanisms, and client-level outcomes. Rehospitalization should be conceptualized as an intermediate variable between OC and client-level outcomes rather than as an ultimate outcome.
In the light of recent legislation, this paper reviews the implementation of the Community Treatment Order (CTO) in terms of clinical efficacy and ethical issues involved in its use. The debate surrounding the introduction of CTOs in other countries is explored.
A Medline search was conducted and references of recent articles followed up, with attention to Australian, New Zealand and international trends. A review of relevant legislation and government reports was conducted.
There has been limited debate in the Australian and New Zealand literature concerning the operation of CTOs. Despite their increasing and widespread use, there is a paucity of research on the efficacy of CTOs. Concerns about their negative effects on civil liberties have been stressed in the United Kingdom and American literature.
If the continued use of CTO is to be justified, both clinically and from the civil liberties perspective, controlled research needs to be carried out to identify whether CTOs are more effective than comprehensive assertive community outreach programs in reducing relapse rates and hospitalisation, and increasing compliance. Clinical guidelines concerning who is most likely to respond to such orders need to be developed. Alternatives to the CTO are explored, and future directions in research are outlined.
A randomised controlled trial was conducted in an acute treatment setting to examine the effectiveness of compliance therapy, a brief pragmatic intervention targeting treatment adherence in psychotic disorders, based on motivational interviewing and recent cognitive approaches to psychosis.
Seventy-four patients with psychotic disorders according to DSM-III-R criteria recruited from consecutive admissions to an acute in-patient unit, received 4-6 sessions of either compliance therapy or non-specific counselling, and were followed-up over 18 months. The principal outcome measures were observer-rated compliance, attitudes to treatment, insight and social functioning.
Significant advantages were found for the compliance therapy group post-treatment on measures of insight, attitudes to treatment and observer-rated compliance which were retained over the follow-up period. Global social functioning improved relatively more over time in the compliance therapy group compared with the control group. Survival in the community prior to readmission was significantly longer in the compliance therapy group.
The results support the effectiveness of compliance therapy in improving functioning and community tenure after an acute psychotic episode.
An emerging trend within managed care, "disease management" (DM), will affect consumers and providers of mental health services, clinicians, and mental health administrators. Central to DM programs is the idea that particular diseases, especially chronic illnesses (including depression), can be "carved out" and managed. Pharmaceutical benefit management (PBM) firms may specialize in managing prescription benefits for employers and other managed care organizations by using DM programs. However, given what is known from the theoretical and empirical literature on adherence to medication for chronic illnesses such as depression, it is questionable whether the techniques that are used by PBMs will be effective in managing illnesses that require a multifaceted approach to care. Because the management of antidepressants may have an impact on members of vulnerable populations (e.g., the elderly), more research is required on the approaches used by PBMs and on the cost and quality of the services provided.
Managed Care and Medication Compliance
- L C Kihlstrom
Kihlstrom, L. C. (1998) 'Managed Care and Medication Compliance'. Journal of Behavioural and Health Services C Research 25: 367-76.
Report of the Conswltative Council on Review of Mental Health Legislation. Melbourne, Australia: Government Printers Community Treatment Orders and Restricted Treatment Orders: Guidelines and Information
- D M Myer
- J R Ball
- D Fitzgerald
Myer, D. M., Ball, J. R. and Fitzgerald, D. (eds) (1981) Report of the Conswltative Council on Review of Mental Health Legislation. Melbourne, Australia: Government Printers. Psychiatric Services Division (1994) Community Treatment Orders and Restricted Treatment Orders: Guidelines and Information. Victoria, Australia: Department of Health and Community Services.
The Mental Health Act into the 1990s. PublicationCompulsory Psychiatric Treatment in the Community
- N Rees
- S Hirsch
Rees, N. (1991) 'Introduction'. In Rees, Neil (ed.) The Mental Health Act into the 1990s. Publication ISBN 0 7241 9927 6. Victoria, Australia: Mental Health Review Board. Sensky, T., Hughes, T. and Hirsch, S. (1991) 'Compulsory Psychiatric Treatment in the Community'. British Journal of Psychiatry 158: 792-804.
State Parliament Records
- D White
White, D. (1986) State Parliament Records, Victoriu, 261b March, 1986. Victoria: Government Publishing Service, pp. 286-8.
- Torrey E. F.